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1.  Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings 
Acta Informatica Medica  2013;21(3):166-169.
The Aim:
To show histopathological diagnoses after colonoscopic polypectomy in the University Hospital Center (KBC) Split with recommendations on further follow-up colonoscopy depending on the endoscopic and histological findings.
Patients and Methods:
The study included 2842 patients who underwent colonoscopy in a two-year period (2008-2009), followed by a detailed analysis of 350 patients in which one or more polyps were simultaneously removed and 163 patients who were only sampled for histological analysis. Patients from the National Program for Colorectal Cancer Prevention and patients in which colonoscopy is indicated as part of daily outpatient or inpatient treatment were included as well.
During 2008 and 2009 in KBC Split, out of a total of 2842 colonoscopies, 350 patients underwent colonoscopic polypectomy, whereby 618 polyps were removed (1-8 polyps in individual patients), while in 163 patients only biopsy specimens were sampled. Out of the total of 557 polyps sent for histological analysis, 236 were hyperplastic (42%), 193 were identified as tubular adenoma (35%), 84 were tubulovillous (15%), 18 villous (3%), 9 were adenocarcinoma (2%) and other 17 (3%). In 35 (15.4%) polyps high-grade dysplasia was found. The largest number of nonpolypectomized changes confirmed the presence of adenocarcinoma (76-47%), adenomas and hyperplastic polyps were 37 (22%) and regular findings 23 (14%). Mucosal high-grade dysplasia was demonstrated in 35 (23.1%) biopsied changes.
Colonoscopies with polypectomy decreased the risk of the formation of colorectal cancer in these patients almost to the level of risk in patients who have not even had a polyp during colonoscopy. Arguably the best method of prevention and early detection of colorectal cancer are already widely established national programs. The next qualitative level is constantly improving the quality of colonoscopy with clear criteria and the establishment of a body to evaluate the performers and the equipment, and making recommendations on the colonoscopy follow-up intervals depending on endoscopic and histopathological findings of patients who for any reason underwent colonoscopy.
PMCID: PMC3804476  PMID: 24167384
colonoscopic polipectomy; surveillance; quality of endoscopy.
2.  Analysis of mtDNA sequence variants in colorectal adenomatous polyps 
Diagnostic Pathology  2010;5:66.
Colorectal tumors mostly arise from sporadic adenomatous polyps. Polyps are defined as a mass of cells that protrudes into the lumen of the colon. Adenomatous polyps are benign neoplasms that, by definition display some characteristics of dysplasia. It has been shown that polyps were benign tumors which may undergo malignant transformation. Adenomatous polyps have been classified into three histologic types; tubular, tubulovillous, and villous with increasing malignant potential. The ability to differentially diagnose these colorectal adenomatous polyps is important for therapeutic intervention. To date, little efforts have been directed to identifying genetic changes involved in adenomatous polyps. This study was designed to examine the relevance of mitochondrial genome alterations in the three adenomatous polyps. Using high resolution restriction endonucleases and PCR-based sequencing, fifty-seven primary fresh frozen tissues of adenomatous polyps (37 tumors and 20 matched surrounding normal tissues) obtained from the southern regional Cooperative Human Tissue Network (CHTN) and Grady Memorial Hospital at Atlanta were screened with three mtDNA regional primer pairs that spanned 5.9 kbp. Results from our data analyses revealed the presence of forty-four variants in some of these mitochondrial genes that the primers spanned; COX I, II, III, ATP 6, 8, CYT b, ND 5, 6 and tRNAs. Based on the MITODAT database as a sequence reference, 25 of the 44 (57%) variants observed were unreported. Notably, a heteroplasmic variant C8515G/T in the MT-ATP 8 gene and a germline variant 8327delA in the tRNAlys was observed in all the tissue samples of the three adenomatous polyps in comparison to the referenced database sequence. A germline variant G9055A in the MT-ATP 6 gene had a frequency of 100% (17/17) in tubular and 57% (13/23) in villous adenomas; no corresponding variant was in tubulovillous adenomas. Furthermore, A9006G variant at MT-ATP 6 gene was observed at frequency of 57% (13/23) in villous adenomas only. Interestingly, variants A9006G and G9055A were absent in the villous tissue samples that were clinicopathological designated as "polyvillous adenomas". Our current data provide a basis for continued investigation of certain mtDNA variants as predictors of the three adenomatous polyps in a larger number of clinicopathological specimens.
PMCID: PMC2959018  PMID: 20929553
3.  Prevalence and Characteristics of Colonic Polyps and Adenomas in 2654 Colonoscopies in Saudi Arabia 
Colorectal cancer (CRC) is the second most common malignancy in the Saudi population, with an increasing incidence over the past 20 years. We aim to determine the baseline polyp as well as adenoma prevalence in a large cohort of patients and to find the possible age in which, if deemed appropriate, a CRC screening program should be initiated.
Patients and Methods:
A retrospective cohort study was conducted using an endoscopic reporting database of individuals seen at a major tertiary care university hospital (King Khalid University Hospital) in Riyadh, Saudi Arabia. Consecutive Saudi patients who underwent a colonoscopy between August 2007 and April 2012 were included. Patients were excluded if the indication for the colonoscopy was colon cancer, colonic resection, active colitis, active diverticulitis, inflammatory bowel disease, or if the patient was referred for polypectomy.
2654 colonoscopies were included in the study. The mean age of the study population was 50.5 years [standard deviation (SD) 15.9] and females represented 57.7%. The polyp detection rate in completed colonoscopies was 20.8% (95% CI: 19.2-22.5). Adenomas were found in 8.1% (95% CI: 7.1-9.1), while advanced adenomas were found in only 0.5% (95% CI: 0.2-0.7). Adenomas were found in the left side of the colon in 33.9%, followed by the rectum in 14.6%, ascending colon and cecum in 14.2%, transverse colon in 8.7%, and in multiple locations in 28.7%. Those with a prior history of polyps or CRC were more likely to have an adenoma at colonoscopy than those who did not (14.3% vs. 6.6%; P < 0.01). The adenoma prevalence varied between age groups and ranged from 6.2% to 13.6% with a higher proportion in older individuals; this trend was seen both in males (6.0-14.5%) and females (6.4-14.6%) as well as in those who had screening colonoscopies (6.3-18.4%). No age could be found at which a CRC screening program would be appropriate to initiate.
The prevalence of polyps and adenomas in this cohort is less than that reported in the Western populations. But as this cohort included younger and symptomatic patients with only a small proportion undergoing screening, further studies in an asymptomatic population are needed.
PMCID: PMC4067911  PMID: 24976278
Adenoma; colon cancer; colonosocopy; early detection; endoscopy; epidemiology; polyp; prevalence; Saudi Arabia; tumor
4.  Is the Distal Hyperplastic Polyp a Marker for Proximal Neoplasia? 
The current literature is unclear about the association between distal hyperplastic polyps and synchronous neoplasia (adenomatous polyps and cancer) in the proximal colon.
To estimate the prevalence of proximal neoplasia associated with distal hyperplastic polyps.
