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Capogreco A, de Sire R, Massimi D, Alfarone L, Maselli R, Hassan C, Repici A. Prophylactic saline-immersion snare-tip vessel coagulation after colorectal endoscopic resection. Endoscopy 2024; 56:E622-E623. [PMID: 39009026 PMCID: PMC11250179 DOI: 10.1055/a-2353-6039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Affiliation(s)
- Antonio Capogreco
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Gastroenterology, IBD Unit, Department of Clinical Medicine and Surgery, University Federico II, Napoli, Italy
| | - Davide Massimi
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Ludovico Alfarone
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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2
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality indicators for colonoscopy. Gastrointest Endosc 2024; 100:352-381. [PMID: 39177519 DOI: 10.1016/j.gie.2024.04.2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/25/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Department of Medicine/Division of Gastroenterology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine/Division of Gastroenterology, White River Junction VAMC, White River Junction, Vermont, USA; University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco; Chief Medical Officer, University of California San Francisco Health System
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA; VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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3
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality Indicators for Colonoscopy. Am J Gastroenterol 2024:00000434-990000000-01296. [PMID: 39167112 DOI: 10.14309/ajg.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Chief Medical Officer, University of California San Francisco Health System, San Francisco, California, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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4
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Tada N, Tamai N, Ito M, Fukuda M, Futakuchi T, Horiuchi H, Kobayashi M, Sumiyama K. Novel reopenable clip with anchor prongs facilitates mucosal defect closure after colorectal endoscopic submucosal dissection: Pilot feasibility study (with video). Dig Endosc 2024. [PMID: 39072898 DOI: 10.1111/den.14891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 07/04/2024] [Indexed: 07/30/2024]
Abstract
Closure of mucosal defects following colorectal endoscopic submucosal dissection (C-ESD) is often performed to prevent post-C-ESD adverse events. However, large mucosal defect closure using conventional clips remains technically challenging. Here, we evaluated the feasibility of the novel endoclip with anchor prongs, called the MANTIS Clip (Boston Scientific, Tokyo, Japan), for mucosal defect closure after C-ESD. This high-volume retrospective study was conducted at a single center. From March until December 2023, consecutive patients who underwent post-C-ESD mucosal defect closure using MANTIS Clip to achieve complete closure were enrolled. Patient clinical characteristics and outcomes were evaluated. Closure of the mucosal defect using the MANTIS Clip was attempted following C-ESD in 32 lesions. The median sizes of the resection specimens and the tumors were 32 mm (range, 17-100 mm) and 23.5 mm (range, 5-96 mm), respectively. The lesions were distributed between the cecum, ascending, transverse, descending, sigmoid, and rectum. Complete closure was achieved in 96.9% of cases (31/32). All lesions up to 61 mm in defect size were completely closed. The median closure time was 7.9 (range, 3.3-18.0) min. The median numbers of MANTIS Clip and additional conventional clips were 3 (range, 1-4) and 5 (range, 1-11), respectively. No adverse events associated with closure, post-ESD bleeding, and delayed perforation occurred. MANTIS Clip closure for large post-C-ESD mucosal defects was found to be feasible and reliable with a high complete closure rate and a short procedure time.
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Affiliation(s)
- Naoya Tada
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoto Tamai
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Mamoru Ito
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Mai Fukuda
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Toshiki Futakuchi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Hideka Horiuchi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
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5
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Yamada K, Tajika M, Niwa Y. Suturing with muscle layer grasping and pulling technique for mucosal defect of colorectal endoscopic submucosal dissection. Dig Endosc 2024; 36:853-854. [PMID: 38725115 DOI: 10.1111/den.14817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/17/2024] [Indexed: 07/13/2024]
Abstract
Watch a video of this article.
