polipos colonicos complejosgastroenterologia.blogs.hospitalelcruce.org/files/2017/... · 2017. 4....
TRANSCRIPT
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POLIPOS COLONICOS COMPLEJOS
Dr. De Maria Julio
Gastroenterología
Hospital El Cruce
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PACIENTE DE SEXO MASCULINO 58 AñOS DE EDAD SIN ANTECEDENTES DE IMPORTANCIA COLONOSCOPIA
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SE PROGRESA HASTA CIEGO OBSERVANDO EN CIEGO LESION ELEVADA GRANULAR TIPO LST QUE ABARCA LA MITAD DE LA CIRCUNFERENCIA CON ZONAS QUE IMPRESIONAN DEPRIMIDAS DE UN TAMAÑO APROXIMADO DE MAS DE 6 CM. IMPRESIONA COMPROMETER VALVULA ILEOCECAL. BIOPSIAS.
Conclusión: LESION LST . BIOPSIAS. CLASIFICACION DE PARIS IIa
HALLAZGOS HISTOPATOLÓGICOS COMPATIBLES CON DISPLASIA DE ALTO GRADO (SEVERA).
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• Preguntas
• Conducta
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Cirugia vs EMR
• Cirugia • Previene riesgo de recurrencia
• Expone al paciente a riesgo incluyendo mortalidad y morbilidad
• EMR• Eficacia
• Seguridad
• Costo- efectividad
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Eficacia
Seguridad
Costo-efectividad
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Endoscopic snare excision of giant colorectal disease
n= 176 polyps > 3cm, 129 sessile 47 pediculados
• sangrado en 24%; no perforación
58 durante el procedimiento tratado en el mismo
3 post procedimiento inmediato
6 tardio 5 tto endoscópico 1 tto conservador
• Coexistencia de malignidad en 12%
• Recurrencia 16% (19/117) 18 tratados exitosamente
Binmoeller, Soehendra GIE 1996
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Practice guidelinesPolyp guideline diagnosis, treatment and surveillance for patients with colorectal
polyps
For technical reasons, many large sessilepolyps (>2 cm) cannot be completely or safely excised during colonoscopy, and the patient should be referred for primary surgical Resection
Large polyps + 2 cm usually contain villous tissue with hight malignant potential , tend to recur after resection
AJG 20003
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GIE 2014
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EMR should be the first-line treatment for large laterally spreading colorectal lesions
GIE 2016Outcome of EMR as an alternative to surgery
in patients with complex colon polyps
Raju , GIE 2016
RME RECURRENCIA DE 5% 203 CASOS EVENTOS ADVERSOS 5% SIN MUERTE LA CIRUGIA TIENE MORTALIDAD 4,4% EVENTOS DE CIRUGIA 24% Y MRE 7% SANGRADO7600 DIFEREENCIA DE COSTOS ESTADIA HOSPITAL 2,8 A FAVOR DE RME ESD RECURRENCIA 3 % CURVA LARGA PERFORACION 5% LOS MAS FAVORECIDOS ES EL GRUPO T1
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• Clin Colon Rectal Surg. 2015 Dec;28(4):215-9. doi: 10.1055/s-0035-1564434.
• Management of Malignant Adenomas.
• Hall JF1.
• Author information
• Abstract
• Most polyps that originate in the colon and rectum are benign. A small subset of polyps will contain a malignancy. Although most malignant adenomas are managed with colonic resection a number can be approached with endoscopic, minimally invasive, and observational techniques. This article reviews the histologic characteristics and adverse risk factors that would portend a poor oncologic outcome and therefore suggest formal colonic resection. Modern endoscopic techniques such as endoscopic mucosal resection and endoscopic submucosal resection are discussed.
• KEYWORDS:
• Haggitt criteria; adenoma; endoscopic mucosal resection; endoscopic submucosal resection; malignancy; polypectomy
• PMID: 26664328 PMCID: PMC4654623 [Available on 2016-12-01] DOI: 10.1055/s-0035-1564434
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Cirugía
PIEZA DE COLECTOMÍA DERECHA: ADENOMA TUBULO VELLOSO CON DISPLASIA EPITELIAL DE ALTO GRADO. AUSENCIA DE COMPROMISO DE LA MUSCULAR DE LA MUCOSAE. MUCOSA COLINDANTE CON SIGNOS DE DISPLASIA DE BAJO GRADO Y MODERADA INFLAMACIÓN CRÓNICA.MÁRGENES QUIRÚRGICOS LIBRES DE LESIÓN. GANGLIOS LINFÁTICOS LIBRE DE LESIÓN. NEGATIVOS (0/7).SEGMENTO DE INTESTINO DELGADO CON DENSO INFILTRADO INFLAMATORIO EN MUCOSA Y ESFACELO PARCIAL DEL EPITELIO DE SUPERFICIE. HIPERPLASIA FOLICULAR LINFOIDE DE MUCOSA INTESTINO DELGADO.MÁRGENES QUIRÚRGICOS LIBRES DE LESIÓN.
