Brian P. Saunders

Imperial College London, Londinium, England, United Kingdom

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Publications (180)1285.79 Total impact

  • Mayur Garg · Ana Wilson · Simon Gabe · Brian P Saunders · Siwan Thomas-Gibson

    No preview · Article · Dec 2015 · Endoscopy

  • No preview · Article · Nov 2015
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    ABSTRACT: OBJECTIVES: The aim of this study was to identify risk factors associated with development of high-grade dysplasia (HGD) or colorectal cancer (CRC) in ulcerative colitis (UC) patients diagnosed with low-grade dysplasia (LGD). METHODS: Patients with histologically confirmed extensive UC, who were diagnosed with LGD between 1993 and 2012 at St Mark’s Hospital, were identified and followed up to 1 July 2013. Demographic, endoscopic, and histological data were collected and correlated with the development of HGD or CRC. RESULTS: A total of 172 patients were followed for a median of 48 months from the date of initial LGD diagnosis (interquartile range (IQR), 15–87 months). Overall, 33 patients developed HGD or CRC (19.1% of study population; 20 CRCs) during study period. Multivariate Cox proportional hazard analysis revealed that macroscopically non-polypoid (hazard ratio (HR), 8.6; 95% confidence interval (CI), 3.0–24.8; P<0.001) or invisible (HR, 4.1; 95% CI, 1.3–13.4; P=0.02) dysplasia, dysplastic lesions ≥1 cm in size (HR, 3.8; 95% CI, 1.5–13.4; P=0.01), and a previous history of “indefinite for dysplasia” (HR, 2.8; 95% CI, 1.2–6.5; P=0.01) were significant contributory factors for HGD or CRC development. Multifocal dysplasia (HR, 3.9; 95% CI, 1.9–7.8; P<0.001), metachronous dysplasia (HR, 3.5; 95% CI, 1.6–7.5; P=0.001), or a colonic stricture (HR, 7.4; 95% CI, 2.5–22.1; P<0.001) showed only univariate correlation to development of HGD or CRC. CONCLUSIONS: Lesions that are non-polypoid or endoscopically invisible, large (≥1 cm), or preceded by indefinite dysplasia are independent risk factors for developing HGD or CRC in UC patients diagnosed with LGD.
    Full-text · Article · Sep 2015 · The American Journal of Gastroenterology
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    ABSTRACT: Background and study aims: Antispasmodics may improve mucosal visualization during colonoscope withdrawal, potentially improving polyp and adenoma detection. Meta-analysis and case-control studies suggest a 9 % to 13 % relative increase in adenoma and polyp detection. We aimed to assess the impact of hyoscine butylbromide on the expected visualization during colonoscope withdrawal using a CT colonography (CTC) simulation. Patients and methods: Datasets from a previous CTC study examining the effect of antispasmodic were re-analyzed with customised CTC software, adjusted to simulate a standard colonoscopic view. Eighty-six patients received intravenous (IV) hyoscine butylbromide 20 mg, 40 mg or no antispasmodic. Main outcome measurements at unidirectional flythrough, simulating colonoscope withdrawal, were percentage colonic surface visualization, numbers and sizes of unseen areas, and colonic length. Results: Use of antispasmodic was associated with a significant relative increase in percentage surface visualization of 2.6 % to 3.9 %, compared with no antispasmodic, P < 0.006. Total numbers of missed areas and intermediate sized (300 - 1000 mm(2)) missed areas were significantly decreased, by approximately 20 %. There were no differences between the 20-mg and 40-mg doses. Mean colonic length (161 - 169 cm) was unchanged by antispasmodic. Conclusions: IV hyoscine butylbromide at simulated colonoscope withdrawal was associated with significant increases in surface visualization, which might explain up to half the improvement in adenoma detection seen in clinical studies.
    No preview · Article · Sep 2015
  • Ana Wilson · Brian P Saunders

