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Liu Y, Li T, Lou L, Yang X, Kang C, Ren G, Zhang L, Zheng R, Kang X, Luo H, Liang S, Nie Y, Lv Y, Pan Y. Association between gastrointestinal lesions in individuals undergoing gastroscopy and colonoscopy simultaneously: a retrospective, observational study. BMC Gastroenterol 2025; 25:403. [PMID: 40413402 DOI: 10.1186/s12876-025-04012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/20/2025] [Indexed: 05/27/2025] Open
Abstract
BACKGROUND Due to the common developmental origination and influences by similar unhealthy lifestyle, upper and lower gastrointestinal (GI) diseases may be closely associated. However, the evidence remains elusive. This study aims to determine the prevalence of GI endoscopic lesions and the correlations between endoscopic lesions in individuals undergoing gastroscopy and colonoscopy simultaneously. METHODS A retrospective study was conducted on 18,556 individuals who underwent simultaneous gastroscopy and colonoscopy at the Endoscopy Center of Xijing Hospital of Digestive Diseases from January 2020 to March 2023. Data on sex, age, pathological and endoscopic results were collected. The Pearson chi-square test was used to analyze the occurrence of various GI lesions among age groups and correlations between GI lesions, and logistic regression was used to determine risk factors for common upper and lower GI lesions. RESULTS The mean age was 50.35 ± 12.31 years, and 55.5% of participants were male. At least one endoscopic abnormality was observed in 16,530 cases (89.1%), with 8253 cases (44.5%) showing abnormalities in both the upper and lower GI tract. The most common upper GI endoscopic lesions were chronic atrophic gastritis (CAG, 47.7%), reflux esophagitis (RE, 24.7%), and other gastritis (18.1%). Colorectal polyps (CPs) were the most prevalent lower GI endoscopic condition, observed in 37.5% of cases. The detection of CAG, RE, CPs increased with age, and was higher in man. Moreover, the presence of CAG was associated with the occurrence of CPs (kappa value = 0.135, p < 0.001), which was independent of age and gender. CONCLUSION Most GI diseases are more prevalent in men and the elderly. Additionally, CAG is independently correlated with the occurrence of endoscopic CPs.
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Affiliation(s)
- Yaling Liu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Tongxin Li
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Lijun Lou
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Xintian Yang
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Chenxi Kang
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Gui Ren
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Linhui Zhang
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Rong Zheng
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Xiaoyu Kang
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Hui Luo
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Shuhui Liang
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Yongzhan Nie
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Yong Lv
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China.
| | - Yanglin Pan
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China.
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Pan H, Zhang YL, Fang CY, Chen YD, He LP, Zheng XL, Li X. Retrospective cohort study investigating association between precancerous gastric lesions and colorectal neoplasm risk. Front Oncol 2024; 14:1320020. [PMID: 38444677 PMCID: PMC10914248 DOI: 10.3389/fonc.2024.1320020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
Background Colorectal cancer (CRC) is considered the most prevalent synchronous malignancy in patients with gastric cancer. This large retrospective study aims to clarify correlations between gastric histopathology stages and risks of specific colorectal neoplasms, to optimize screening and reduce preventable CRC. Methods Clinical data of 36,708 patients undergoing gastroscopy and colonoscopy from 2005-2022 were retrospectively analyzed. Correlations between gastric and colorectal histopathology were assessed by multivariate analysis. Outcomes of interest included non-adenomatous polyps (NAP), conventional adenomas (CAs), serrated polyps (SPs), and CRC. Statistical analysis used R version 4.0.4. Results Older age (≥50 years) and Helicobacter pylori infection (HPI) were associated with increased risks of conventional adenomas (CAs), serrated polyps (SPs), non-adenomatous polyps (NAP), and colorectal cancer (CRC). Moderate to severe intestinal metaplasia specifically increased risks of NAP and CAs by 1.17-fold (95% CI 1.05-1.3) and 1.19-fold (95% CI 1.09-1.31), respectively. For CRC risk, low-grade intraepithelial neoplasia increased risk by 1.41-fold (95% CI 1.08-1.84), while high-grade intraepithelial neoplasia (OR 3.76, 95% CI 2.25-6.29) and gastric cancer (OR 4.81, 95% CI 3.25-7.09) showed strong associations. More advanced gastric pathology was correlated with progressively higher risks of CRC. Conclusion Precancerous gastric conditions are associated with increased colorectal neoplasm risk. Our findings can inform screening guidelines to target high-risk subgroups, advancing colorectal cancer prevention and reducing disease burden.