Database searches (medline and embase from 1966 to 2001) and manual search of the bibliographies of included and excluded studies, case reports, editorials, review articles, and textbooks of Gastroenterology.
Studies describing the prevalence of proximal neoplasia in persons with distal hyperplastic polyps.
Demographics, clinical variables, study design, and prevalence of proximal neoplasia associated with various distal colorectal findings.
Of 18 included studies, 12 involved asymptomatic individuals in which the pooled absolute risk of any proximal neoplasia associated with distal hyperplastic polyps was 25% (95% confidence interval [95% CI], 21% to 29%). In 4 studies where colonoscopy was performed irrespective of distal findings, the absolute risk was 21% (95% CI, 14% to 28%). The relative risk of finding any proximal neoplasia in persons with distal hyperplastic polyps was 1.3 (95% CI, 0.9 to 1.8) compared to those with no distal polyps. Among 6 studies of patients with symptoms or risk factors for neoplasia, the absolute risk of proximal neoplasia was 35% (95% CI, 32% to 39%) in persons with distal hyperplastic polyps. In 2 studies of screening colonoscopy, advanced proximal neoplasia (cancer, or a polyp with villous histology or severe dysplasia, or a tubular adenoma ≥1 cm) was present in 4% to 5% of persons with distal hyperplastic polyps, which was 1.5 to 2.6 times greater than in those with no distal polyps.
In asymptomatic persons, a distal hyperplastic polyp is associated with a 21% to 25% risk for any proximal neoplasia and a 4% to 5% risk of advanced proximal neoplasia, and may justify examination of the proximal colon. Further study is needed to determine the risk of advanced proximal neoplasia associated with size and number of distal hyperplastic polyps.
PMCID: PMC1494823  PMID: 12542588
colorectal cancer; cancer screening; sigmildoscopy; colorectal neoplasms; systemetic review
5.  Referring patients to nurses: Outcomes and evaluation of a nurse flexible sigmoidoscopy training program for colorectal cancer screening 
Colorectal cancer is a significant health burden. Several screening options exist that can detect colorectal cancer at an early stage, leading to a more favourable prognosis. However, despite years of knowledge on best practice, screening rates are still very low in Canada, particularly in Ontario. The present paper reports on efforts to increase the flexible sigmoidoscopy screening capacity in Ontario by training nurses to perform this traditionally physician-performed procedure. Drawing on American, British and local experience, a professional regulatory framework was established, and training curriculum and assessment criteria were developed. Training was initiated at Princess Margaret Hospital and Sunnybrook and Women’s College Health Sciences Centre in Toronto, Ontario. (During the study, Sunnybrook and Women’s College Health Sciences Centre was deamalgamated into two separate hospitals: Women’s College Hospital and Sunnybrook Health Sciences Centre.) Six registered nurses participated in didactic, simulator and practical training. These nurses performed a total of 77 procedures in patients, 23 of whom had polyps detected and biopsied. Eight patients were advised to undergo colonoscopy because they had one or more neoplastic polyps. To date, six of these eight patients have undergone colonoscopy, one patient has moved out of the province and another patient is awaiting the procedure. Classifying the six patients according to the most advanced polyp histology, one patient had a negative colonoscopy (no polyps found), one patient’s polyps were hyperplastic, one had a tubular adenoma, two had advanced neoplasia (tubulovillous adenomas) and one had adenocarcinoma. All these lesions were excised completely at colonoscopy. Overall, many difficulties were anticipated and addressed in the development of the training program; ultimately, the project was affected most directly by challenges in encouraging family physicians to refer patients to the program. As health human resource strategies continue to evolve, it is believed that lessons learned from experience make an important contribution to the knowledge of how nontraditional health services can be organized and delivered.
PMCID: PMC2657712  PMID: 17505566
Colorectal cancer screening; Flexible sigmoidoscopy; Health human resource strategy; Nonphysician endoscopy
6.  Clinical predictors of colorectal polyps and carcinoma in a low prevalence region: Results of a colonoscopy based study 
AIM: To estimate the prevalence of colorectal cancer (CRC) in patients with long lasting colonic symptoms undergoing total colonoscopy; and to establish clinical features predicting its occurrence.
METHODS: This prospective study was carried out in Imam Hospital, Tabriz University of medical sciences, Iran. Continuous patients with long lasting lower gastrointestinal tract symptoms who had the criteria of a colonoscopy were included. The endoscopist visualized the caecum documented by a photo and/or a specimen from terminal ileum.
RESULTS: Four hundred and eighty consecutive symptomatic patients [mean age (SD): 42.73 (16.21)] were included. The prevalence of colorectal neoplasia was 15.3% (34 subjects) and 37.7% (181 subjects) had a completely normal colon. Adenomatous polyps were detected in 56 (11.7%) patients, in 12.3% of men and 10.9% of women. The mean age of the patients with a polyp was significantly higher than the others (49.53 ± 14.16 vs 41.85 ± 16.26, P = 0.001). Most of the adenomatous polyps were left sided and tubular; only 22.5% of polyps were more than 10 mm. Cancer was detected in 16 (3.6%) of our study population, which was mostly right sided (57.2%). The mean age of patients with cancer was significantly higher than the others (60.25 ± 8.26 vs 42.13 ± 16.08, P < 0.005) and higher than patients with polyps [60.25 (8.26) vs 49.53 (1.91) (P < 0.0005)]. None of the symptoms (diarrhea, abdominal pain, rectal bleeding, constipation, altering diarrhea and constipation, history of cancer, known irritable bowel disease, history of polyp and fissure or family history of cancer) were predictors for cancer or polyps, but the age of the patient and unexplained anemia independently predicted cancer.
CONCLUSION: Less advanced patterns and smaller sizes of adenomas in Iran is compatible with other data from Asia and the Middle East, but in contrast to western countries. Prevalence of colonic neoplasia in our community seems to be lower than that in western population. Colonic symptoms are not predictors for polyps or cancer but unexplained anemia and elder age can predict CRC.
PMCID: PMC2693747  PMID: 18330943
Colorectal cancer; Adenomatous polyp; Colonic symptom; Prevalence; Iran
7.  Fecal Occult Blood Test for Colorectal Cancer Screening 
Executive Summary
The colorectal cancer (CRC) screening project was undertaken by the Medical Advisory Secretariat (MAS) in collaboration with the Cancer Care Ontario (CCO).
In November 2007, the Ontario Health Technology Advisory Committee (OHTAC) MAS to conduct an evidence-based analysis of the available data with respect to colorectal cancer diagnosis and prevention. The general purpose of the project was to investigate the effectiveness, cost effectiveness, and safety of the various methods and techniques used for colorectal cancer screening in average risk people, 50 years of age and older.
The options currently offered for colorectal cancer screening were reviewed and five technologies were selected for review:
Computed tomographic (CT) colonography
Magnetic resonance (MR) colonography
Wireless capsule endoscopy (PillCam Colon)
Fecal occult blood test (FOBT)
Flexible sigmoidoscopy
In this review, colonoscopy was considered as the “gold standard” technique by which the effectiveness of all other modalities could be evaluated. An economic analysis was also conducted to determine cost-effectiveness of different screening modalities.
