Nicholas Burgess | University Of Sydney (original) (raw)

Papers by Nicholas Burgess

Digestive Endoscopy, 2015

Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques n... more Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques now exist for the resection of polyps, and the endoscopist must decide on the appropriate resection approach for individual patients and lesions. This decision should maximize efficacy, safety and cost effectiveness and provide optimal oncological outcomes whilst minimizing unnecessary surgical treatment. Advances in endoscopic imaging technology are improving the accuracy of endoscopic diagnosis and allowing more precise risk assessment of colonic lesions. Resection technique can be tailored to the endoscopic findings. Diminutive (≤5 mm) and small polyps (≤9 mm) are best resected primarily by snare techniques. Cold snare polypectomy has proven safety, but efficacy and technique require further study. There is variation in techniques used for polyps 6-20 mm in size and incomplete resection rates for conventional polypectomy may be considerable. Endoscopic mucosal resection (EMR) is well established, safe and effective for lesions without submucosal invasion (SMI), however recurrence is a key limitation. Endoscopic submucosal dissection (ESD) is well established in the East, however it is resource intensive and its role in lesions with a low risk of SMI is questionable. ESD in the West remains incompletely defined and is associated with high adverse event rates, however it is becoming increasingly available and successful as experience grows. Emerging full thickness resection technologies are still in their infancy, and remain experimental due to the absence of reliable closure devices and techniques. Patient focused outcomes should guide technique selection. This article is protected by copyright. All rights reserved.

Gastrointestinal endoscopy, Jan 10, 2015

Laterally spreading lesions ≥20 mm (LSL) are conventionally removed by endoscopic mucosal resecti... more Laterally spreading lesions ≥20 mm (LSL) are conventionally removed by endoscopic mucosal resection (EMR). Endoscopic clips are increasingly used to mitigate the risk of delayed bleeding. Clips may alter the endoscopic appearance of the post-EMR scar, interfering with the assessment of adenoma recurrence. We aimed to evaluate this. Prospective, single-center data from the Australian Colonic Endoscopic resection study (ACE) was analyzed (January 2011 to May 2015). Patients undergoing EMR of LSL with endoscopic clips used at the EMR defect were eligible. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Clips were used in 111 of 885 (12.5%) lesions. 62 of 111 clipped lesions had standardized high-definition white light and narrow-band images of the post-EMR scar at first surveillance colonoscopy and were enrolled. Analysis of the images showed 4 situations: a bland scar (N = 27), residual adenoma (N = 6), mucosal elevation with normal ...

Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, Jan 10, 2015

&... more & Aims: Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However many patients still undergo surgery. Endoscopic treatment may be more cost effective. We compared the costs of endoscopic vs surgical management of large LSL. We performed a prospective, observational, multi-center study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, as well as findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis related group codes were used to estimate average cost per patient. EMR was performed on 1489 lesions (mean size 36 mm) in 1353 patients (mean age, 67 years; 52.1% male). Total costs involved in the endoscopic management of large LSL were US 6,316,593andtotalinpatienthospitalizationlengthofstay(ILOS)was1180days.ThetotalcostpredictedforthesurgicalmanagementgroupwasUS6,316,593 and total inpatient hospitalization length of stay (ILOS) was 1180 days. The total cost predicted for the surgical management group was US 6,316,593andtotalinpatienthospitalizationlengthofstay(ILOS)was1180days.ThetotalcostpredictedforthesurgicalmanagementgroupwasUS16,601,502, with a total ILOS of 4986 days. Endoscopic management produced a potential total cost saving of US 10,284,909;themeancostdifferenceperpatientwasUS10,284,909; the mean cost difference per patient was US 10,284,909;themeancostdifferenceperpatientwasUS7602 (95% confidence interval, 8458−8458-8458−9220; P<.001). ILOS was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94; P<.001). In a large multi-center study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. ClinicalTrials.gov no: NCT01368289.