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Affiliation(s)
- Keisaku Yamada
- Department of Endoscopy, Aichi Cancer Center Hospital, Aichi, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Aichi, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Aichi, Japan
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Aoki T, Sadashima E, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Hayakawa Y, Fujishiro M, Kaise M, Nagata N. High risk stigmata and treatment strategy for acute lower gastrointestinal bleeding: a nationwide study in Japan. Endoscopy 2024; 56:291-301. [PMID: 38354743 DOI: 10.1055/a-2232-9630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND The rebleeding risks and outcomes of endoscopic treatment for acute lower gastrointestinal bleeding (ALGIB) may differ depending on the bleeding location, type, and etiology of stigmata of recent hemorrhage (SRH) but have yet to be fully investigated. We aimed to identify high risk endoscopic SRH and to propose an optimal endoscopic treatment strategy. METHODS We retrospectively analyzed 2699 ALGIB patients with SRH at 49 hospitals (CODE BLUE-J Study), of whom 88.6 % received endoscopic treatment. RESULTS 30-day rebleeding rates of untreated SRH significantly differed among locations (left colon 15.5 % vs. right colon 28.6 %) and etiologies (diverticular bleeding 27.5 % vs. others [e. g. ulcerative lesions or angioectasia] 8.9 %), but not among bleeding types. Endoscopic treatment reduced the overall rebleeding rate (adjusted odds ratio [AOR] 0.69; 95 %CI 0.49-0.98), and the treatment effect was significant in right-colon SRH (AOR 0.46; 95 %CI 0.29-0.72) but not in left-colon SRH. The effect was observed in both active and nonactive types, but was not statistically significant. Moreover, the effect was significant for diverticular bleeding (AOR 0.60; 95 %CI 0.41-0.88) but not for other diseases. When focusing on treatment type, the effectiveness was not significantly different between clipping and other modalities for most SRH, whereas ligation was significantly more effective than clipping in right-colon diverticular bleeding. CONCLUSIONS A population-level endoscopy dataset allowed us to identify high risk endoscopic SRH and propose a simple endoscopic treatment strategy for ALGIB. Unlike upper gastrointestinal bleeding, the rebleeding risks for ALGIB depend on colonic location, bleeding etiology, and treatment modality.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Eiji Sadashima
- Department of Medical Research Institute, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
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Wehbe H, Gutta A, Gromski MA. Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon. Gastrointest Endosc Clin N Am 2024; 34:363-381. [PMID: 38395489 DOI: 10.1016/j.giec.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.
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Affiliation(s)
- Hisham Wehbe
- Department of Internal Medicine, Indiana University School of Medicine, 550 University Boulevard, UH 3533, Indianapolis, IN 46202, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA
| | - Mark A Gromski
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA.
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Stark EM, Lahr RE, Shultz J, Vemulapalli KC, Guardiola JJ, Rex DK. Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit. Endosc Int Open 2024; 12:E579-E584. [PMID: 38654968 PMCID: PMC11039037 DOI: 10.1055/a-2284-9739] [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: 12/12/2023] [Accepted: 02/26/2024] [Indexed: 04/26/2024] Open
Abstract
Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.
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Affiliation(s)
- Easton M. Stark
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Rachel E. Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Jeremiah Shultz
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Krishna C. Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - John J. Guardiola
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Douglas K. Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
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9
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Copland AP, Kahi CJ, Ko CW, Ginsberg GG. AGA Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review. Clin Gastroenterol Hepatol 2024; 22:470-479.e5. [PMID: 38032585 DOI: 10.1016/j.cgh.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
DESCRIPTION In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.