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Affiliation(s)
- Hui Pan
- Gastrointestinal Endoscopy Center, Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Yu-Long Zhang
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, China
| | - Chao-Ying Fang
- Gastrointestinal Endoscopy Center, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China
| | - Yu-Dai Chen
- Gastrointestinal Endoscopy Center, Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Li-Ping He
- Gastrointestinal Endoscopy Center, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China
| | - Xiao-Ling Zheng
- Gastrointestinal Endoscopy Center, Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaowen Li
- Gastrointestinal Endoscopy Center, Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
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Liu XR, Wen ZL, Liu F, Li ZW, Liu XY, Zhang W, Peng D. Colonoscopy plays an important role in detecting colorectal neoplasms in patients with gastric neoplasms. World J Gastrointest Oncol 2024; 16:133-143. [PMID: 38292850 PMCID: PMC10824114 DOI: 10.4251/wjgo.v16.i1.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/14/2023] [Accepted: 12/04/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Gastric cancer (GC) and colorectal cancer (CRC) are the fifth and third most common cancer worldwide, respectively. Nowadays, GC is reported to have a potential predictive value for CRC, especially for advanced CRC. AIM To evaluate the necessity of colonoscopy for gastric neoplasm (GN) patients. METHODS Four databases, including PubMed, EMBASE, the Cochrane Library, and Ovid, were used to perform the search strategy on May 2, 2023. The prevalence of colorectal neoplasms (CRN) and baseline characteristics were compared between the neoplasm group and the control group. Continuous variables are expressed as the mean difference and standard deviation. Relationships of categorical variables in the two groups are expressed as odds ratios (OR) and 95% confidence intervals (95%CIs). Subgroup analysis according to different kinds of GNs was conducted for more in-depth analysis. The results of this study are represented by forest plots. Publication bias was evaluated by a funnel plot. All data analyses were performed by STATA SE 16.0 software. RESULTS A total of 3018 patients with GNs and 3905 healthy controls (age and sex matched) were enrolled for analysis. After comparing the prevalence of CRNs between the two groups, CRNs were detected significantly more frequently in GN patients than in controls (OR = 1.69, 95%CI = 1.28 to 2.23, I2 = 85.12%, P = 0.00), especially in patients with GC (OR =1.80, 95%CI = 1.49 to 2.18, I2 = 25.55%, P < 0.1). Moreover, other risk factors including age (OR = 1.08, 95%CI = 1.00 to 1.17, I2 = 90.13%, P = 0.00) and male sex (OR = 2.31, 95%CI = 1.26 to 4.22, I2 = 87.35%, P = 0.00), were related to the prevalence of CRNs. For patients in the GN group, body mass index (BMI, OR = 0.88, 95%CI = 0.80 to 0.98, I2 = 0.00%, P = 0.92) and smoking (OR = 1.03, 95%CI = 1.01 to 1.05, I2 = 0.00%, P = 0.57) were protective and risk factors for CRNs, respectively. CONCLUSION Patients are recommended to undergo colonoscopy when diagnosed with GNs, especially GC patients with a low BMI and a history of smoking.