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Pólipos colon complejos
• Lesiones planas o polipoides de mas de 2 cm
• Pólipos localizados cerca del orificio apendicular
• Pólipos sobre la válvula ileocecal
• Pólipos sobre la línea dentada
• Pólipos sobre un pliegue
• Pólipos con resección previa incompleta
Estos son desafiantes para los endoscopistas para resecar completamente y en forma segura y tienen mas riesgo de ca colorectal Cirugía previene la recurrencia pero expone a mas morbilidad y mortalidad
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Endoscopic snare excision of giant colorectal disease
n= 176 polyps > 3cm, 129 sessile 47 pediculados
• sangrado en 24%; no perforación
58 durante el procedimiento tratado en el mismo
3 post procedimiento inmediato
6 tardio 5 tto endoscópico 1 tto conservador
• Coexistencia de malignidad en 12%
• Recurrencia 16% (19/117) 18 tratados exitosamente
Binmoeller, Soehendra GIE 1996
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Practice guidelinesPolyp guideline diagnosis, treatment and surveillance for patients with colorectal
polyps
For technical reasons, many large sessilepolyps (>2 cm) cannot be completely or safely excised during colonoscopy, and the patient should be referred for primary surgical Resection
Large polyps + 2 cm usually contain villous tissue with hight malignant potential , tend to recur after resection
AJG 20003
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50 ESTUDIOS 6442 PACIENTES
CIRUGIA PARA RESECCIONES NO CURATIVAS 503/6442 8%
CANCER INVASOR 310/6442 5%
Gut. 2016 May;65(5):806-20. doi: 10.1136/gutjnl-2014-308481. Epub 2015 Feb 13.
Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis.Hassan C1, Repici A2, Sharma P3, Correale L4, Zullo A1, Bretthauer M5, Senore C6, Spada C7, Bellisario C8, Bhandari P9, Rex DK9.
Mortality related with management of large polyps was reported in 5/6278 cases
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Evaluacion polipo
• Pit patron
• Clasificacion de Paris
• Granular vs no granular
Evaluar paciente y riesgo edad, comorbilidades, condición física y medicaciones
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Pit patrón
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Clasificacion de Paris
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Granular vs no granular
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Resección de pólipos grandes Puntos de interés
Coexistencia de malignidad
Seguridad
Resección incompleta
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Coexistencia de malignidadCoexistencia de malignidad: relevante solo si hay invasión profunda
33- 50 % en los primeros estudios
Meta-analysis, 5 studies (n = 1213 pts)SM1 invasion -> 1.9% rate of LN metastasesSM2 14,6 %
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DISPLASIA VS CANCER
• Todos los adenomas tienen displasia
Bajo grado vs alto grado
Carcinoma in situ, carcinoma intramucoso HGD
• Cáncer: invasión de elementos displasicos en la submucosa
• Por que esta definición? No hay linfáticos en la mucosa
• Lesiones ubicadas en la mucosa no tienen chances de metástasis
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Profundidad de invasión
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Profundidad de invasión
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NO LIFTING
12/205 no lifting 83% ca invasorPositive NLS > invasive cancer into SM
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“Non-lifting sign”
Conventional endoscopic features are not sufficient to differentiate small, early colorectal cancerWan Park, Bun Kim, [...], and Sung Pil Hong.World J Gastroenterol 2014 June 7; 20(21): 6586-6593
morphological features and non-lifting sign for submucosal cancer.
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Signo no lifting No siempre confiable
False-positives:
> prior attempt at resection ,Inyeccion , Tatoo(Friedland, Diag Ther Endosc 2013)
> prior biopsies (Hans, GIE 2007)
False-negatives:
10/26 lesions (38%) invading SM2 lifted(Kobayashi, Endoscopy 2007)
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El intento previo produce NLS
199 pólipos 30 con NLS 15 %
26 de estos intervención previa
• 65 % resección parcial
• 15 % tatoo en base
• 12 % biopsias solo
4 sin intento previo: 50% ca invasor
24/26 resecados 21 requirieron APC para resección completa
26 % adenoma residual
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Inyeccion submucosa .Porque
• Seguridad durante la resección
• Disminuye riesgo de perforación
• Disminuye riesgo de injuria térmica transmural
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Inyección submucosa RME
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Inyección SM puede aumentar el riesgo en la EMR
• Injection into layer between the circ. and long.