    No preview · Article · Sep 2015 · Gastrointestinal endoscopy
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    ABSTRACT: This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system 1 2 was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE recommends endoscopic en bloc resection for superficial esophageal squamous cell cancers (SCCs), excluding those with obvious submucosal involvement (strong recommendation, moderate quality evidence). Endoscopic mucosal resection (EMR) may be considered in such lesions when they are smaller than 10 mm if en bloc resection can be assured. However, ESGE recommends endoscopic submucosal dissection (ESD) as the first option, mainly to provide an en bloc resection with accurate pathology staging and to avoid missing important histological features (strong recommendation, moderate quality evidence). 2 ESGE recommends endoscopic resection with a curative intent for visible lesions in Barrett's esophagus (strong recommendation, moderate quality evidence). ESD has not been shown to be superior to EMR for excision of mucosal cancer, and for that reason EMR should be preferred. ESD may be considered in selected cases, such as lesions larger than 15 mm, poorly lifting tumors, and lesions at risk for submucosal invasion (strong recommendation, moderate quality evidence). 3 ESGE recommends endoscopic resection for the treatment of gastric superficial neoplastic lesions that possess a very low risk of lymph node metastasis (strong recommendation, high quality evidence). EMR is an acceptable option for lesions smaller than 10 - 15 mm with a very low probability of advanced histology (Paris 0-IIa). However, ESGE recommends ESD as treatment of choice for most gastric superficial neoplastic lesions (strong recommendation, moderate quality evidence). 4 ESGE states that the majority of colonic and rectal superficial lesions can be effectively removed in a curative way by standard polypectomy and/or by EMR (strong recommendation, moderate quality evidence). ESD can be considered for removal of colonic and rectal lesions with high suspicion of limited submucosal invasion that is based on two main criteria of depressed morphology and irregular or nongranular surface pattern, particularly if the lesions are larger than 20 mm; or ESD can be considered for colorectal lesions that otherwise cannot be optimally and radically removed by snare-based techniques (strong recommendation, moderate quality evidence). © Georg Thieme Verlag KG Stuttgart · New York.
    Full-text · Article · Sep 2015 · Endoscopy
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    ABSTRACT: Introduction Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic neoplasia. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity. This study examined the quality-of-life benefits and risks of local excision compared with results after colectomy, for low- and high-risk T1 colonic cancer. Method Decision analysis using a Markov simulation model was performed: patients were managed with either local excision (advanced therapeutic endoscopy) or colectomy. Lesions were considered high-risk according to accepted national guidelines. Probabilities and utilities were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients, with low- or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). Results In low-risk T1 colonic neoplasia, local excision increases QALE by 2.72 QALYS for fit 65-year olds (15.5% increase over surgery) and by 0.93 for unfit 80-year-olds (20.9% increase). For high-risk T1 cancers, the QALE benefit for local excision is 1.82 QALYs for fit 65-year-olds (10.5% improvement) and 0.82 for unfit 80-year-olds (18.6% improvement). In sensitivity analysis, colectomy was only preferred for 65-year-old patients, when risk of recurrence following local excision exceeded 17.3%. Conclusion Under a wide range of assumptions, for all patient cohorts, local excision is a reasonable treatment option for both low- and high-risk T1 colonic cancer. Exploration of methods to facilitate local excision of T1 colonic neoplasia appears warranted. Disclosure of interest None Declared.
    Full-text · Conference Paper · Jun 2015
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    ABSTRACT: These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Preview · Article · Jun 2015 · Gut