Evidence-based analyses have been prepared for each of these technologies, as well as summary document that includes an economic analysis, all of which are presented at the MAS Web site:
The objective of this evidence review is to examine the effectiveness and cost-effectiveness of fecal occult blood testing (FOBT), including guaiac FOBT (gFOBT) and immunochemical FOBT (iFOBT), for use in colorectal cancer (CRC) screening in asymptomatic, average-risk adults.
Is the use of gFOBT or iFOBT associated with a reduction in CRC and overall mortality?
What are the sensitivity and specificity of gFOBT and iFOBT for the detection of 1) CRC and 2) large polyps (≥ 1 cm)?
Clinical Need
CRC is the most common cause of non-tobacco related cancer death in Canada. It has been estimated that in 2007, 7,800 people were diagnosed with CRC in Ontario and 3,250 died from the disease, making the province’s incidence and mortality rate of CRC amongst the highest in the world.
Description of Technology/Therapy
There are two general types of FOBT that are categorized according to the analyte detected: guaiac FOBT (gFOBT) and immunochemical FOBT (iFOBT). Blood in the stool is a nonspecific finding but may originate from CRC or larger (>1 cm) polyps (small adenomatous polyps do not tend to bleed). Bleeding from cancers and larger polyps may be intermittent and not always detectable in a single sample. The FOBT thus requires regular testing that consists of collecting specimens from consecutive bowel movements. A positive gFOBT or iFOBT involves a diagnostic workup with colonoscopy to examine the entire colon in order to rule out the presence of cancer or advanced neoplasia.
Methods of Evidence-Based Analysis
A literature search was conducted from January 2003 to June 2008 that included OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment/Centre for Review and Dissemination.
Inclusion Criteria
Patients at average risk for CRC
All patients must be at least 50 years of age
Biennial FOBT as a screening modality and use of colonoscopy as the reference standard
Systematic reviews and randomized controlled trials (RCTs)
Outcomes: CRC mortality, overall mortality, sensitivity, specificity, adverse effects
Exclusion Criteria
Studies involving fewer than 100 patients
Studies that do not report sufficient data for analysis
Comparisons of Interest
Evidence exists for these comparisons of interest:
gFOBT compared with the reference “gold standard” colonoscopy (or double-contrast barium enema where colonoscopy is incomplete or contraindicated)
iFOBT compared with the reference gold standard colonoscopy (or DCBE where colonoscopy is incomplete or contraindicated)
gFOBT compared with iFOBT
The quality of the diagnostic studies was examined according to the ‘GRADE Working Group criteria’ for grading quality of evidence and strength of recommendations for diagnostic tests and strategies.
Summary of Findings
Single-Test Studies
There is limited direct/indirect evidence that iFOBT has sensitivity/specificity superior to that of unrehydrated gFOBT for CRC detection:
sensitivity for gFOBT:
pooled iFOBT sensitivity:
There is evidence that iFOBT and gFOBT have lower sensitivities for adenoma detection than for CRC detection:
sensitivity for rehydrated gFOBT
pooled iFOBT sensitivity
Repeated-Test Studies
No trials have examined CRC mortality outcomes after repeated testing of iFOBT.
Two RCTs from the United Kingdom and Denmark showed significant reduction in CRC mortality using unrehydrated gFOBT biennially
Relative risk reductions of 13% (UK trial) and 16% (Danish trial); absolute difference of 0.1% (UK trial) and 0.2% (Danish trial).
No significant reduction in overall mortality
Interval cancers (CRC that develop in the intervals between routine screening)
United Kingdom trial: 236 CRCs detected by positive test, 236 interval CRCs after negative test
Danish trial: 120 CRCs detected by positive test, 146 interval CRCs after negative test
Unrehydrated gFOBT has low sensitivity for CRC detection (45% in the UK trial and 54% in the Danish trial).
true positive rate
false positive rate
true negative rate
false negative rate
Guaiac FOBT – GRADE Quality of Evidence for Interventions
CRC indicates colorectal cancer; FOBT, fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation; RCT, randomized controlled trial.
Unlikely to be an important uncertainty.
GRADE Quality of Evidence for Diagnostic Tests: Implications of Testing Focusing on Accuracy
Benefit from diagnosis and treatment after confirmatory colonoscopy
Small risk of bowel perforation during colonoscopy
Benefit of reassurance
Anxiety/worry leading up to confirmatory colonoscopy
Small risk of bowel perforation during confirmatory colonoscopy
Detriment from delayed diagnosis
Some uncertainty (until after confirmatory colonoscopy)
No Uncertainty
FOBT indicates fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation.
Immunochemical FOBT – GRADE Quality of Evidence for Diagnostic Studies
FN indicates false negative; FOBT, fecal occult blood test; FP, false positive; Development and Evaluation; TN, true negative; TP, true positive.
Uncertainty until after confirmatory colonoscopy
Stress/worry for patient until confirmatory colonoscopy
Detrimental effects due to delayed diagnosis.
For these 3 reasons, downgrade quality from High to Moderate.
For these 3 reasons, downgrade quality from Moderate to Low.
Considerations for the Ontario Health System
Executive Summary Table 4 shows the potential system pressures and benefit/risk analysis for the use of FOBT and colonoscopy to screen for CRC in average-risk adults, ages 50 and over in Ontario.
Summary of Potential System Pressures for FOBT Screening
Prevent and detect
Every 10 years
Must repeat at regular intervals
Every 2 years
Must repeat at regular intervals
Observational studies
Used as gold standard in studies
Intervention GRADE quality: High (gFOBT)
Diagnostic GRADE quality: Low (iFOBT)
No RCTs examining the effectiveness of repeated iFOBT on CRC mortality reduction were identified
Limited direct/indirect evidence that iFOBT has superior sensitivity/specificity to unrehydrated gFOBT for detection of CRC
0.1% risk of serious bleeding and perforation requiring surgery
0.3% risk of serious complications (stroke/bleeding requiring hospitalization/ myocardial infarction)
High interval cancer rate
The small benefit in CRC mortality reduction (absolute difference 0.1% to 0.2%) also coincides with a 0.3% risk of serious complications.
No food 1 day prior to exam
Office/hospital visit
Complete bowel preparation
Eliminate citrus fruit and juices and vitamin C from diet for 3 days prior to/during stool collection.
Person applies 2 samples per bowel movement (each occurring on 3 different days) onto test areas of FOBT cards.
Increased demand for colonoscopies and colonoscopists or nurses who perform colonoscopies.
Patient receives kit from family physician, pharmacist
Patients mail completed FOBT kit to participating laboratory
Results sent back to patient
Increased demand for colonoscopies for positive patients
Removal of polyp during colonoscopy or surgery
Referral to colonoscopy
2nd of 5 choices in a patient survey study
5th of 5 choices in a patient survey study
FOBT indicates fecal occult blood test;; gFOBT, guaiac FOBT; GRADE, Grading of Recommendations Assessment, Development and Evaluation; iFOBT, immunochemical FOBT; RCT, randomized controlled trial.
