Brian P Saunders

Imperial College London, Londinium, England, United Kingdom

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Publications (118)682.91 Total impact

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    ABSTRACT: Introduction The prevalence of multifocal neoplasia and interval cancer in patients with ulcerative colitis (UC) is unclear. Furthermore, there is a continuing debate on the change in colorectal cancer (CRC) incidence over time and the risk of progression from each grade of dysplasia to CRC. This study reports on data collected from patients with extensive UC between 1971 and 2012 at a large tertiary center in the UK, with an aim to answer these important questions. Methods A retrospective analysis of UC patients enrolled in long-term surveillance was performed. Data were obtained from medical records, surgical, endoscopy and histology reports. The primary end point was defined as death, colectomy, withdrawal from surveillance, or the census date (January 1, 2013). Raised dysplastic lesions arising within a diseased segment were classified as sporadic adenoma or UC-associated dysplasia according to the clinical consensus made at the time of diagnosis. Cox proportional hazards models and Kaplan-Meier curves were used to assess the risk of cancer progression. Results A total of 1,375 patients underwent 8,650 colonoscopies (median, 5 per patient; interquartile range (IQR), 3 – 8 per patient) during 17,138 patient-years of follow-up (median, 11 years; IQR, 7 – 17 years). Colorectal cancer was detected in 72 patients (5% of study population), of which 45.8% were interval cancers. Out of 64 CRCs where a surgical specimen was available, 24 (37.5%) had synchronous cancers or a spatially distinct focus of dysplasia. The cumulative incidence of CRC by disease duration was 0.07% at 10 years, 2.9% at 20 years, 6.7% at 30 years and 10% at 40 years. Linear regression revealed no significant change in the overall incidence of CRC during the four decades of the surveillance program (R = -0.13; p=0.42). However, there was a significant reduction in incidence of colectomy performed for dysplasia or CRC over time (R = -0.43; p=0.007). The risk of developing CRC for each type of neoplasia compared with patients with no neoplasia was: sporadic adenoma (hazard ratio (HR), 0.50; 95% confidence interval (CI), 0.15 – 1.64; p=0.25), indefinite for dysplasia (HR, 6.1; 95% CI, 1.7–21.5; p=0.005), low-grade dysplasia (HR, 7.8; 95% CI 2.4–25.7; p<0.001), and high-grade dysplasia (HR, 33.1; 95% CI, 9.7–112.9; p<0.001). There was no significant difference in the risk of CRC between indefinite for dysplasia and low-grade dysplasia group (log-rank; p=0.786). Conclusion The overall risk of CRC was considerably lower than previously reported. However, there was no significant change in CRC incidence over time. Multifocal neoplasia and interval cancer was common, highlighting the importance of careful inspection with advanced imaging technologies to ensure no lesions are missed. Patients with indefinite dysplasia should be regarded as a significant-risk, and carefully monitored.
    United European Gastroenterology Week, Vienna; 10/2014
  • United European Gastroenterology Week, Vienna, Austria; 10/2014
  • United European Gastroenterology Week; 10/2014
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    ABSTRACT: This Position Paper is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of iatrogenic perforation occurring during diagnostic or therapeutic digestive endoscopic procedures. Main recommendations 1 ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforation, including the definition of procedures that carry a high risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 In the case of an endoscopically identified perforation, ESGE recommends that the endoscopist reports: its size and location with a picture; endoscopic treatment that might have been possible; whether carbon dioxide or air was used for insufflation; and the standard report information. 3 ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be carefully evaluated and documented, possibly with a computed tomography (CT) scan, in order to prevent any diagnostic delay. 4 ESGE recommends that endoscopic closure should be considered depending on the type of perforation, its size, and the endoscopist expertise available at the center. A switch to carbon dioxide insufflation, the diversion of luminal content, and decompression of tension pneumoperitoneum or tension pneumothorax should also be done. 5 After closure of an iatrogenic perforation using an endoscopic method, ESGE recommends that further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of the iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
    Endoscopy 07/2014; · 5.74 Impact Factor
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    ABSTRACT: Piecemeal endoscopic mucosal resection (pEMR) is a minimally invasive endoscopic technique for the resection of sessile/flat colorectal polyps (larger than 2 cm). It has been suggested that patients should have a check procedure at 3 or 6 months to ensure complete initial excision of the lesion, and subsequent colonoscopic surveillance at between 1 and 3 years to identify recurrence.