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal endoscopy, Jan 22, 2015

Cold snare polypectomy (CSP) is widely practiced; however, the endoscopic features of the CSP muc... more Cold snare polypectomy (CSP) is widely practiced; however, the endoscopic features of the CSP mucosal defect have not been studied. In particular, protrusions within the cold snare defect (CSDPs) may create concern for residual polyp. The frequency and constituents of this phenomenon are unknown. To describe the frequency, predictors, and histologic constituents of CSDPs. Prospective observational study. Tertiary-care hospital endoscopy unit. Eighty-eight consecutive patients undergoing CSP for a polyp ≤ 10 mm in size. Inspection of the cold snare mucosal defect with high-definition white light and biopsy sampling of CSDPs for separate histologic assessment, when present. Frequency and constituents of CSDPs. Two hundred fifty-seven consecutive polyps ≤ 10 mm in size were removed in 88 patients (50 men [57%], mean age 63 years). Polyps were predominately adenomatous (162, 63%), located in the proximal colon (159, 62%) and flat (200, 78%). Mean lesion size was 5.5 mm (range, 2-10 mm)....

Gastrointestinal endoscopy, 2015

Endoscopy, Jan 12, 2015

Background and study aims: Endoscopic mucosal resection (EMR) of laterally spreading lesions (LSL... more Background and study aims: Endoscopic mucosal resection (EMR) of laterally spreading lesions (LSLs) involving the ileocecal valve (ICV) is technically demanding. Conventionally, these lesions are considered too challenging for endoscopic therapy and are primarily managed surgically. The aims of the study were to describe effectiveness, safety, and outcomes following EMR of LSLs at the ICV. Patients and methods: This was a single-center, prospective, observational, cohort study performed at an academic, tertiary referral center. Patients undergoing EMR for LSLs ≥ 20 mm involving the ICV were recruited over a 5-year period. Standard or cap-assisted colonoscopy with inject-and-resect EMR technique was performed with standardized post-EMR management. Procedural success, safety, and outcomes compared with non-ICV LSLs managed during the same period were analyzed. Results: A total of 53 patients with ICV LSLs were referred for EMR (median age 69 years; median lesion size 35.0 mm; 52.8 % f...

The New Zealand medical journal, Jan 26, 2012

To examine whether stroke care processes and outcomes are improved following the institution of a... more To examine whether stroke care processes and outcomes are improved following the institution of an acute stroke unit (ASU) at a medium-sized New Zealand hospital. Two retrospective audits over 12-month periods were carried out at Hutt Valley Hospital before and after the institution of a 6-bed ASU. Data was collected on demographics, length of stay, stroke type, investigations, processes of care and outcomes. 139 strokes pre ASU and 155 strokes post ASU were studied. 86.8% of strokes received stroke unit care in the 2009 audit. There were more intracerebral haemorrhages in 2006 (17.2% vs. 9.0%). Significant improvements were seen between 2006 and 2009 in time to aspirin administration (52.7 versus 14.5 hours), swallow assessment within 24 hours (88.5% versus 96.1%), lag time to carotid Doppler studies (21 days versus 4.5 days), pressure risk assessments (19.6%, versus 87.2%) and urinary infection rates (10.8% versus 2.0% ). Total length of stay (TLOS) and mortality were reduced but ...

Gastrointestinal Endoscopy, 2014

Gut, 2015

Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of ad... more Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of advanced colonic mucosal neoplasia up to 120 mm in size, but has been criticised for its potentially high recurrence rates. We aimed to quantify recurrence at 4 months (early) and 16 months (late) following successful WF-EMR and identify its risk factors and clinical significance. Ongoing multicentre, prospective, intention-to-treat analysis of sessile or laterally spreading colonic lesions ≥20 mm in size referred for WF-EMR to seven academic endoscopy units. Surveillance colonoscopy (SC) was performed 4 months (SC1) and 16 months (SC2) after WF-EMR, with photographic documentation and biopsy of the scar. 1134 consecutive patients were enrolled when 1000 successful EMRs were achieved, of whom 799 have undergone SC1. 670 were normal. Early recurrent/residual adenoma was present in 128 (16.0%, 95% CI 13.6% to 18.7%). One case was unknown. The recurrent/residual adenoma was diminutive in 71.7...