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Affiliation(s)
- Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Charles J Kahi
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Cynthia W Ko
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Ogiyama H, Kato M, Yamaguchi S, Kanesaka T, Yamada T, Yamamoto M, Komori M, Nagaike K, Nakahara M, Tsutsui S, Tsujii Y, Saita R, Iijima H, Hayashi Y, Takehara T. Efficacy of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulant therapy: Multicenter prospective study. Dig Endosc 2024. [PMID: 38375544 DOI: 10.1111/den.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The high rate of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) in patients undergoing anticoagulant therapy remains a problem. Whether prophylactic clip closure reduces the rate of delayed bleeding in these patients is unclear. This study aimed to evaluate the efficacy of prophylactic clip closure in patients receiving anticoagulants. METHODS This multicenter prospective interventional trial was conducted at nine referral centers in Japan. Patients regularly taking anticoagulants, including warfarin potassium or direct oral anticoagulants, and undergoing ESD for colorectal neoplasms were enrolled. The discontinuation of anticoagulants was minimized according to recent guidelines. After the ESD, post-ESD ulcers were prophylactically closed using endoclips. The primary end-point was the incidence of delayed bleeding. The sample size was 45 lesions, and prophylactic clip closure was considered effective when the upper limit of the 90% confidence interval (CI) for delayed bleeding did not exceed 20%. RESULTS Forty-five lesions were used, and three were excluded. Complete closure was achieved in 41/42 lesions (97.6%). The overall delayed bleeding rate was low, at 4.9% (2/41; 90% [CI] 0.8-14.5), which was significantly lower than that at the prespecified threshold of 20% (P = 0.007). The median closure procedure time was 17 min, and the median number of clips was nine. No massive delayed bleeding requiring transfusion, interventional radiology, or surgery was observed, and no thromboembolic events were observed. CONCLUSION Prophylactic clip closure may reduce the risk of delayed bleeding following colorectal ESD in patients receiving anticoagulants. TRIAL REGISTRATION UMIN Clinical Trial Registry (UMIN000036734).
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Affiliation(s)
- Hideharu Ogiyama
- Departments of Gastroenterology and Hepatology, Itami City Hospital, Hyogo, Japan
- Departments of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Osaka, Japan
| | - Minoru Kato
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Osaka, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Masato Komori
- Department of Gastroenterology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Masanori Nakahara
- Departments of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Osaka, Japan
| | - Shusaku Tsutsui
- Departments of Gastroenterology and Hepatology, Itami City Hospital, Hyogo, Japan
| | - Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryotaro Saita
- Department of Medical Innovation, Osaka University Hospital, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
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11
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Dong L, Zhu W, Zhang X, Xie X. Does Prophylactic Closure Improve Outcomes After Colorectal Endoscopic Submucosal Dissection? A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2024; 34:94-100. [PMID: 38011072 DOI: 10.1097/sle.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Several studies have described prophylactic closure after endoscopic submucosal dissection (ESD) of colorectal lesions for improving postoperative outcomes. We reviewed the evidence on the impact of prophylactic closure after ESD. METHODS A literature search was conducted on PubMed, Embase, CENTRAL, and Web of Science by 2 reviewers independently for studies published up to July 9, 2023. All types of comparative studies were eligible. RESULTS Ten studies compared 939 patients undergoing prophylactic closure with 1074 controls. Three were randomized controlled trials (RCTs) while the rest were observational. Pooled data from all included studies showed that prophylactic closure resulted in reduced incidence of delayed bleeding after ESD [odds ratio (OR): 0.30; 95% CI: 0.15, 0.72; I2 =0%]. These results were significant only for observational studies but not for RCTs. Meta-analysis showed no significant difference in the risk of delayed perforation (OR: 0.55; 95% CI: 0.18, 1.70; I2 =0%) or post-ESD coagulation syndrome (PECS) (OR: 1.15; 95% CI: 0.41, 3.19; I2 =63%) between closure and nonclosure groups. CONCLUSIONS Observational data suggest that prophylactic closure of colorectal mucosal defects after ESD may reduce the risk of delayed bleeding. However, the results are not concurred by RCTs. Furthermore, there seems to be no impact of prophylactic closure on the risk of delayed perforation and PECS.