PMCID: PMC3377532  PMID: 23074514
8.  Patients with adenomatous polyps and carcinomas have increased colonic mucosal prostaglandin E2. 
Gut  1994;35(5):675-678.
Colorectal carcinoma in humans and animal models is associated with increased synthesis of prostaglandin E2 (PGE2). PGE2 synthesis was measured in normal and neoplastic human colorectal mucosa to investigate its role in the adenoma-carcinoma sequence. Paired mucosal biopsy specimens for PGE2 synthesis and histological examination were obtained during 39 diagnostic colonoscopies. Twelve control patients in whom colonoscopies and histology were normal synthesised similar amounts of PGE2 at all sites. Their results were (mean (SD) pg PGE2/mg tissue) caecum 102.8 (15.9) (n = 6), ascending colon 110.8 (24.3) (n = 10), transverse colon 103.9 (19.5) (n = 11), descending colon 102.9 (23.2) (n = 12), sigmoid colon 96.4 (18.0) (n = 12), and rectum 107.1 (17.6) (n = 12). Nineteen patients had a total of 27 adenomatous polyps (rectum (1), sigmoid (22), descending (1), transverse (1), and ascending colon (1): histology-tubular (16), tubulo-villous (8), and villous adenomous (3)). The polyps (178.0 (55.0), n = 27) synthesised more PGE2 than controls (p < 0.001), but the values in polyp-associated mucosa (mean (SD) 115.4 (21.9), n = 15) were not different to control results. Eight patients had carcinomas (rectal (2), sigmoid (4), and caecal (2)) all of which were adenocarcinomas. The cancers (193.6 (40.2), n = 8) synthesised more PGE2 than control specimens (p < 0.001), but were not different to polyps. Cancer-associated mucosa (140.3 (27.7) n = 8) synthesised more PGE2 than control and polyp-associated mucosa. Colorectal neoplasia is associated with a progressive increase in PGE2 synthesis which may have a role in tumourigenesis and be a pathophysiological explanation for the beneficial effects of NSAIDs in animal models and human disease.
PMCID: PMC1374755  PMID: 8200564
9.  The impact of advance care planning of place of death, a hospice retrospective cohort study 
BMJ Supportive & Palliative Care  2013;3(2):168-173.
There is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in a 2.5-year period to see if use of ACP affected actual place of death, hospital use and cost of hospital care in the last year.
969 patients were included. 550 (57%) people completed ACP. 414 (75%) achieved their choice of place of death. For those who chose home, 34 (11.3%) died in hospital; a care home 2 (1.7%) died in hospital; a hospice 14 (11.2%) died in hospital and 6 (86%) who chose to die in hospital did so. 112 (26.5%) of people without ACP died in hospital. Mean number of days in hospital in the last year of life was 18.1 in the ACP group and 26.5 in the non-ACP group(p<0.001). Mean cost of hospital treatment during the last year of life for those who died in hospital was £11,299, those dying outside of hospital £7,730 (p<0.001). Mean number of emergency admissions for those who died in hospital was 2.2 and who died elsewhere was 1.7 (p<0.001).
ACP can be used routinely in a hospice setting. Those who used ACP spent less time in hospital in their last year. ACP is associated with a reduction in the number of days in hospital in the last year of life with less hospital costs, supporting the assumptions made in the End of Life Care Strategy 2008.
PMCID: PMC3632964  PMID: 23626905
Hospice care; Cancer; Chronic conditions; Communication; Service evaluation
10.  Standard forward-viewing colonoscopy versus full-spectrum endoscopy: an international, multicentre, randomised, tandem colonoscopy trial 
The lancet oncology  2014;15(3):353-360.
Although colonoscopy is the accepted standard for detection of colorectal adenomas and cancers, many adenomas and some cancers are missed. To avoid interval colorectal cancer, the adenoma miss rate of colonoscopy needs to be reduced by improvement of colonoscopy technique and imaging capability. We aimed to compare the adenoma miss rates of full-spectrum endoscopy colonoscopy with those of standard forward-viewing colonoscopy.
We did an international, multicentre, randomised trial at three sites in Israel, one site in the Netherlands, and two sites in the USA between Feb 1, 2012, and March 31, 2013. Patients aged 18–70 years referred for colorectal cancer screening, polyp surveillance, or diagnostic assessment underwent same-day, back-to-back tandem colonoscopy with standard forward-viewing colonoscope and the full-spectrum endoscopy colonoscope. The patients were randomly assigned (1:1), via computer-generated randomisation with block size of 20, to which procedure was done first. The endoscopist was masked to group allocation until immediately before the start of colonoscopy examinations; patients were not masked. The primary endpoint was adenoma miss rates. We did per-protocol analyses. This trial is registered with, number NCT01549535.
197 participants were enrolled. 185 participants were included in the per-protocol analyses: 88 (48%) were randomly assigned to receive standard forward-viewing colonoscopy first, and 97 (52%) to receive full-spectrum endoscopy colonoscopy first. By per-lesion analysis, the adenoma miss rate was significantly lower in patients in the full-spectrum endoscopy group than in those in the standard forward-viewing procedure group: five (7%) of 67 vs 20 (41%) of 49 adenomas were missed (p<0·0001). Standard forward-viewing colonoscopy missed 20 adenomas in 15 patients; of those, three (15%) were advanced adenomas. Full-spectrum endoscopy missed five adenomas in five patients in whom an adenoma had already been detected with first-pass standard forward-viewing colonoscopy; none of these missed adenomas were advanced. One patient was admitted to hospital for colitis detected at colonoscopy, whereas five minor adverse events were reported including vomiting, diarrhoea, cystitis, gastroenteritis, and bleeding.
Full-spectrum endoscopy represents a technology advancement for colonoscopy and could improve the efficacy of colorectal cancer screening and surveillance.
PMCID: PMC4062184  PMID: 24560453
11.  Gastric Helicobacter pylori infection associates with an increased risk of colorectal polyps in African Americans 
BMC Cancer  2014;14:296.
Gastric Helicobacter pylori (H. pylori) infection and colorectal polyps are more prevalent in African Americans than in the general population. We aimed to investigate whether gastric H. pylori infection is associated with colorectal polyps in African Americans.
Medical records of African Americans, 40 years and older (n = 1256) who underwent bidirectional gastrointestinal endoscopy on the same day were reviewed. H. pylori status was assessed by immunohistochemistry on gastric specimens. Colorectal polyps were confirmed by histological examination of colorectal biopsies. A subset of serum samples from healthy and polyp-bearing patients (n = 163) were analyzed by ELISA for anti-H. pylori and anti-CagA antibodies. The crude and adjusted effect of H. pylori on the risk of colorectal adenoma and polyp were computed by logistic regression models.