    Gut 06/2014; 63(Suppl 1):A143-A144. · 10.73 Impact Factor
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    ABSTRACT: The presence of multiple (5-100) colorectal adenomas suggests an inherited predisposition, but the genetic aetiology of this phenotype is undetermined if patients test negative for Mendelian polyposis syndromes such as familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP). We investigated whether 18 common colorectal cancer (CRC) predisposition single-nucleotide polymorphisms (SNPs) could help to explain some cases with multiple adenomas who phenocopied FAP or MAP, but had no pathogenic APC or MUTYH variant. No multiple adenoma case had an outlying number of CRC SNP risk alleles, but multiple adenoma patients did have a significantly higher number of risk alleles than population controls (P=5.7 × 10(-7)). The association was stronger in those with ≥10 adenomas. The CRC SNPs accounted for 4.3% of the variation in multiple adenoma risk, with three SNPs (rs6983267, rs10795668, rs3802842) explaining 3.0% of the variation. In FAP patients, the CRC risk score did not differ significantly from the controls, as we expected given the overwhelming effect of pathogenic germline APC variants on the phenotype of these cases. More unexpectedly, we found no evidence that the CRC SNPs act as modifier genes for the number of colorectal adenomas in FAP patients. In conclusion, common colorectal tumour risk alleles contribute to the development of multiple adenomas in patients without pathogenic germline APC or MUTYH variants. This phenotype may have 'polygenic' or monogenic origins. The risk of CRC in relatives of multiple adenoma cases is probably much lower for cases with polygenic disease, and this should be taken into account when counselling such patients.European Journal of Human Genetics advance online publication, 7 May 2014; doi:10.1038/ejhg.2014.74.
    European journal of human genetics: EJHG 05/2014; · 3.56 Impact Factor
  • Digestive Disease Week, Chicago; 05/2014
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    ABSTRACT: Background Until recently a finding of dysplasia arising within segment of bowel affected by ulcerative colitis (UC) was an indication for colectomy. However, some dysplastic lesions are discrete and endoscopically resectable. Long-term follow-up data for these selected patients is currently limited. The aim of this study was to evaluate the long term outcomes of patients with UC who have had an endoscopic resection of dysplasia within segment of bowel affected by colitis. Methods Patients who had a surveillance colonoscopy for UC at St Mark's Hospital between 1998 and 2008 and had an endoscopic resection of dysplastic lesions were identified from the endoscopic and histology databases. Clinical notes, endoscopy and histopathology reports were reviewed. Results One hundred patients met the inclusion criteria (male: female = 66: 34). Eighty-seven had extensive and 13 left-sided colitis, with median disease duration of 24 (IQR 13–33). The median age at disease onset and time of dysplasia diagnosis was 34 (IQR 27–48) and 61 (IQR 54–69) years old, respectively. There were 121 discrete lesions in 100 patients (Ip (60), Is (36), IIa (3), IIb (4), IIa/c (1), LST (1), and 16 were described as “appearance suspicious for DALM (Paris classification not recorded)” but which were also resected endoscopically. Median size was 8 mm (IQR 4–15). Lesions were removed using snare polypectomy (43), EMR (29), hot biopsy (20) or ESD (3) techniques. Histology showed LGD in 111 lesions and HGD in 10 lesions: 36 (30%) favoured UC-associated dysplasia, 56 (46%) favoured adenoma, and 29 (24%) lesions were inconclusive between dysplasia and adenoma. Median duration of follow up was 70 months (IQR 53–89). Overall, two cancers were detected during that time: one in same and one in distant segment to the previous dysplasia. The proportion of patients who developed dysplasia recurrence was 24% with median duration to recurrence of 41 months (IQR=16–55). Nineteen patients (19%) had recurrence to the same grade of dysplasia that was initially treated: three patients had colectomy (2 LGDs and 1 with no dysplasia), two patients died from unrelated cause, and 14 patients are still on endoscopic follow-up. Four patients (4%) have progressed from LGD to HGD which were all detected during surveillance: three patients had colectomy (Duke's A CRC, LGD, and indeterminate dysplasia, respectively), and one patient refused surgery whose latest colonoscopy showed LGD. One patient was lost in follow up for 5 years and subsequent colonoscopy detected Duke's C cancer. Conclusion Patients with endoscopically resectable, well circumscribed dysplastic lesions within the segment of colitis have a good outcome with endoscopic treatment with close surveillance.