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Affiliation(s)
- Liang Dong
- Department of Gastroenterology, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
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12
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王 跃, 张 敬, 薛 福, 于 静, 李 小. [Risk factors for delayed bleeding after intestinal polypectomy in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:48-53. [PMID: 38269459 PMCID: PMC10817730 DOI: 10.7499/j.issn.1008-8830.2306060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/03/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVES To investigate the clinical characteristics and risk factors of delayed bleeding after intestinal polypectomy in children, and to provide a theoretical basis for clinical surgical intervention of intestinal polyps. METHODS A retrospective analysis was conducted on the clinical data of 2 456 children with intestinal polyps who underwent endoscopic high-frequency electrocoagulation loop resection in the Endoscopy Center of Children's Hospital Affiliated to Zhengzhou University from January 2014 to December 2021. According to the presence or absence of delayed bleeding after surgery, they were divided into bleeding group with 79 children and non-bleeding group with 2 377 children. A multivariate logistic regression analysis was used to investigate the risk factors for delayed bleeding. The receiver operating characteristic (ROC) curve was used to investigate the value of various indicators in predicting delayed bleeding. RESULTS Of all 2 456 children, 79 (3.22%) experienced delayed bleeding, among whom 5 children with severe delayed bleeding underwent emergency colonoscopy for hemostasis and 74 received conservative treatment, and successful hemostasis was achieved for all children. There were significant differences between the bleeding and non-bleeding groups in age, body mass index, constipation rate, location of lesion, time of endoscopic procedure, resection method (P<0.05). Children with a diameter of polyps of 6-10 mm and >20 mm were more likely to develop delayed bleeding after resection (P<0.05). The multivariate logistic regression analysis showed that endoscopic operation time, polyp diameter, and resection method were significantly associated with delayed bleeding (P<0.05). The ROC curve analysis showed that the endoscopic operation time, polyp diameter, and resection method had a good value in predicting delayed bleeding after intestinal polypectomy, with an area under the ROC curve of 0.706, 0.688, and 0.627, respectively. CONCLUSIONS Endoscopic high-frequency electrocoagulation loop resection has a lower incidence of delayed bleeding in children with intestinal polyps, and the endoscopic operation time, polyp diameter, and resection method are closely associated with the occurrence of postoperative delayed bleeding.
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13
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Elimeleh Y, Gralnek IM. Diagnosis and management of acute lower gastrointestinal bleeding. Curr Opin Gastroenterol 2024; 40:34-42. [PMID: 38078611 DOI: 10.1097/mog.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
PURPOSE OF REVIEW We review and summarize the most recent literature, including evidence-based guidelines, on the evaluation and management of acute lower gastrointestinal bleeding (LGIB). RECENT FINDINGS LGIB primarily presents in the elderly, often on the background of comorbidities, and constitutes a significant healthcare and economic burden worldwide. Therefore, acute LGIB requires rapid evaluation, informed decision-making, and evidence-based management decisions. LGIB management involves withholding and possibly reversing precipitating medications and concurrently addressing risk factors, with definitive diagnosis and therapy for the source of bleeding usually performed by endoscopic or radiological means. Recent advancements in LGIB diagnosis and management, including risk stratification tools and novel endoscopic therapeutic techniques have improved LGIB management and patient outcomes. In recent years, the various society guidelines on acute lower gastrointestinal bleeding have been revised and updated accordingly. SUMMARY By integrating the most recently published high-quality clinical studies and society guidelines, we provide clinicians with an up-to-date and comprehensive overview on acute LGIB diagnosis and management.
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Affiliation(s)
- Yotam Elimeleh
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
- The Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel
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14
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Xiao Q, Eckardt M, Mohamed A, Ernst H, Behrens A, Homann N, Hielscher T, Kähler G, Ebert M, Belle S, Zhan T. Onset Time and Characteristics of Postprocedural Bleeding after Endoscopic Resection of Colorectal Lesions: A Multicenter Retrospective Study. Dig Dis 2023; 42:78-86. [PMID: 37812925 DOI: 10.1159/000534109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Postprocedural bleeding is a major adverse event after endoscopic resection of colorectal lesions, but the optimal surveillance time after endoscopy is unclear. In this study, we determined onset time and characteristics of postprocedural bleeding events. METHODS We retrospectively screened patients who underwent endoscopic resection of colorectal lesions at three German hospitals between 2010 and 2019 for postprocedural bleeding events using billing codes. Only patients who required re-endoscopy were included for analysis. For identified patients, we collected demographic data, clinical courses, characteristics of colorectal lesions, and procedure-related variables. Factors associated with late-onset bleeding were determined by univariate and multivariate logistic regression analysis. RESULTS From a total of 6,820 patients with eligible billing codes, we identified 113 cases with postprocedural bleeding after endoscopic mucosal (61.9%) or snare resection (38.1%) that required re-endoscopy. The median size of the culprit lesion was 20 mm (interquartile range 14-30 mm). The median onset time of postprocedural bleeding was day 3 (interquartile range: 1-6.5 days), with 48.7% of events occurring within 48 h. Multivariate logistic regression analysis demonstrates that a continued intake of antiplatelet drugs (OR: 3.98, 95% CI: 0.89-10.12, p = 0.025) and a flat morphology of the colorectal lesion (OR: 2.98, 95% CI: 1.08-8.01, p = 0.031) were associated with an increased risk for late postprocedural bleeding (>48 h), whereas intraprocedural bleeding was associated with a decreased risk (OR: 0.12, 95% CI: 0.04-0.50, p = 0.001). CONCLUSION Significant postprocedural bleeding can occur up to 18 days after endoscopic resection of colorectal lesions, but was predominantly observed within 48 h. Continued intake of antiplatelet drugs and a flat polyp morphology are associated with risk for late postprocedural bleeding.