  • No preview · Article · Jun 2015 · Gut

  • No preview · Article · Jun 2015 · Gut
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    ABSTRACT: Introduction Colorectal cancer is preventable through polypectomy at colonoscopy. Most polyps are adenomas, with malignant potential, or hyperplastic with no malignant risk. Most adenomas are small (<10 mm) with minimal chance of harbouring cancer. Accurate optical diagnosis during colonoscopy would allow small adenomas to be removed and discarded and rectosigmoid hyperplastic polyps to be left in-situ. Narrow band imaging (NBI) in expert hands allows accurate optical diagnosis and assignment of surveillance intervals. Method The accuracy of surveillance interval assigned by NBI optical diagnosis was compared with the current reference standard of histopathological diagnosis in a prospective, blinded calibration study in 6 community hospitals in northeast England. Adults undergoing routine colonoscopy between July 2012 and February 2014 were eligible. Exclusion criteria were: inflammatory bowel disease; polyposis syndromes; pregnancy. Participating colonoscopists (n = 28) passed a validated training module utilising the NBI International Colorectal Endoscopic (NICE) classification. Optical diagnosis was provided for all polyps <10 mm and surveillance interval when only small polyps were present. Results Of 1688 patients recruited, 723 (42.8%) had polyps <10 mm of which 567 (78.4%) only had polyps <10 mm. The sensitivity, specificity and negative predictive value of optical diagnosis (n = 499 patients) in determining the need for colonoscopic surveillance were 73.0% (95% CI: 66.9–79.9%), 75.6% (95% CI: 70.9–80.1%) and 85.2% (95% CI: 81.0–89.1%). The sensitivity and specificity per polyp (n = 1620 polyps) was 76.1% and 77.5%. If ≥ 2 NICE features were identified, then sensitivity was 95–100%. Conclusion The findings of this study suggest that NBI optical diagnosis cannot yet be recommended for use in routine clinical practice. Sensitivity per polyp was acceptable when ≥2 NICE features were present. Further work is required to determine if variation is due to colonoscopist or polyp characteristics. Disclosure of interest None Declared.
    No preview · Article · Jun 2015 · Gut
  • N Ding · WM Yip · B Saunders · S Thomas-Gibson · A Humphries · A Hart
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    ABSTRACT: Introduction A clinically relevant stricture is usually defined as a luminal narrowing with pre-stenotic dilatation and obstructive symptoms. Surgical resection is an effective treatment for Crohn’s anastomotic strictures, however disease recurrence after 15 years is more than 50%, often with the need for a further resection.1The long-term outcome of endoscopic balloon dilatation is unclear as most cohorts have a follow-up time of less than 3 years. Method All endoscopic balloon dilatations performed at a single centre for patients with anastomotic Crohn’s strictures between 2004–2009 were retrospectively reviewed with the aim of collecting long-term follow up data. The stricture length, signs of disease activity and evidence of upstream dilatation were assessed from imaging. Clinical data on medical therapy and escalation to anti-TNF or thiopurines was obtained. Endoscopic data including disease activity, balloon size and therapeutic success, along with histological reports were recorded. Results A total of 54 patients were identified with a median age of 52 years (46–62). The median follow-up period was 6.48 years (5.34–7.42) with a disease duration of 28 years (19–32). Stricture length at cross-sectional imaging was described in all cases with a median of 20 mm (10–30) with features of active mucosal inflammation at the anastomosis in 38/54(70%) and upstream dilatation in 25/54(46%). At the time of endoscopy, active disease was described in 37/54(68%) of cases, a median balloon dilatation of 15 mmHg was used to achieve therapeutic success in 48/54 (89%). 10/54(18%) subsequently required surgical resection. The median number of dilatations was 2(1–9) with a time to repeat dilatation of 23 months (7.2–56.9) with 31/44 (70%) of patients being managed endoscopically requiring repeat dilatations. There was one perforation which resulted in a resection of the anastomosis and temporary ileostomy. Active disease at time of first endoscopy (p = 0.049) and stricture length >20 mm (p = 0.015) predicted need for repeat dilatations (Table 1). Furthermore, escalation of medical therapy to either azathioprine or anti-TNF appeared to delay time to further dilatation. Conclusion At long term follow-up, 18% of patients required surgical resection. 32% of patients were well with no further endoscopic intervention required. 68% required intercurrent endoscopic dilatations. This is the longest follow-up period in the literature and demonstrates that the effects can be durable if patients have escalation in medical therapy to thiopurine or anti-TNF and avoidance of surgery is possible in a group of patients with anastomotic strictures. Disclosure of interest None Declared. Reference
    No preview · Article · Jun 2015 · Gut

  • No preview · Article · May 2015 · Gastrointestinal Endoscopy
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    ABSTRACT: Introduction Colonic polyps deemed difficult to access or resect at endoscopy are often referred for surgical resection. We report our experience using laparoscopic assisted colonoscopic polyp resection at a single tertiary referral centre. Method Combined procedures from 2012 to 2014 for patients referred for resection of colonic polypsons deemed not amenable for safe endoscopic resection or where access was difficult, and therefore planned for laparoscopic assistance, were analysed. Clinical data regarding primary lesion, reason for referral for laparoscopic assistance, and outcomes were recorded. Results 15 patients have so far been planned for laparo-endoscopic procedures following multidisciplinary meetings, of whom 1 patient proceeded with surgery alone. 14 patients, with median age 73.0 years (range 35.7–85.1 years) were studied. The main reasons for laparoscopic assistance were: large high risk polyps, unfavourable location and the presence of diverticular disease. The median size of the polyps was 5 cm (range 2.3–15 cm). All procedures were performed under general anaesthetic. Completion of colonoscopic resection was performed with surgical presence without laparoscopic assistance in one. Laparoscopic adhesiolysis was performed in 5 patients to facilitate access. Seven patients required surgical resection (laparoscopic right hemicolectomy in 6 and sigmoid resection in 1). A cancer was confirmed histologically in 3 of these patients, with the other four being adenomas with high-grade dysplasia (HGD, 1) or low grade dysplasia (LGD, 3). In the remaining 7 patients, complete polypectomy was achieved, with histopathology showing adenomas with HGD (2), LGD (1), and lipomas in 3 patients with submucosal lesions, and non-diagnostic material in one patient. Median post-operative length of stay was 2 days (range 1 to 5 days) following colonoscopic resection, and uncomplicated except for post-polypectomy syndrome in one patient. Three of these patients have been followed-up to 6 months, with no recurrence of the lesion seen. Amongst patients requiring surgical resection, length of stay was longer (median 6 days [range 3–21 days], p = 0.002, Mann Whitney), with one patient suffering from anastomotic leak and another from an intra-abdominal fluid collection managed conservatively. Conclusion Attempted laparoscopic-assisted colonoscopic polypectomy is an effective strategy in a selected patients, enabling safe and complete polypectomy for lesions that are difficult to resect at primary colonoscopy. This approach may help to reduce surgical morbidity and reduce length of hospital stay. Disclosure of interest None Declared.
    No preview · Article · May 2015 · Gastrointestinal Endoscopy