> raise circular muscle
> may result in snare capture of muscle
• Injection outside the serosa
> local peritonitis, infection
serosa
Muscular longit
submucosa
Muscular circular
Muscularis mucosae
Mucosa
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Resección incompleta(recurrencia)
MOSS GASTRO 2011
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Recurrencia post EMRLarge polyps, 14 studies, mean = 26%Gastrointest Endosc. 2009 Dec;70(6):1128-36. doi:
10.1016/j.gie.2009.05.039. Epub 2009 Sep 12.
Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos).
Swan MP1, Bourke MJ, Alexander S, Moss A, Williams SJ.
193 difficult polyps (186 laterally spreading, mean size 30 mm [range 10-80 mm]).
173 laterally spreading lesions by EMR (115 piecemeal, 58 en bloc). Invasive adenocarcinoma was found in 6 lesions-5 treated successfully with EMR. Eleven patients were referred directly to surgery without an endoscopic attempt due to suspected invasive carcinoma. Seven >30-mm, pedunculated polyps were removed
Khashab et al, GIE 2009
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14 estudios
1622 polipos grandes
Tasa de adenoma residual 26%
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Estudio CARE 11 endoscopists at 2 centers
• Prospective study • n=346 neoplastic polyps (211 pts)
• 7%- 23%incompletely resected15
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Prior ablation: risk factor for recurrence
N =479 sessile polyps > 2cm
Uso de argon plasma
Odds ratio 3.51 ic 95% 1.69 7.27 p .001
Moss et al, Gastro 2011
. (A) jet sign, where the fluid sprays back into the lumen at high pressure as it is injected. Submucosal fibrosis has obliterated the submucosal space, resulting in the jet sign, and nonlifting of the lesion. (B and C) Submucosal fibrosis is visible endoscopically during EMR. The white tissue bands are fibrotic deposits caused by electrocautery during the previous resection. (D) Fibrosis is visible histologically with H&E staining of the EMR specimen.
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Intento previo resección :factor de riesgo para recurrencia
N = 479 sessile polyps > 2cm
Invasion SM 30/514 6 %
II A + C 32 %
No granular 15 %
Kudo V 56 %
II A + C no granular 46 %
II A + C no granular Kudo V 56 %
II A granular 1,4 %
Intervención previa 3.75 1.77 7.94 p .001
F Moss et al, Gastro 2011
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Otras causas de fibrosis submucosa
In multivariate analysis, prior biopsy sampling was an independent predictor for inability to perform complete resection without ablation of visible residual (odds ratio .24, P < .05) and for recurrence (odds ratio 11.5, P = .004) compared with nonmanipulated lesions. Prior advanced manipulation was an independent predictor for inability to perform en-bloc resection (odds ratio .024, P = .001), for inability to perform complete resection without ablation of visible residual (odds ratio .081, P < .001), and for recurrence (odds ratio 18.8, P = .001).
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Porque el intento previo disminuye el exito
Otras causas de fibrosis submucosa
Study retrospective 132 pólipos + 2 cm
Resección blocNo manipulación n 46 35%
Bx n 44 16 %
Manipulación previa n 42 5%
ResidualNo manipulación n 46 8%
Bx n 44 41%
Manipulación previa n 42 54 %
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Inconvenientes de SM inyección
Puede hacer difícil la captura con asa
Aumenta la tensión del tejido submucoso
Flattening paradoxical del pólipo
Disminución de la luz con distorsión anatómica y desplazamiento del pólipo
Sangrado mucosa Inyecciones repetidos Costo- tiempo
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Underwater EMR without submucosa inyecction for large
sesile colorectal polyps
60 ptes con 62 pólipos media 34 mm
Resección media tiempo 18 min
62/62 clínicamente exitosa
3 ptes 5% sangrado
Follow up colonoscopia 54 ptes
90% 1 con adenoma residual 1,9%
En bloc: 55%; Complication: 4% (1 delayed bleed, 1 abd pain); Incomplete: 5%GIE 2015
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Puntos claves
• Excluir malignidad e invasión profunda con imágenes mejorada.
• Una oportunidad para curar
• Intento de extracción en bloque
• Resecar y retirar no ablacionar
• Seguir de cerca el sitio de la cicatriz de biopsia
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• El tamaño no importa . Clasificación de Paris, granular – no granular y el patrón Pit de Kudo predicen la invasión submucosa.
• Todos los adenomas sin invasión submucosa deberían ser resecados endoscópicamente
• Conocer sus limitaciones referir en forma temprana si no es capaz de resecarlo en el primer intento