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Affiliation(s)
- Qiyun Xiao
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian Eckardt
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Awsan Mohamed
- Department of Medicine IV, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Helmut Ernst
- Department of Medicine IV, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Alexander Behrens
- Department of Internal Medicine II, Academic Teaching Hospital Wolfsburg, Wolfsburg, Germany
| | - Nils Homann
- Department of Internal Medicine II, Academic Teaching Hospital Wolfsburg, Wolfsburg, Germany
| | - Thomas Hielscher
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Ebert
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Cancer Center, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Belle
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tianzuo Zhan
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Cancer Center, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Janik VH. Bleeding After Endoscopic Resection of Colonic Adenomatous Polyps Sized 4-10 mm. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:157-164. [PMID: 37453110 DOI: 10.2478/prilozi-2023-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Introduction: Colonoscopy with polypectomy is an efficacious procedure in reducing the risk of colorectal cancer development, the precursor are adenomatous polyps. The most common method for resection of polyps measuring 4-10 mm are cold (CSP) and hot snare polypectomy (HSP). CSP has a lower incidence of adverse events, especially delayed post-polypectomy bleeding. Aim: To evaluate the presence of immediate and delayed bleeding in the cold snare polypectomy of sub-centimeter polyps of the colon compared with hot snare polypectomy. Materials and Methods: This prospective clinical study is comprised all patients who were incidentally detected to have adenomatous colonic polyps measuring 4-10 mm during a colonoscopy screening. Polypectomy was done with (hot snare) or without electrocautery (cold snare). After removal of polyps, immediate bleeding, delayed bleeding, and methods for were analyzed. Results: The CSP and HSP groups included 116 patients, 113 (54.4%) polyps in 61 (52.6%) patients with CSP while 95 (45.6%) polyps in 55 (47.4%) patients with HSP. 25 (22.1%) polyps after CSP had immediate bleeding. In 5 patients (20.0%), five hemostatic clips were inserted after CSP for bleeding longer than 150 sek. The average percentage difference between immediate bleeding versus total number of resected polyps using the cold snare method is not statistically significant (p<0.05) (Difference test, p=0.0000). Delayed bleeding was not registered using this method. In the second investigated group (HSP), one patient had delayed bleeding. This was stopped with 2 clips. Immediate bleeding was not registered. Conclusion: CSP is safer than HSP in resecting colon polyps sized 4-10 mm, without risk of delayed bleeding.
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16
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Libânio D, Pimentel-Nunes P, Bastiaansen B, Bisschops R, Bourke MJ, Deprez PH, Esposito G, Lemmers A, Leclercq P, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, Fuccio L, Bhandari P, Dinis-Ribeiro M. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55:361-389. [PMID: 36882090 DOI: 10.1055/a-2031-0874] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.