    European Crohn's Colitis Organisation, Copenhagen; 02/2014
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    ABSTRACT: Background While it is well recognised that patients with ulcerative colitis (UC) have an increased risk of colorectal cancer (CRC), the precise magnitude and the proportion of patients progressing to CRC from pre-malignant neoplastic lesions is still being debated. This study reports on data collected from patients with endoscopically and histologically confirmed extensive UC over a 40-year period from a tertiary centre in the UK. Methods A retrospective analysis of UC patients enrolled in long-term surveillance at St Marks Hospital, UK was performed. Data were obtained from the prospective surveillance database, medical records, surgical, endoscopy and histology reports. The primary end point was defined as death, colectomy, withdrawal from surveillance, or census date (January 1, 2013). Results Since 1971, a total of 1,375 patients underwent 8,623 (median = 5, IQR 3–8) colonoscopies during 17,444 patient-years of follow up. The median follow up duration was 10 years (IQR 6–15 years), and 857 patients were still on the surveillance program as of January 1, 2013. Median age of UC onset was 30 years (IQR 22–40). A total of 318 (23.1%) patients developed neoplasia of which 69 (5%) had CRC. The proportion of patients who had progressed to CRC for each type of neoplasia during surveillance was: adenoma (3/79, 3.8%), indefinite dysplasia (12/49, 24.5%), LGD (19/131, 14.5%), and HGD (8/27, 30%). Median age and disease duration at the time of CRC diagnosis was 55 years (IQR 49–63) and 22 years (IQR 14–29), respectively. The locations of CRCs were: distal to splenic flexure (40, 58%), proximal to splenic flexure (24, 35%), multifocal CRC involving both proximal and distal colon (3, 4%), or unidentified (2, 3%). Surgical specimen revealed that 21 (30%) of CRCs were accompanied by at least one or more focus of DALM, of which 6 (8.4%) were multi-focal CRCs affecting two or more segments of colorectum. Within surveillance, the cumulative incidence of CRC by disease duration was 0.2% at 10 years, 2.6% at 20 years, 7.3% at 30 years, 10.1% at 40 years and 13.1% at 50 years. Conclusion The overall incidence of CRC, even among patients with extensive UC at the tertiary referral centre, was considerably lower than reports from other earlier published studies. However, neoplasia in any form (i.e. adenoma, LGD, HGD, or CRC) was common, eventually affecting almost 1 in 4 patients undergoing surveillance. Given the variable rates of progression from dysplasia to CRC and relatively high incidence of multifocal lesions, patients with any grade of dysplasia require close monitoring and a careful pan-colonic examination to ensure that no lesions are missed.
    European Crohn's Colitis Organisation, Copenhagen; 02/2014
  • Gastroenterology 01/2014; 146(5):S-118. · 12.82 Impact Factor
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    ABSTRACT: Serrated polyposis is a condition of the colon characterised by multiple serrated polyps. This review aims to provide a practical guide to the day-to-day management of serrated polyposis including diagnosis, endoscopic identification of serrated polyps, surveillance, the role of endoscopic and surgical management and screening of family members. The literature was searched using Pubmed and Medline databases for the terms "serrated polyp, serrated polyposis, hyperplastic polyposis". English language abstracts were read and the full article was retrieved if relevant to the review. Expert opinion from the authors was also sort. Advances in our knowledge of the molecular pathways involved in serrated polyposis and an improved clinical picture of the disease from retrospective studies have led to better understanding of its pathogenesis and natural history. However there are still areas not answered by the literature, and hence empirical management or expert opinion has to be followed. Improvements in our understanding of serrated polyposis together with improvements in endoscopic equipment and technique have enabled the endoscopist to be at the forefront of managing this condition from diagnosis to endoscopic surveillance and control of the polyps. This article is protected by copyright. All rights reserved.