  • No preview · Article · May 2015 · Gastrointestinal Endoscopy
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    ABSTRACT: Introduction Although colonoscopy is considered the optimal procedure for bowel cancer screening, it remains an imperfect tool for cancer prevention, due to missed adenomas and early cancers. The Endocuff is a simple device attached at the end of the colonoscope that opens up the field of view by retracting folds during withdrawal. Little is known regarding the Endocuff’s impact on a colonoscopist’s performance. Method The aim of this study was to evaluate the impact of the Endocuff-visionTM(ARC Design Ltd, UK) on the quality indicators for each operator. A prospective observational evaluation study was performed from April 2013 to September 2014, divided in three consecutive periods: pre-cuff (no device used), during-cuff (device used) and post-cuff (no device used). Four screening endoscopists (BPS, STG, NS, AH) utilised the Endocuff-visionTMat their own discretion when device was available to them. Quality colonoscopy indicators {(Adenoma Detection Rate (ADR), Mean number of adenomas per procedure (MAP), Caecal intubation time (CIT)} were analysed (t-test two sample assuming equal variances) in equivalent number of procedures. The total number of procedures performed was 399, 133 per period (BPS/26, STG/53, NS/31, AH/23). Results The mean ADR was 55.13% in the pre-cuff period, 68.98% in the during-cuff period and 61.74% in the post-cuff period. All four operators showed significant improvement in detection when using the device, which resulted in an overall increased ADR of 13.8% (p < 0.05). During the post-cuff period, the detection performance of the three endoscopists declined while maintaining a high detection rate. The mean MAP was 1.2 in the pre-cuff period, 2.2 in the during-cuff period and 1.55 in the post-cuff period. The mean MAP increased significantly in all four operators at the during-cuff period (83%, p < 0.05). During the post-cuff, 3 endoscopists returned almost to the baseline MAP pre-cuff level. The mean CIT was 9.66min in the pre-cuff period, 7.5min in the during-cuff period and 9.54min in the post-cuff period. A decrease in mean CIT was featured (22.36%, p < 0.005) to all operators when using the device, returning to about the pre-cuff levels afterwards. No complications were reported from the use of the Endocuff-vision although it was electively removed in 4 cases with severe sigmoid colon diverticulosis and one case due to anal discomfort. Conclusion In this study, use of the Endocuff-visionTMimproved overall performance by making colonoscopy a quicker (CIT) and more efficient (MAP/ADR) procedure. Further randomised evaluation of this simple novel device is warranted. Disclosure of interest None Declared.
    No preview · Article · May 2015 · Gastrointestinal Endoscopy

  • No preview · Article · May 2015 · Gastrointestinal Endoscopy

  • No preview · Article · May 2015 · Gastrointestinal Endoscopy
  • Ana Ignjatovic Wilson · Brian P Saunders
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    ABSTRACT: "Polypectomy at colonoscopy has been shown to reduce the subsequent risk of colorectal cancer. With the advent of national screening programs, the number of colonoscopies performed has increased worldwide. In addition, the recent drive for quality improvement combined with advances in colonoscopic technology has resulted in increased numbers of polyps detected, resected, and sent for histopathology leading to spiraling costs associated with the procedure. Being able to diagnose small polyps in vivo (optical diagnosis) would allow for adenomas to be resected and discarded without the need to retrieve them or send them for formal histopathology." Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Apr 2015 · Gastrointestinal endoscopy clinics of North America

  • No preview · Article · Apr 2015 · Gastroenterology

Publication Stats

6k Citations
1,285.79 Total Impact Points

Institutions

  • 2007-2015
    • Imperial College London
      • Section of Biosurgery and Surgical Technology
      Londinium, England, United Kingdom
    • Middlesex University, UK
      Londinium, England, United Kingdom
  • 1994-2015
    • St. Mark's Hospital
      Harrow, England, United Kingdom
  • 2014
    • New York Presbyterian Hospital
      New York, New York, United States
  • 2012
    • University Medical Center Utrecht
      • Department of Gastroenterology and Hepatology
      Utrecht, Utrecht, Netherlands
  • 2011
    • Konkuk University Medical Center
      Changnyeong, Gyeongsangnam-do, South Korea
  • 2002-2009
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 2006-2007
    • St. Mark's Hospital
      Salt Lake City, Utah, United States
  • 1996
    • King Edward VII's Hospital
      Londinium, England, United Kingdom