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Affiliation(s)
- Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute - Porto, Portugal.,MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Pedro Pimentel-Nunes
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, FMUP, Porto, Portugal.,Gastroenterology, Unilabs, Portugal
| | - Barbara Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia.,Western Clinical School, University of Sydney, Sydney, Australia
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gianluca Esposito
- Department of Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philippe Leclercq
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy. Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brueder Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.,University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, Gastroenterology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute - Porto, Portugal.,MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Porto, Portugal
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17
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WEO Newsletter. Dig Endosc 2023; 35:408-417. [PMID: 36892129 DOI: 10.1111/den.14522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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18
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Lau LHS, Jiang W, Guo CLT, Lui RN, Tang RSY, Chan FKL. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in aspirin users: a propensity-score analysis. Gastrointest Endosc 2023; 97:517-527.e1. [PMID: 36209766 DOI: 10.1016/j.gie.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Antithrombotic use is a significant risk factor of postpolypectomy bleeding (PPB). Evidence of prophylactic clipping is only available for proximal and large colonic lesions in the general population. Dedicated studies to examine the benefit of prophylactic clipping in patients on aspirin remain scarce. METHODS A propensity score-weighted retrospective cohort study was performed in a tertiary referral center from January 2018 to September 2021. Patients who received aspirin and underwent colonoscopic polypectomy, EMR, or endoscopic submucosal dissection were included. Data on baseline demographics, medications, and endoscopic factors (polyp number, size, location, and morphology; resection method; and prophylactic clipping) were captured. Propensity score-weighted models were developed between prophylactic clipping and no clipping groups. The primary outcome was delayed PPB within 30 days, with a composite endpoint consisting of repeated colonoscopy for hemostasis, requirement of blood transfusion, or hemoglobin drop >2 g/dL. RESULTS A total of 1373 patients with 3952 polyps were included. Baseline characteristics were balanced between the 2 groups. In the multivariate analysis, the largest polyp size was a significant risk factor for PPB (odds ratio, 1.07; 95% confidence interval, 1.02-1.11; P = .002). Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio, 1.34; 95% confidence interval, .83-2.18; P = .240) and did not show any risk reduction in subgroups with different polyp sizes and locations and endoscopic resection techniques. CONCLUSIONS Prophylactic clipping was not associated with a lower risk of PPB in aspirin users after endoscopic resection of colorectal polyps. Aspirin use should not be regarded as the only factor for the routine use of prophylactic clips.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Wei Jiang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Rashid N Lui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
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Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy. Am J Gastroenterol 2023; 118:812-819. [PMID: 36434811 DOI: 10.14309/ajg.0000000000002076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/06/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The periprocedural management of patients with atrial fibrillation (AF) using a direct oral anticoagulant (DOAC) undergoing elective gastrointestinal (GI) endoscopic procedure remains uncertain. We investigated the safety of a standardized periprocedural DOAC management strategy. METHODS The Periprocedural Anticoagulation Use for Surgery Evaluation cohort study enrolled adult patients receiving a DOAC (apixaban, rivaroxaban, or dabigatran) for AF scheduled for an elective procedure or surgery. This analysis addresses patients undergoing digestive endoscopy. Standardized periprocedural management consisted of DOAC interruption 1 day preendoscopy with resumption 1 day after procedure at low-moderate risk of bleeding or 2 days in case of a high bleeding risk. Thirty-day outcomes included GI bleeding, thromboembolic events, and mortality. RESULTS Of 556 patients on a DOAC (mean [SD] age of 72.5 [8.6] years; 37.4% female; mean CHADS 2 score 1.7 [1.0]), 8.6% were also on American Society of Anesthesiology (ASA) and 0.7% on clopidogrel. Most of the patients underwent colonoscopies (63.3%) or gastroscopies (14.0%), with 18.9% having both on the same procedural day. The mean total duration of DOAC interruption was 3.9 ± 1.6 days. Four patients experienced an arterial thromboembolic event (0.7%, 0.3%-1.8%) within 24.2 ± 5.9 days of DOAC interruption. GI bleeding events occurred in 2.5% (1.4%-4.2%) within 11.1 ± 8.1 days (range: 0.6; 25.5 days) of endoscopy, with major GI bleeding in 0.9% (0.4%-2.1%). Three patients died (0.5%; 0.2%-1.6%) 15.6-22.3 days after the endoscopy. DISCUSSION After a contemporary standardized periprocedural management strategy, patients with AF undergoing DOAC therapy interruption for elective digestive endoscopy experienced low rates of arterial thromboembolism and major bleeding.