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Affiliation(s)
- Xu-Rui Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Ze-Lin Wen
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
| | - Fei Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Zi-Wei Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Tsuchida C, Yoshitake N, Kino H, Kaneko Y, Nakano M, Tsuchida K, Tominaga K, Sasai T, Masuyama H, Yamagishi H, Imai Y, Hiraishi H. Clinical importance of colonoscopy in patients with gastric neoplasm undergoing endoscopic submucosal dissection. World J Gastroenterol 2017; 23:4262-4269. [PMID: 28694666 PMCID: PMC5483500 DOI: 10.3748/wjg.v23.i23.4262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/29/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the usefulness of total colonoscopy (TCS) for patients undergoing gastric endoscopic submucosal dissection (ESD) and to assess risk factors for colorectal neoplasms.
METHODS Of the 263 patients who underwent ESD at our department between May 2010 and December 2013, 172 patients undergoing TCS during a one-year period before and after ESD were targeted. After excluding patients with a history of surgery or endoscopic therapy for colorectal neoplasms, 158 patients were analyzed. Of the 868 asymptomatic patients who underwent TCS during the same period because of positive fecal immunochemical test (FIT) results, 158 patients with no history of either surgery or endoscopic therapy for colorectal neoplasms who were matched for age and sex served as the control group for comparison.
RESULTS TCS revealed adenoma less than 10 mm in 53 patients (33.6%), advanced adenoma in 17 (10.8%), early colorectal cancer in 5 (3.2%), and advanced colorectal cancer in 4 (2.5%). When the presence or absence of adenoma less than 10 mm, advanced adenoma, and colorectal cancer and the number of adenomas were compared between patients undergoing ESD and FIT-positive patients, there were no statistically significant differences in any of the parameters assessed. The patients undergoing ESD appeared to have the same risk of colorectal neoplasms as the FIT-positive patients. Colorectal neoplasms were clearly more common in men than in women (P = 0.031). Advanced adenoma and cancer were significantly more frequent in patients with at least two of the following conditions: hypertension, dyslipidemia, and diabetes mellitus (P = 0.019).
CONCLUSION In patients undergoing gastric ESD, TCS appears to be important for detecting synchronous double neoplasms. Advanced adenoma and cancer were more common in patients with at least two of the following conditions: hypertension, dyslipidemia, and diabetes mellitus. Caution is therefore especially warranted in patients with these risk factors.
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Imai K, Hotta K, Yamaguchi Y, Kawata N, Kakushima N, Tanaka M, Takizawa K, Matsubayashi H, Shimoda T, Mori K, Ono H. Clinical impact of colonoscopy for patients with early gastric cancer treated by endoscopic submucosal dissection: A matched case-control study. Dig Liver Dis 2017; 49:207-212. [PMID: 27810400 DOI: 10.1016/j.dld.2016.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/14/2016] [Accepted: 10/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastric cancer frequently occurs synchronously with colorectal cancer (CRC). AIMS The aim of the present study was to assess the value of colonoscopy in patients with primariy early gastric cancer (EGC) indicated for endoscopic submucosal dissection (ESD) and to identify predictors for the risk of high-risk adenomas. METHODS A total of 130 patients with EGC, who underwent both colonoscopy and gastric ESD, and 260 controls matched for age and sex, who underwent a colonoscopy as part of our institutional health check-up program. The prevalence of high-risk adenomas in EGC patients vs. controls was evaluated. RESULTS High-risk adenomas were found in 43 (33%) EGC patients and 37 (14%) controls (P<0.01). Multivariate analysis showed the presence of EGC was significantly associated with high-risk adenoma [odds ratio (OR) 2.8, 95% confidence interval (CI): 1.7-4.9]. Among EGC patients, high serum CEA level (OR 2.4, 95% CI: 1.2-5.0) was an independent predictor for high-risk adenoma. CONCLUSIONS Patients with EGC had a significant risk for colorectal cancer. When endoscopists detected an early gastric cancer indicated for ESD, colonoscopy should be considered for EGC patients with high serum CEA levels.
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan.