Journal of Gastroenterology and Hepatology, 2011

Multichannel Intraluminal Impedance (MII) Monitoring is a method of examining oesophageal bolus t... more Multichannel Intraluminal Impedance (MII) Monitoring is a method of examining oesophageal bolus transit without the need for radiation. In combination with oesophageal manometry it allows correlation of bolus transit with peristaltic activity. The clinical application of impedance manometry is still being refined. This audit looked to examine whether impedance manometry had advantages over standard manometry in assessment of patients with dysphagia. 41 patients with the presenting symptom of dysphagia were assessed by combined MII and oesophageal manometry at a Wellington Hospital between February 2008 and December 2009. Each underwent manometry and MII using standardised techniques. Achalasia was diagnosed in 23 patients (56.1%), Ineffective oesophageal motility (IEM) in 5 patients (12.2%), Diffuse oesophageal Spasm (DES) in 7 patients (17.1%), and Nutcracker oesophagus in 2 patients (4.9%). 4 patients had normal manometry studies (9.8%). All patients with achalasia, IEM, and DES had abnormal bolus transit. All patients with normal manometry had abnormal bolus transit. Both patients with nutcracker oesophagus had normal bolus transit. 4 patients with achalasia had undergone previous Hellers myotomy. Two of these patients (50.0%) now had normal LES relaxation pressures, but all four still had abnormal oesophageal peristalsis and abnormal bolus transit. Multichannel Intraluminal Impedance manometry has advantages over standard manometry in characterising the physiological abnormalities associated with dysphagia. Patients in this study had severe defects including achalasia where bolus transit was invariably poor meaning little further information was gained. Extension of this study to include a wider group of patients with dysphagia may yield different results.

Gastrointestinal Endoscopy, 2014

Gastrointestinal Endoscopy, 2014

Gastrointestinal Endoscopy, 2014

Digestive Endoscopy, 2015

Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques n... more Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques now exist for the resection of polyps, and the endoscopist must decide on the appropriate resection approach for individual patients and lesions. This decision should maximize efficacy, safety and cost effectiveness and provide optimal oncological outcomes whilst minimizing unnecessary surgical treatment. Advances in endoscopic imaging technology are improving the accuracy of endoscopic diagnosis and allowing more precise risk assessment of colonic lesions. Resection technique can be tailored to the endoscopic findings. Diminutive (≤5 mm) and small polyps (≤9 mm) are best resected primarily by snare techniques. Cold snare polypectomy has proven safety, but efficacy and technique require further study. There is variation in techniques used for polyps 6-20 mm in size and incomplete resection rates for conventional polypectomy may be considerable. Endoscopic mucosal resection (EMR) is well established, safe and effective for lesions without submucosal invasion (SMI), however recurrence is a key limitation. Endoscopic submucosal dissection (ESD) is well established in the East, however it is resource intensive and its role in lesions with a low risk of SMI is questionable. ESD in the West remains incompletely defined and is associated with high adverse event rates, however it is becoming increasingly available and successful as experience grows. Emerging full thickness resection technologies are still in their infancy, and remain experimental due to the absence of reliable closure devices and techniques. Patient focused outcomes should guide technique selection. This article is protected by copyright. All rights reserved.

Gastrointestinal endoscopy, Jan 10, 2015

Laterally spreading lesions ≥20 mm (LSL) are conventionally removed by endoscopic mucosal resecti... more Laterally spreading lesions ≥20 mm (LSL) are conventionally removed by endoscopic mucosal resection (EMR). Endoscopic clips are increasingly used to mitigate the risk of delayed bleeding. Clips may alter the endoscopic appearance of the post-EMR scar, interfering with the assessment of adenoma recurrence. We aimed to evaluate this. Prospective, single-center data from the Australian Colonic Endoscopic resection study (ACE) was analyzed (January 2011 to May 2015). Patients undergoing EMR of LSL with endoscopic clips used at the EMR defect were eligible. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Clips were used in 111 of 885 (12.5%) lesions. 62 of 111 clipped lesions had standardized high-definition white light and narrow-band images of the post-EMR scar at first surveillance colonoscopy and were enrolled. Analysis of the images showed 4 situations: a bland scar (N = 27), residual adenoma (N = 6), mucosal elevation with normal ...

Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, Jan 10, 2015

&... more & Aims: Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However many patients still undergo surgery. Endoscopic treatment may be more cost effective. We compared the costs of endoscopic vs surgical management of large LSL. We performed a prospective, observational, multi-center study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, as well as findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis related group codes were used to estimate average cost per patient. EMR was performed on 1489 lesions (mean size 36 mm) in 1353 patients (mean age, 67 years; 52.1% male). Total costs involved in the endoscopic management of large LSL were US 6,316,593andtotalinpatienthospitalizationlengthofstay(ILOS)was1180days.ThetotalcostpredictedforthesurgicalmanagementgroupwasUS6,316,593 and total inpatient hospitalization length of stay (ILOS) was 1180 days. The total cost predicted for the surgical management group was US 6,316,593andtotalinpatienthospitalizationlengthofstay(ILOS)was1180days.ThetotalcostpredictedforthesurgicalmanagementgroupwasUS16,601,502, with a total ILOS of 4986 days. Endoscopic management produced a potential total cost saving of US 10,284,909;themeancostdifferenceperpatientwasUS10,284,909; the mean cost difference per patient was US 10,284,909;themeancostdifferenceperpatientwasUS7602 (95% confidence interval, 8458−8458-8458−9220; P<.001). ILOS was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94; P<.001). In a large multi-center study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. ClinicalTrials.gov no: NCT01368289.

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal Endoscopy, 2015

Gastrointestinal endoscopy, Jan 22, 2015

Cold snare polypectomy (CSP) is widely practiced; however, the endoscopic features of the CSP muc... more Cold snare polypectomy (CSP) is widely practiced; however, the endoscopic features of the CSP mucosal defect have not been studied. In particular, protrusions within the cold snare defect (CSDPs) may create concern for residual polyp. The frequency and constituents of this phenomenon are unknown. To describe the frequency, predictors, and histologic constituents of CSDPs. Prospective observational study. Tertiary-care hospital endoscopy unit. Eighty-eight consecutive patients undergoing CSP for a polyp ≤ 10 mm in size. Inspection of the cold snare mucosal defect with high-definition white light and biopsy sampling of CSDPs for separate histologic assessment, when present. Frequency and constituents of CSDPs. Two hundred fifty-seven consecutive polyps ≤ 10 mm in size were removed in 88 patients (50 men [57%], mean age 63 years). Polyps were predominately adenomatous (162, 63%), located in the proximal colon (159, 62%) and flat (200, 78%). Mean lesion size was 5.5 mm (range, 2-10 mm)....

Gastrointestinal endoscopy, 2015

Endoscopy, Jan 12, 2015

Background and study aims: Endoscopic mucosal resection (EMR) of laterally spreading lesions (LSL... more Background and study aims: Endoscopic mucosal resection (EMR) of laterally spreading lesions (LSLs) involving the ileocecal valve (ICV) is technically demanding. Conventionally, these lesions are considered too challenging for endoscopic therapy and are primarily managed surgically. The aims of the study were to describe effectiveness, safety, and outcomes following EMR of LSLs at the ICV. Patients and methods: This was a single-center, prospective, observational, cohort study performed at an academic, tertiary referral center. Patients undergoing EMR for LSLs ≥ 20 mm involving the ICV were recruited over a 5-year period. Standard or cap-assisted colonoscopy with inject-and-resect EMR technique was performed with standardized post-EMR management. Procedural success, safety, and outcomes compared with non-ICV LSLs managed during the same period were analyzed. Results: A total of 53 patients with ICV LSLs were referred for EMR (median age 69 years; median lesion size 35.0 mm; 52.8 % f...