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20
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Masunaga T, Kato M, Sasaki M, Iwata K, Miyazaki K, Kubosawa Y, Mizutani M, Takatori Y, Matsuura N, Nakayama A, Takabayashi K, Yahagi N. Modified double-layered suturing for a mucosal defect after colorectal endoscopic submucosal dissection (Origami method) (with video). Gastrointest Endosc 2023; 97:962-969. [PMID: 36642200 DOI: 10.1016/j.gie.2023.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Through-the-scope clips (TTSCs) are among the most common devices used to close colorectal post-endoscopic submucosal dissection (ESD) defects. Although TTSCs are easy to deliver, even to the proximal colon, simple clipping of large defects results in mucosa-mucosa closure, which could be unreliable. We developed a novel endoscopic closure technique using a modified double-layered suturing called the origami method (OGM). This method closes not only the mucosal layer but also the muscle layer with only TTSCs, which can obtain robust closure even for large defects. This study aimed to evaluate the feasibility of this new closure method for colorectal post-ESD defects. METHODS This retrospective observational study was conducted at a tertiary care hospital. We reviewed the cases of the OGM attempted after colorectal ESD at our institute between October 2021 and October 2022 and measured the clinical characteristics and outcomes of enrolled cases. RESULTS The OGM was attempted in 47 cases after colorectal ESD. Thirty-one cases (66%) were in the proximal colon, 5 (11%) in the distal colon, 6 (13%) in the upper rectum, and 5 (10%) in the lower rectum. The median defect size was 38 mm, with the largest being 85 mm. Complete closure was achieved in 44 cases (94%), including all lower rectum cases. No perforations were caused by clips during closure, and delayed perforation and bleeding were not observed. CONCLUSIONS This new closure method is feasible and recommended. The OGM could achieve reliable closure of large defects in any location, including the proximal colon and thick-walled lower rectum, using only TTSCs.
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Affiliation(s)
- Teppei Masunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Iwata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kurato Miyazaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Kubosawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023; 35:216-231. [PMID: 35778927 DOI: 10.1111/den.14397] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/30/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.
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Affiliation(s)
- Hideki Kobara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Naoya Tada
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shintaro Fujihara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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22
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Wadhwa V, Patel N, Grover D, Ali FS, Thosani N. Interventional gastroenterology in oncology. CA Cancer J Clin 2022; 73:286-319. [PMID: 36495087 DOI: 10.3322/caac.21766] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
Abstract
Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.
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Affiliation(s)
- Vaibhav Wadhwa
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nicole Patel
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Dheera Grover
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Faisal S Ali
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
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23
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Response. Gastrointest Endosc 2022; 96:1095-1096. [PMID: 36404095 DOI: 10.1016/j.gie.2022.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/30/2022] [Indexed: 11/19/2022]
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24
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Xu JH, Gao P, Zhou M, Gao S, Dong ZQ, Shen YC, Zhang QS. Clip-assisted endoloop ligation of the mucosal defect after resection of colorectal polyps decreased postprocedural delayed bleeding. Therap Adv Gastroenterol 2022; 15:17562848221131132. [PMID: 36406056 PMCID: PMC9669683 DOI: 10.1177/17562848221131132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Postprocedural delayed bleeding (PDB) remains the most common major complication of colorectal polypectomy. Incomplete clip closure of mucosal defect and unclosed injured blood vessels in gaps between clips may be the risk factors for PDB. OBJECTIVES To observe whether completely no-gap closure of mucosal defect after polypectomy can reduce PDB occurrence. DESIGN Single-center, retrospective case-control study. METHODS In this study based on historical comparisons of patients in 2 time periods, only the patients with polyps sized between 6 and 15 mm were included. A new clip-assisted endoloop ligation (CAEL, treatment group) method was used between January 2019 and December 2020, and a traditional simple clip closure (SCC, control) was used Between January 2017 and December 2018 to prevent PDB after polypectomy. The rate of PDB of two groups and risk factors for PDB were evaluated. RESULTS Totally 4560 patients were included in the study; 2418 patients belong to CAEL group, and 2142 patients belong to SCC group. The overall rate of PDB was significantly lower in CAEL group compared to SCC group (0.6% versus 1.5%, p < 0.00). On multivariate logistic analysis, CAEL was a significant independent preventive factor for PDB (odds ratio (OR), 0.092; 95% confidence interval (CI), 0.029-0.3335; p = 0.000). Polyps located at rectum (colon versus rectum) represented a significant independent risk factor for PDB (OR, 11.888; 95% CI, 3.343-42.269; p = 0.001). CONCLUSION Completely no-gap closure of mucosal defect after polypectomy further reduced the rate of PDB for polyps sized between 6 and 15 mm. CAEL may be a significant independent preventive factor for PDB. Polyps located at the rectum may be a significant independent risk factor for PDB.