The prevalence of colorectal polyps and adenomas were 456 (36%) and 300 (24%) respectively. Colorectal polyps were more prevalent in gastric H. pylori infected than non-infected subjects [43% vs. 34%; Odds Ratio (OR) (95% CI): 1.5 (1.2-1.9), P = 0.001]. Patients with H. pylori-associated chronic active gastritis were at high risk to have adenomas [Unadjusted OR (95% CI): 1.3 (1.0-1.8); P = 0.04]. There was no difference in histopathology, size, or location of polyps with respect to H. pylori status. Gastric H. pylori infection, age, male gender and high risk clinical presentations were independent risk factors for colorectal polyps. Serological testing also revealed a higher prevalence of H. pylori and its toxin Cag-A in polyp patients vs. non polyp patients’ sera, although in a non-statistically significant manner.
This study showed that current gastric H. pylori infection is associated with an increased risk of colorectal polyps in African Americans. Patients with H. pylori induced gastritis may benefit from early screening colonoscopy as a preventative measure for colorectal cancer.
PMCID: PMC4022546  PMID: 24774100
African Americans; H. pylori infection; Colorectal neoplasm; Gastric lesion; Risk factors; Forty year and older
12.  Growth of colorectal polyps: redetection and evaluation of unresected polyps for a period of three years. 
Gut  1996;39(3):449-456.
BACKGROUND, AIMS, AND PATIENTS: In a prospective follow up and intervention study of colorectal polyps, leaving all polyps less than 10 mm in situ for three years, analysis of redetection rate, growth, and new polyp formation was carried out in 116 patients undergoing annual colonoscopy. The findings in relation to growth and new polyp formation were applied to 58 subjects who received placebo. RESULTS: Redetection rate varied from 75-90% for each year, and was highest in the rectum and sigmoid colon. There was no net change in size of all polyps in the placebo group, however, polyps less than 5 mm showed a tendency to net growth, and polyps 5-9 mm a tendency to net regression in size, both for adenomas and hyperplastic polyps. This pattern was verified by computerised image analysis. Patients between 50 and 60 years showed evidence of adenoma size increase compared with the older patients, and the same was true for those with multiple adenomas (four to five) compared with those with a single adenoma. The new adenomas were significantly smaller and 71% were located in the right side of the colon. Patients with multiple adenomas had more new polyps at all the follow up examinations than patients with a single adenoma. One patient developed an invasive colorectal carcinoma, which may be evolved from a previously overlooked polyp. Two polyps, showing intramucosal carcinoma after follow up for three years, were completely removed, as judged by endoscopy and histological examination. CONCLUSIONS: The results show that follow up of unresected colorectal polyps up to 9 mm is safe. The consistency of growth retardation of medium sized polyps suggests extended intervals between the endoscopic follow up examinations, but the increased number of new polyps in the proximal colon indicates total colonoscopy as the examination of choice. The growth retardation of the medium sized polyps may partly explain the discrepancy between the prevalence of polyps and the incidence of colorectal cancer.
PMCID: PMC1383355  PMID: 8949653
13.  Phenotype and Polyp Landscape in Serrated Polyposis Syndrome: A Series of 100 Patients from Genetics Clinics 
Serrated polyposis syndrome (SPS), also known as hyperplastic polyposis, is a syndrome of unknown genetic basis defined by the occurrence of multiple serrated polyps in the large intestine and associated with an increased risk of colorectal cancer (CRC). There are a variety of SPS presentations, which may encompass a continuum of phenotypes modified by environmental and genetic factors. To explore the phenotype of SPS, we recorded the histologic and molecular characteristics of multiple colorectal polyps in patients with SPS recruited between 2000 and 2010 from genetics clinics in Australia, New Zealand, Canada and the USA. Three specialist gastrointestinal pathologists reviewed the polyps, which they classified into conventional adenomas or serrated polyps, with various subtypes, according to the current WHO criteria. Mutations in BRAF and KRAS and mismatch repair protein expression were determined in a subset of polyps. A total of 100 patients were selected for the study, comprising 58 females and 42 males. The total polyp count per patient ranged from 6 to 150 (median: 30). The vast majority of patients (89%) had polyposis affecting the entire large intestine. From this cohort, 406 polyps were reviewed. Most of the polyps (83%) were serrated polyps: microvesicular hyperplastic polyps (HP) (n=156), goblet cell HP (n=25), sessile serrated adenoma/polyps (SSA/P) (n=110), SSA/P with cytological dysplasia (n=28) and traditional serrated adenomas (TSA) (n=18). A further 69 polyps were conventional adenomas. BRAF mutation was mainly detected in SSA/P with dysplasia (95%), SSA/P (85%), microvesicular HP (76%), and TSA (54%) while KRAS mutation was present mainly in goblet cell HP (50%) and in tubulovillous adenoma (45%). Four of 6 SSA/Ps with high grade dysplasia showed loss of MLH1/PMS2 expression. CRC was diagnosed in 39 patients who were more often found to have a conventional adenoma compared to patients without CRC (P = 0.003). Patients with SPS referred to genetics clinics had a pancolonic disease with high polyp burden and high rate of BRAF mutation. The occurrence of CRC was associated with the presence of conventional adenoma.
PMCID: PMC3354022  PMID: 22510757
Serrated polyposis; Colorectal Polyps; Colorectal Cancer
14.  The association of serum lipids with the histological pattern of rectosigmoid adenoma in Taiwanese adults 
BMC Gastroenterology  2011;11:54.
The mortality rate of colorectal cancer ranks third behind lung and hepatic cancer in Taiwan. Colorectal cancer mostly arises from adenomatous polyps of left colon. The aim of our study was to examine the association of serum lipids with the histological pattern of rectosigmoid adenoma.
There were 2,506 eligible examinees aged 20 and above who underwent sigmoidoscopy as a screening examination in National Cheng Kung University Hospital between January 2003 and October 2006. They were classified into three groups: tubular adenoma (333 subjects), villous-rich (tubulovillous/villous) adenoma (53 subjects) and normal (2,120 subjects). We defined high total cholesterol (TC) as a level ≧200 mg/dl, low high-density lipoprotein cholesterol (HDL-C) as a level <40 mg/dL, and high triglyceride (TG) as a level ≧200 mg/dl according to the third report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. Adenoma histology was classified as tubular, tubulovillous and villous according to the proportion of villous part.
Among the study population, 333 subjects (13.3%) had tubular adenomas and 53 subjects (2.1%) had villous-rich adenomas. The odds ratio (OR) for villous-rich adenoma in subjects with TG≧200 mg/dL compared to those with TG < 200 mg/dL was 3.20 (95% confidence interval [CI]:1.71-6.01), after adjusting for age, gender, general obesity, central obesity, diabetes, hypertension, smoking, and alcohol consumption. If further taking high TC and low HDL-C into consideration, the OR was 4.42 (95% CI:2.03-9.63).
Our study showed that subjects with high serum TG tended to have a higher risk of tubulovillous/villous adenoma in rectosigmoid colon. Therefore, reducing the serum TG level might be one method to prevent the incidence of colorectal cancer.