The New Zealand medical journal, Jan 26, 2012

To examine whether stroke care processes and outcomes are improved following the institution of a... more To examine whether stroke care processes and outcomes are improved following the institution of an acute stroke unit (ASU) at a medium-sized New Zealand hospital. Two retrospective audits over 12-month periods were carried out at Hutt Valley Hospital before and after the institution of a 6-bed ASU. Data was collected on demographics, length of stay, stroke type, investigations, processes of care and outcomes. 139 strokes pre ASU and 155 strokes post ASU were studied. 86.8% of strokes received stroke unit care in the 2009 audit. There were more intracerebral haemorrhages in 2006 (17.2% vs. 9.0%). Significant improvements were seen between 2006 and 2009 in time to aspirin administration (52.7 versus 14.5 hours), swallow assessment within 24 hours (88.5% versus 96.1%), lag time to carotid Doppler studies (21 days versus 4.5 days), pressure risk assessments (19.6%, versus 87.2%) and urinary infection rates (10.8% versus 2.0% ). Total length of stay (TLOS) and mortality were reduced but ...

Gastrointestinal Endoscopy, 2014

Gut, 2015

Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of ad... more Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of advanced colonic mucosal neoplasia up to 120 mm in size, but has been criticised for its potentially high recurrence rates. We aimed to quantify recurrence at 4 months (early) and 16 months (late) following successful WF-EMR and identify its risk factors and clinical significance. Ongoing multicentre, prospective, intention-to-treat analysis of sessile or laterally spreading colonic lesions ≥20 mm in size referred for WF-EMR to seven academic endoscopy units. Surveillance colonoscopy (SC) was performed 4 months (SC1) and 16 months (SC2) after WF-EMR, with photographic documentation and biopsy of the scar. 1134 consecutive patients were enrolled when 1000 successful EMRs were achieved, of whom 799 have undergone SC1. 670 were normal. Early recurrent/residual adenoma was present in 128 (16.0%, 95% CI 13.6% to 18.7%). One case was unknown. The recurrent/residual adenoma was diminutive in 71.7...

Journal of Gastroenterology and Hepatology, 2011

Multichannel Intraluminal Impedance (MII) Monitoring is a method of examining oesophageal bolus t... more Multichannel Intraluminal Impedance (MII) Monitoring is a method of examining oesophageal bolus transit without the need for radiation. In combination with oesophageal manometry it allows correlation of bolus transit with peristaltic activity. The clinical application of impedance manometry is still being refined. This audit looked to examine whether impedance manometry had advantages over standard manometry in assessment of patients with dysphagia. 41 patients with the presenting symptom of dysphagia were assessed by combined MII and oesophageal manometry at a Wellington Hospital between February 2008 and December 2009. Each underwent manometry and MII using standardised techniques. Achalasia was diagnosed in 23 patients (56.1%), Ineffective oesophageal motility (IEM) in 5 patients (12.2%), Diffuse oesophageal Spasm (DES) in 7 patients (17.1%), and Nutcracker oesophagus in 2 patients (4.9%). 4 patients had normal manometry studies (9.8%). All patients with achalasia, IEM, and DES had abnormal bolus transit. All patients with normal manometry had abnormal bolus transit. Both patients with nutcracker oesophagus had normal bolus transit. 4 patients with achalasia had undergone previous Hellers myotomy. Two of these patients (50.0%) now had normal LES relaxation pressures, but all four still had abnormal oesophageal peristalsis and abnormal bolus transit. Multichannel Intraluminal Impedance manometry has advantages over standard manometry in characterising the physiological abnormalities associated with dysphagia. Patients in this study had severe defects including achalasia where bolus transit was invariably poor meaning little further information was gained. Extension of this study to include a wider group of patients with dysphagia may yield different results.

Gastrointestinal Endoscopy, 2014

Gastrointestinal Endoscopy, 2014

Gastrointestinal Endoscopy, 2014