    Colorectal Disease 11/2013; · 2.08 Impact Factor
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    ABSTRACT: Measuring quality is a current need of medical services either to assess their cost-effectiveness or to identify discrepancies requiring refinement. With the advent of bowel cancer screening and increasing patient awareness of bowel symptoms, there has been an unprecedented increase in demand for colonoscopy. Consequently, there is an expanding open-discussion on missed rates of cancer or precancerous polyps during diagnostic/screening colonoscopy and on the rate of adverse events related to therapeutic colonoscopy. Delivering a quality colonoscopy service is therefore a healthcare priority. Colonoscopy is a multi-step process and therefore assessment of all aspects of the procedure must be addressed. Quality in colonoscopy refers to a combination of many patient-centered technical and non-technical skills and knowledge aiming to patient's safety and satisfaction through a continuous effort for improvement. The benefits of this endless process are hiding behind small details which can eventually make the difference in colonoscopy. Identifying specific quality metrics help to define and shape an optimal service and forms a secure basis of improvement. Τhis paper does not aim to give technical details on how to perform colonoscopy but to summarize what to measure and when, in accordance with the current identified quality indicators and standards for colonoscopy.
    World journal of gastrointestinal endoscopy. 10/2013; 5(10):468-75.
  • Gastroenterology 09/2013; · 12.82 Impact Factor
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    ABSTRACT: Diverticular disease (DD) and colonic cancer share common epidemiological characteristics, similar aetiological dietary factors and may present with bleeding.(1) The incidence of both disease entities has increased in parallel over the course of the last century. Additionally, DD of the colon is rare in developing populations where there is also a low incidence of colonic cancer.The association of DD and colonic cancer is unclear and not evidence based, although certain retrospective studies suggest a causal relationship between DD and left sided colorectal cancer.(2) This article is protected by copyright. All rights reserved.
    Colorectal Disease 08/2013; · 2.08 Impact Factor
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    ABSTRACT: A simple endoscopic classification to accurately predict deep submucosal invasive (SM-d) carcinoma would be clinically useful. To develop and assess the validity of the NBI international colorectal endoscopic (NICE) classification for the characterization of SM-d carcinoma. The study was conducted in 4 phases: (1) evaluation of endoscopic differentiation by NBI-experienced colonoscopists; (2) extension of the NICE classification to incorporate SM-d (type 3) by using a modified Delphi method; (3) prospective validation of the individual criteria by inexperienced participants, by using high-definition still images without magnification of known histology; and (4) prospective validation of the individual criteria and overall classification by inexperienced participants after training. Japanese academic unit. Performance characteristics of the NICE criteria (phase 3) and overall classification (phase 4) for SM-d carcinoma; sensitivity, specificity, predictive values, and accuracy. We expanded the NICE classification for the endoscopic diagnosis of SM-d carcinoma (type 3) and established the predictive validity of its individual components. The negative predictive values of the individual criteria for diagnosis of SM-d carcinoma were 76.2% (color), 88.5% (vessels), and 79.1% (surface pattern). When any 1 of the 3 SM-d criteria was present, the sensitivity was 94.9%, and the negative predictive value was 95.9%. The overall sensitivity and negative predictive value of a global, high-confidence prediction of SM-d carcinoma was 92%. Interobserver agreement for an overall SM-d carcinoma prediction was substantial (kappa 0.70). Single Japanese center, use of still images without prospective clinical evaluation. The NICE classification is a valid tool for predicting SM-d carcinomas in colorectal tumors.