PMCID: PMC3112117  PMID: 21575164
15.  Prevalence of Different Subtypes of Serrated Polyps and Risk of Synchronous Advanced Colorectal Neoplasia in Average-Risk Population Undergoing First-Time Colonoscopy 
A growing body of evidence indicates that patients with sessile serrated adenoma/polyp (SSA/P) and traditional serrated adenoma (TSA) are at risk for subsequent malignancy. Despite increasing knowledge on histological categorization of serrated polyps (SPs) data are lacking on the actual prevalence and the association of each SP subtype with advanced colorectal neoplasia.
We prospectively determined the prevalence of different SP subtypes and evaluate the association with synchronous advanced neoplasia in asymptomatic average-risk subjects undergoing first-time colonoscopy. All retrieved polyps were examined by two independent pathologists. Serrated lesions were classified into hyperplastic polyps (HP), SSA/P (without and with cytological dysplasia, SSA/P/DIS), and TSA, and were screened for BRAF and K-ras mutations.
Among 258 polyps detected in 985 subjects, the proportion of SSA/P and TSA was 8.9% and 1.9% with an overall prevalence of 2.3% and 0.6%, respectively. SSA/Ps were small without significant difference in their location between proximal and distal colon; TSA were predominantly left-sided. BRAF mutation was common in SSA/Ps and K-ras mutation was present in all TSA. Independent predictors of advanced neoplasia were male sex (odds ratio (OR)=2.0, 95% confidence interval (CI) 1.0–4.0), increasing age (OR=4.5, 95% CI 1.5–13.4 for 50–69 years and OR=9.9, 95% CI 3.1–31.5 for >70 years), current smoking (OR=2.0, 95% CI 1.3–6.8), >3 tubular adenoma (OR=3.6, 95% CI 1.9–6.4), and SSA/P (OR=6.0, 95% CI 1.9–19.5).
The substantial prevalence of BRAF-mutated SSA/P and the independent association with synchronous advanced colorectal neoplasia in asymptomatic average-risk subjects support the overall impact of the serrated pathway on colorectal cancer (CRC) risk in general population. The endoscopic characteristics of SSA/P emphasize the need of high-quality colonoscopy as a key factor for an effective CRC screening program.
PMCID: PMC3365671  PMID: 23238028
16.  Prevalence of colorectal polyps in pediatric colonoscopy 
Digestive diseases and sciences  2011;57(4):10.1007/s10620-011-1972-8.
The available data regarding the prevalence, types, and clinical determinants of colonic polyps in children is limited.
We aimed to estimate the prevalence of colorectal polyps in a large cohort of children.
We conducted a cross-sectional study to determine the presence, number, and location of colorectal polyps reported in all children (0–20 years) who underwent colonoscopy at 14 pediatric facilities between January 2000 and December 2007 recorded in Pediatric Endoscopy Database System Clinical Outcomes Research Initiative (PEDS-CORI). We compared procedures with and without polyps with respect to procedure indication, age, sex, and race. We also reviewed a sample of histopathologic reports from one participating center.
We analyzed 13,115 colonoscopy procedures performed in 11,637 patients. Colorectal polyps were reported in 810 procedures (6.1%; 95% CI: 5.7% to 6.5%) performed in 705 patients, and in 12% of patients with lower GI bleeding. Children with colorectal polyps were significantly younger (8.9y vs. 11.9y; p<0.0001), male (58.3% vs. 49.0%; p<0.001), non-white race (27.5% vs. 21.9%; p<0.001), and had lower GI bleeding (54.4% vs. 26.6%; p<0.001) as compared to children without polyps. In a sample of 122 patients with polyps from a single center, the histological types were solitary juvenile in 91 (70.5%), multiple juvenile in 20 (15.5%), adenoma in 14 (10.9%) and hyperplastic polyps in 4 patients (3.1%).
Colorectal polyps are detected in 6.1% overall and in 12.0% among those with lower gastrointestinal bleeding during pediatric colonoscopy. Approximately 26% are multiple juvenile or adenoma.
PMCID: PMC3878076  PMID: 22147243
colonic polyps; hematochezia; colonoscopy
17.  Evaluation of results of lower gastrointestinal endoscopic biopsi 
Aim: The endoscopic examination is widely used and also the the gold standard in lower gastrointestinal system (LGIS) in the diagnosis and treatment of mucosal pathology. Colon and rectum often hosts premalignant lesions and relatively easily accessible organs. Therefore, colorectal cancer (CRC) is a early detectable disease. And to prevent the development of CRC and to capture at early stage the screening tests such as screening endoscopy are used. In our study was aimed to evaluate the biopsy results of the lower gastrointestinal endoscopy. Materials and Methods: The lower gastrointestinal endoscopy (LGE) biopsy results of 135 cases and demographic characteristics of the patients were evaluated retrospectively who admitted to Department of Pathology between January 2013-November 2013. Results: 135 patients enrolled in the study, 89 (65.92%) of male and 46 (34.07%) were female. The age of patients were between 15 and 82 with a mean age of 53.00 ± 14.6. 85 of 135 cases (62.96%) were colitis, 3 (2.22%) were hyperplastic polyps, 22 (16.30%) were tubular adenoma, 15 (11.11%) of them tubulovillous adenoma, 1 (0%, 74) of submucosal lipoma, 9 (6.67%) patients were diagnosed with cancer. All of the cancer cases were in adenocarcinoma histology, one of developing from villous adenoma, one of them from tübülovillous adenoma. Cases of adenomas were included to only cancer groups because there is no duplication of data. Conclusion: Colonoscopy in the detection of both benign and malignant LGIS pathologies is the gold standard method. The upper and lower gastrointestinal endoscopy(LGE) must be remembered as a reliable method in the population, with a low complication rate and high diagnosis rate and when there is clinical necessity gastrointestinal endoscopy should not be avoided as planned.
PMCID: PMC4307560  PMID: 25664113
Lower gastrointestinal system (LGIS); colorectal cancer (CRC); lower gastrointestinal endoscopy (LGE)
18.  Prevalence of Adenomas and Hyperplastic Polyps in Mismatch Repair Mutation Carriers Among CAPP2 Participants: Report by the Colorectal Adenoma/Carcinoma Prevention Programme 2 
Journal of Clinical Oncology  2008;26(20):3434-3439.
To determine the prevalence of adenomatous and hyperplastic polyps in a large cohort of individuals with a germline mutation in a mismatch repair (MMR) gene, the major genetic determinant of hereditary nonpolyposis colorectal cancer (HNPCC). These prevalences have been estimated previously in smaller studies, and the results have been found to be variable.
Patients and Methods
Colorectal Adenoma/Carcinoma Prevention Programme 2 trial is a chemoprevention trial in people classified as having HNPCC. The 695 patients with a proven germline MMR mutation and documented screening history before the chemoprevention study were the focus of this study. The number, histology, size, and location of polyps found at the participants' first ever colonoscopy were analyzed in a cross-sectional study.