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Yuichiro Yamaguchi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Tadakazu Shimoda
- Division of Pathology, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi-cho, Suntogun, Shizuoka, Japan
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Wu ZJ, Lin Y, Xiao J, Wu LC, Liu JG. Clinical significance of colonoscopy in patients with upper gastrointestinal polyps and neoplasms: a meta-analysis. PLoS One 2014; 9:e91810. [PMID: 24637723 PMCID: PMC3956699 DOI: 10.1371/journal.pone.0091810] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 02/14/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Some authors have studied the relationship between the presence of polyps, adenomas and cancers of upper gastrointestinal tract (stomach and duodenum) and risk of colorectal polyps and neoplasms; however, the results are controversial, which may be due to study sample size, populations, design, clinical features, and so on. No meta-analysis, which can be generalized to a larger population and could provide a quantitative pooled risk estimate of the relationship, of this issue existed so far. METHODS We performed a meta-analysis to evaluate risk of colorectal polyps or neoplasms in patients with polyps, adenomas or cancers in upper gastrointestinal tract comparing with controls. A search was conducted through PubMed, EMBASE, reference lists of potentially relevant papers, and practice guidelines up to 27 November 2013 without languages restriction. Odd ratios (ORs) were pooled using random-effects models. RESULTS The search yielded 3 prospective and 21 retrospective case-control studies (n = 37152 participants). The principal findings included: (1) OR for colorectal polyps was 1.15 (95% CI, 1.04-1.26) in the gastric polyps group comparing with control groups; (2) Patients with gastric polyps and neoplasms have higher risk (OR, 1.31 [95% CI, 1.06-1.62], and 1.72 [95% CI, 1.42-2.09], respectively) of colorectal neoplasms comparing with their controls; and (3) Positive association was found between the presence of colorectal neoplasms and sporadic duodenal neoplasms (OR, 2.59; 95% CI, 1.64-4.11). CONCLUSIONS Findings from present meta-analysis of 24 case-control studies suggest that the prevalence of colorectal polyps was higher in patients with gastric polyps than in those without gastric polyps, and the risk of colorectal neoplasms increases significantly in patients with gastric polyps, neoplasms, and duodenal neoplasms. Therefore, screening colonoscopy should be considered for patients with upper gastrointestinal polyps and neoplasms.
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Affiliation(s)
- Zhen-Jie Wu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China
| | - Yuan Lin
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China
- * E-mail:
| | - Jun Xiao
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China
| | - Liu-Cheng Wu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China
| | - Jun-Gang Liu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China
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Ojima T, Iwahashi M, Nakamori M, Nakamura M, Katsuda M, Iida T, Hayata K, Takifuji K, Yamaguchi S, Yamaue H. Is preoperative colonoscopy necessary for patients undergoing gastric cancer surgery? Ann Surg Oncol 2014; 21 Suppl 3:S379-84. [PMID: 24562939 DOI: 10.1245/s10434-014-3580-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to evaluate the necessity of preoperative colonoscopy (CS) in gastric cancer (GC) patients and to assess the outcomes of different treatments in patients with synchronous GC and colorectal neoplasms (CRN). We also determined the risk factors influencing the comorbidity of colorectal cancer (CRC) in patients with GC. METHODS This retrospective study included 1891 consecutive GC patients who underwent CS before surgery from January 1, 1999, through June 30, 2012. RESULTS There was a high prevalence of concurrent CRN (28.4 %) and CRC (3.2 %) in our patients with GC. Sixty-one patients with GC had synchronous CRC. Twenty-three of the 61 tumors were perioperatively treated by endoscopic resection. The other 38 tumors were treated by simultaneous surgery for the GC and CRC. Surgical complications were not found in either the endoscopic or surgical resection group. The multivariate logistic regression analysis indicated that the prevalence of synchronous CRC in patients with GC was significantly associated with the incidence of multiple GCs [P < 0.0001; odds ratio (OR) 15.3], having anemia (P = 0.002; OR 3.0), and having a smoking history (P = 0.021; OR 1.9). CONCLUSIONS We recommend preoperative CS screening for GC patients. In particular, preoperative CS screening is indispensable for patients with multiple GCs. In addition, simultaneous treatments for patients with synchronous GC and CRN are safe and feasible procedures.
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Affiliation(s)
- Toshiyasu Ojima
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
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