    Gastrointestinal endoscopy 07/2013; · 6.71 Impact Factor
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    Gut 06/2013; 77(5):AB132–AB133. · 10.73 Impact Factor
  • Gut 06/2013; 62(Suppl 1):A277. · 10.73 Impact Factor
  • Gareth Horgan, James E. East, Brian P. Saunders
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    ABSTRACT: Malignant polyps are now being encountered more frequently because of increased colorectal cancer screening. Endoscopy offers a minimally invasive option for treating some malignant polyps thus reducing surgical morbidity and mortality. This chapter reviews the endoscopic assessment of colorectal polypoid lesions and risk stratification using gross polyp morphology (Paris classification), lesion surface appearance (Kudo pit pattern and mucosal microvessel appearance, via high-magnification chromoendoscopy and narrow-band imaging), and by the lesion's lifting characteristics (“nonlifting sign”). In combination, these features allow an assessment of the potential for malignancy as well as the likely depth of submucosal invasion, so as to guide appropriate management. We also consider possible adjunct assessment modalities, such as endoscopic ultrasound, and discuss postpolypectomy histologic classification, including Haggitt staging for pedunculated lesions and Kikuchi staging for sessile lesions or laterally spreading tumors. Finally, we describe endoscopic resection techniques for removal of malignant polyps, including endoscopic mucosal resection and endoscopic submucosal dissection, and compare these with surgical management options.
    Techniques in Gastrointestinal Endoscopy 04/2013; 15(2):106–112.
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    ABSTRACT: Background and aim: This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy. Methods: This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence. Results: The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).
    Endoscopy 01/2013; · 5.74 Impact Factor
  • Zacharias P Tsiamoulos, Brian P Saunders
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    ABSTRACT: Difficult and unstable endoscopic access to large sessile/flat colon polyps in the sigmoid colon may prevent successful and complete EMR. We report our experience with the use of an endoscopic cuff, a new endoscopic accessory, to improve endoscopic access during endoscopic therapy and scar assessment. Single-center, retrospective, feasibility case series. Tertiary referral academic endoscopy unit. Nonconsecutive patients referred for endoscopic resection of large flat/sessile sigmoid colon polyps or surveillance of postpolypectomy scars in the sigmoid colon. When conventional methods to achieve stable access and visualization were unsuccessful, the endoscopic cuff was used to retract sigmoid colon folds. Safety, procedural success, and complications. Five patients (mean age 62 years, 3 male/2 female) underwent endoscopic cuff-assisted EMR polypectomy, and 7 patients (mean age 62 years, 2 male/5 female) underwent post-EMR scar surveillance with an endoscopic cuff-assisted flexible sigmoidoscopy. All sessile/flat polyps (mean size 29 mm) or post-EMR scar sites (mean size 15 mm) were located at acute bends in the sigmoid colon. With the endoscopic cuff placed around the tip of the colonoscope, endoscopic access improved significantly by flattening/depressing colon folds close to the lesion/scar. The entire polyp/scar surface was revealed, facilitating a complete polyp excision and a meticulous scar assessment. No immediate or delayed adverse events were seen. Single-center, nonrandomized case series. An endoscopic cuff appears to be a safe and easily used accessory to facilitate colonoscopic access for complex polypectomy and scar assessment in the sigmoid colon.
    Gastrointestinal endoscopy 12/2012; 76(6):1242-5. · 6.71 Impact Factor

Publication Stats

3k Citations
682.91 Total Impact Points

Institutions

  • 2008–2014
    • Imperial College London
      • Section of Biosurgery and Surgical Technology
      Londinium, England, United Kingdom
  • 2002–2014
    • St. Mark's Hospital
      Harrow, England, United Kingdom
  • 2007–2008
    • St. Mark's Hospital
      Salt Lake City, Utah, United States
    • Lenox Hill Hospital
      New York City, New York, United States
  • 2004–2006
    • North Tees and Hartlepool NHS Foundation Trust
      Middlesborough, England, United Kingdom