Seventy-four patients (10.6%) were found to have at least one adenoma at first colonoscopy, whereas 37 (5.3%) had at least one hyperplastic polyp. The frequency of an adenoma at first colonoscopy increased from 5.0% (95% CI, 2.8% to 8.3%) in patients younger than 35 years old to 18.9% (95% CI, 9.4% to 32.0%) in patients age at least 55 years (P = .0001 for trend). No such trend was observed for hyperplastic polyps. No sex differences were found for either type of polyp. A marginal association was found between the co-occurrence of adenomas and hyperplastic polyps. Adenomas tended to be more proximally distributed through the colon, whereas hyperplastic polyps tended to be located in the distal colon.
Adenoma prevalence increases with age among MMR mutation carriers, whereas hyperplastic polyp prevalence is consistent. No sex differences were observed for either type of lesion.
PMCID: PMC2645083  PMID: 18612159
19.  Incidence and Multiplicities of Adenomatous Polyps in TNM Stage I Colorectal Cancer in Korea 
In recent years, the incidence of early-stage colorectal cancer (CRC) has markedly increased in the population within the Republic of Korea. The aim of this study was to evaluate the clinicopathologic features of adenomatous polyps in TNM stage I CRC patients and in the general population.
Between March 2003 and September 2009, 168 patients with stage I CRC were enrolled in this study. In addition, the records of 4,315 members of the general population without CRC, as determined by colonoscopy during a health check-up, were reviewed.
Of the 168 patients with stage I CRC, 68 (40.5%) had coexisting colorectal adenomatous polyps and of the 4,315 members of the general population, 1,112 (26.0%) had coexisting adenomatous polyps (P = 0.006). The prevalences of adenomatous polyp multiplicity in early CRC and in the general population were 32% and 15%, respectively (P = 0.023). Patients with coexisting adenomatous polyps had a higher frequency of tubulovillous or villous adenomas than members of the general population with polyps (7.5% vs. 2.0%, P = 0.037). Furthermore, a subgroup analysis showed that the occurrence (44% vs. 34%, P = 0.006) and the multiplicity (32% vs. 15%, P = 0.023) of adenomatous polyps were greater for T2 than T1 cancer.
The prevalence and the multiplicity of adenomatous polyps in TNM stage I CRC is higher than it is in the general population. The findings of this study suggest that depth of invasion of early stage CRC affects the prevalence and the number of adenomatous polyps in the remaining colon and rectum.
PMCID: PMC3440491  PMID: 22993708
Colorectal carcinoma; Adenomatous polyp; Stage I; Colonoscopy
20.  Results of National Colorectal Cancer Screening Program in Croatia (2007-2011) 
AIM: To study the epidemiologic indicators of uptake and characteristic colonoscopic findings in the Croatian National Colorectal Cancer Screening Program.
METHODS: Colorectal cancer (CRC) was the second leading cause of cancer mortality in men (n = 1063, 49.77/100  000), as well as women (n = 803, 34.89/100  000) in Croatia in 2009. The Croatian National CRC Screening Program was established by the Ministry of Health and Social Welfare, and its implementation started in September, 2007. The coordinators were recruited in each county institute of public health with an obligation to provide fecal occult blood testing (FOBT) to the participants, followed by colonoscopy in all positive cases. The FOBT was performed by hypersensitive guaiac-based Hemognost card test (Biognost, Zagreb). The test and short questionnaire were delivered to the home addresses of all citizens aged 50-74 years consecutively during a 3-year period. Each participant was required to complete the questionnaire and send it together with the stool specimen on three test cards back to the institute for further analysis. About 4% FOBT positive cases are expected in normal risk populations. A descriptive analysis was performed.
RESULTS: A total of 1  056  694 individuals (born between 1933-1945 and 1952-1957) were invited to screening by the end of September 2011. In total, 210  239 (19.9%) persons returned the envelope with a completed questionnaire, and 181 102 of them returned it with a correctly placed stool specimen on FOBT cards. Until now, 12  477 (6.9%), FOBT-positive patients have been found, which is at the upper limit of the expected values in European Guidelines for Quality Assurance in CRC Screening and Diagnosis [European Union (EU) Guidelines]. Colonoscopy was performed in 8541 cases (uptake 66%). Screening has identified CRC in 472 patients (5.5% of colonoscopied, 3.8% of FOBT-positive, and 0.26% of all screened individuals). This is also in the expected range according to EU Guidelines. Polyps were found and removed in 3329 (39% of colonoscopied) patients. The largest number of polyps were found in the left half of the colon: 64% (19%, 37% and 8% in the rectum, sigma, and descendens, respectively). The other 36% were detected in the proximal part (17% in the transverse colon and 19% in ceco-ascending colon). Small polyps in the rectum (5-10 mm in diameter), sigmoid and descending colon were histologically found to be tubular adenomas in 60% of cases, with a low degree of dysplasia, and 40% were classified as hyperplastic. Polyps of this size in the transverse or ceco-ascending colon in almost 20% had a histologically villous component, but still had a low degree of dysplasia. Polyps sized 10-20 mm in diameter were in 43% cases tubulovillous, and among them, 32% had areas with a high degree of dysplasia, especially those polyps in the ceco-ascending or transverse part. The characteristics of the Croatian CRC Screening National Program in the first 3 years were as follows: relatively low percentage of returned FOBT, higher number of FOBT-positive persons but still in the range for population-based programs, and higher number of pathologic findings (polyps and cancers).
CONCLUSION: These results suggest a need for intervention strategies that include organizational changes and educational activities to improve awareness of CRC screening usefulness and increase participation rates.
PMCID: PMC3436044  PMID: 22969192
Colorectal cancer screening; Fecal occult blood testing; Croatian National Colorectal Cancer Screening Program; Colonoscopy; Uptake
21.  Characteristics of Colorectal Polyps and Cancer; a Retrospective Review of Colonoscopy Data in Iran 
Early diagnosis and endoscopic resection of adenomatous polyps is the main approach for screening and prevention of colorectal cancer (CRC). We aimed to assess polyp detection rate (PDR) and to characterize demographic, clinical, and pathological features of colorectal polyps in an Iranian population.
We retrospectively analyzed the data from 5427 colonoscopies performed during 2007-2012 at Masoud Clinic, the main endoscopy center associated with Sasan Alborz Biomedical Research Center, in Tehran, Iran.
Our sample included 2928 (54%) women and 2499 (46%) men, with the mean age of 48.3 years (SD=16.1). The most common reasons for colonoscopy included screening in 25.0%, and gastrointestinal bleeding in 15.2%. Cecal intubation was successful in 86% of patients. The quality of bowel preparation was fair to excellent in 78.1% (n=4235) of colonoscopies. Overall PDR was 42.0% (95% CI: 40.6-43.3). The PDR in men (51.1%, 95% CI: 49.1-53.1) was significantly higher than women (34.2%, 95% CI: 32.4-35.9, p<0.001). Polyps were more frequently observed in patients after the 6th decade of life (F=3.2; p=0.004). CRC was detected in 2.9% (73/2499) of men and 1.9% (57/2928) of women (p=0.02). The mean age for patients with cancer was significantly higher than that for individuals with polyps, 60.9 (SD=13.4) year vs. 56.9 (SD=13.7) year, respectively (p=0.001). Almost 82.8% of the lesions were precancerous with tubular type predominance (62.3%) followed by tubulo-villous (10.3%), villous (6.6%), and serrated (3.6%). Hyperplastic/inflammatory polyps comprised 17.2% of lesions.
Distal colon was more prone to develop polyps and cancer than proximal colon in our series. These findings provide a great infrastructure for next preventive programs and have implications for colorectal cancer screening at population-level.
PMCID: PMC4119671  PMID: 25093062
Colon Cancer; Colonoscopy; Colonic Polyps
22.  Efficacy, risk factors and complications of endoscopic polypectomy: Ten year experience at a single center 
AIM: To examine the efficacy and complications of colonoscopic resection of colorectal polypoid lesions.
METHODS: We retrospectively reviewed 1354 polypectomies performed on 1038 patients over a ten-year period. One hundred and sixty of these were performed for large polyps, those measuring ≥ 20 mm. Size, shape, location, histology, the technique of polypectomy used, complications, drugs assumption and associated intestinal or extra intestinal diseases were analyzed. For statistical analysis, the Pearson χ2 test, NPC test and a Binary Logistic Regression were used.
RESULTS: The mean patient age was 65.9 ± 12.4 years, with 671 men and 367 women. The mean size of polyps removed was 9.45 ± 9.56 mm while the size of large polyps was 31.5 ± 10.8 mm. There were 388 pedunculated and 966 sessile polyps and the most common location was the sigmoid colon (41.3%). The most frequent histology was tubular adenoma (55.9%) while for the large polyps was villous (92/160 -57.5%). Coexistent malignancy was observed in 28 polyps (2.1%) and of these, 20 were large polyps. There were 17 procedural bleeding (1.3%) and one perforation. The statistical analysis showed that cancer is correlated to polyp size (P < 0.0001); sessile shape (P < 0.0001) and bleeding are correlated to cardiac disease (P = 0.034), tubular adenoma (P = 0.016) and polyp size.
CONCLUSION: The endoscopic resection is a simple and safe procedure for removing colon rectal neoplastic lesions and should be considered the treatment of choice for large colorectal polyps. The polyp size is an important risk factor for malignancy and for bleeding.
PMCID: PMC2705091  PMID: 18416463
Colonoscopy; Polypectomy; Large polyps; Colorectal neoplastic lesions; Endoscopic resection
23.  A retrospective study of patients with colorectal polyps 
The aim of this study was to report the anatomical location and histologic type of colorectal polyps in a large series of Iranian patients that attended for colonoscopy.
Polyps that develop through the adenoma-carcinoma pathway are considered neoplastic and may eventually progress to invasive carcinomas. In addition polyps can develop with no neoplastic potential. These neoplastic and non-neoplastic polyps can be identified and removed at colonoscopy.
Patients and methods
In this retrospective study, the medical records of patients who had attended for colonoscopy were reviewed. Patient demographics and colonoscopy findings were reviewed. The anatomical location, macroscopic appearance and histological assessment of any polyps were recorded.
716 patients’ records were reviewed. 437 patients (61 %) were male and 279(39%) were females. The mean patient age was 55.3 yr (18-89 yr). A total of 936 polyps were identified. 779 (83.3%) were neoplastic and 157(16.7%) polyps were non-neoplastic.727 of the polyps were adenomatous. Of the 727 adenomatous polyps: 198(27.2%) were in sigmoid, 156(21.24%) were in caecum and ascending colon, 153(21%) were in descending colon, 131(18%) were in transverse colon and 89(12.3%) were in rectum. 39.5% of adenomas were proximal to the splenic flexure. Carcinoma was observed in 52 cases. 18 carcinomas (34.5%) were left sided and 34 (65.5% of carcinomas) were right sided. Of the 716 patients, 179 patients (25%) had synchronous lesion(s).
A significant number of adenomas and carcinomas lie proximal to the splenic flexure and occur in the absence of distal lesions. These lesions would be missed if the distal colon was examined and the entire colon examined only if a distal lesion was identified.
PMCID: PMC4017400  PMID: 24834150
Colorectal cancer; Screening; Colonoscopy
24.  Adiposity factors are not related to the presence of colorectal adenomas 
Adiposity has been thought to be related to colorectal carcinogenesis. The aim of this study was to explore any association between obesity factors and the presence of colorectal adenoma, a potential precancerous lesion.
Patients and methods
Two hundred and six consecutive patients undergoing colonoscopy without colorectal cancer were enrolled in the study. Anthropometric measures and other adiposity-related laboratory variables including insulin resistance and serum adiponectin levels were recorded and correlated with the presence of adenoma.
Colorectal adenoma was detected in 68/206 patients (33%), tubular adenoma(s) in 38 patients, and tubulovillous or villous in 30 patients. Twenty-one patients (10.2%) had at least one proximal polyp. The size of the largest adenoma was ≤10 mm in 40 patients and >10 mm in 28 patients. No statistically significant difference was observed in body mass index, waist circumference, fasting plasma glucose concentration, insulin, homeostatic metabolic assessment, cholesterol, low-density lipoproteins, high-density lipoprotein, or triglycerides between patients with and without adenoma. In addition, there was no difference in plasma adiponectin between patients with adenoma (11.1 ± 6 μg/mL) and controls (10.2 ± 7.8 μg/mL). Furthermore, no significant difference in any parameter was found between patients with advanced adenoma and no advanced adenoma, nor between patients with proximal or distal tumors.
This study found that the presence of colorectal adenoma is not correlated with any adiposity factor. Moreover, obesity does not appear to be associated with the site or the presence of more advanced lesions.
PMCID: PMC3234123  PMID: 22162929
adiposity; colorectal adenoma; polyp; adiponectin
25.  Colonic Adenoma Risk in Familial Colorectal Cancer – a Study of Six Extended Kindreds 
Most colorectal cancers arise from adenomatous polyps, but the effects of colorectal cancer family history on adenoma risk are not well known. This issue is clinically relevant since several medical societies currently recommend earlier and more rigorous colorectal screening for individuals with a strong family history of colorectal cancer.
Colonoscopies were performed in 236 first-, second-, and third- degree relatives of 40 index colorectal cancer cases from 6 large kindreds selected from a large population database. The kindreds were selected for significantly increased risk of colorectal cancers compared with the overall population. Known hereditary colon cancer syndromes were clinically and genetically excluded.
37% of relatives were found to have adenomas on colonoscopy. The average age of diagnosis for colon cancer was 63 years and advanced adenomas 56 years. Independent predictors of adenomatous polyps in the relatives were advancing age (p<0.0001), male gender (p<0.001), and greater degree of relation to colorectal cancer cases (p<0.01). There was no significant predilection of colorectal tumors for the right or left colon. A higher degree of relationship to CRC cases was a significant predictor of having simple and advanced adenomas, but not hyperplastic polyps after adjustment for age and gender.
These data support the current recommendations for colonoscopy starting before the age of 50 years in individuals with a strong family history of colorectal cancer.
PMCID: PMC2922112  PMID: 18671820

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