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Affiliation(s)
- Jian-hua Xu
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Peng Gao
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Min Zhou
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Shuang Gao
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Zhi-qi Dong
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Yu-cui Shen
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
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Crockett SD, Pohl H. Reply. Clin Gastroenterol Hepatol 2022; 20:2656-2657. [PMID: 35123086 DOI: 10.1016/j.cgh.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Seth D Crockett
- Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, VA Medical Center, White River Junction, Vermont
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26
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Lu Q, Lv XH, Yang JL. Some Issues Considered for Clip Closure After Endoscopic Resection of Large Serrated Polyps. Clin Gastroenterol Hepatol 2022; 20:2656. [PMID: 35032635 DOI: 10.1016/j.cgh.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Qing Lu
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiu-He Lv
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin-Lin Yang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Al Ghamdi SS, Ngamruengphong S. Prevention of clinically significant post-EMR bleeding: To clip or not to clip? Gastrointest Endosc 2022; 96:732-734. [PMID: 36127161 DOI: 10.1016/j.gie.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Sarah S Al Ghamdi
- Division of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University, Saudi Arabia
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Li DF, Van Overbeke L, Ohata K, Wang LS, Yao J. Efficacy and safety of cold snare polypectomy for sessile serrated polyps ≥ 10 mm: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1486-1493. [PMID: 35168877 DOI: 10.1016/j.dld.2022.01.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. However, the efficacy and safety of this technique remain undetermined. AIMS We aimed to comprehensively evaluate the efficacy and safety of CSP for SSPs ≥ 10 mm. METHODS PubMed, EMBASE, Web of Science and Cochrane Library were searched up to January 2021. RESULTS A total of 10 studies consisting of 1727 SSPs (range, 10-40 mm) from 1021 patients were included. The overall rates of technical success, adverse events (AEs) and residual SSPs were 100%, 0.7% and 2.9%, respectively. Subgroup analysis showed that the rates of technical success and AEs were comparable between CSP and cold endoscopic mucosal resection (EMR) (99.9% vs. 100% and 1.3% vs. 0.5%, respectively), between the proximal and distal colon (100% vs. 99.9% and 0.3% vs. 0, respectively), and between polyps of 10-19 mm and ≥20 mm (99.8% vs. 100% and 0.9% vs. 0, respectively). However, subgroup analysis showed that the rate of residual SSPs was slightly lower in CSP compared with cold EMR (1.3% vs. 3.9%), as well as in polyps of 10-19 mm compared with those ≥20 mm (3.1% vs. 4.7%). CONCLUSION CSP was an effective and safe technique for removing SSPs ≥ 10 mm.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China
| | | | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China.
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China.
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29
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Forbes N, Gupta S, Frehlich L, Meng ZW, Ruan Y, Montori S, Chebaa BR, Dunbar KB, Heitman SJ, Feagins LA, Albéniz E, Pohl H, Bourke MJ. Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials. Gastrointest Endosc 2022; 96:721-731.e2. [PMID: 35667388 DOI: 10.1016/j.gie.2022.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm. METHODS We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses. RESULTS From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of .31 (95% confidence interval [CI], .17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of .78 (95% CI, .17-3.54) and .67 (95% CI, .20-2.22), respectively. CONCLUSIONS Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Benjamin R Chebaa
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Kerry B Dunbar
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven J Heitman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Linda A Feagins
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eduardo Albéniz
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain; Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA; Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA; Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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30
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El Rahyel A, Rex DK. Outcomes of large colorectal polyp endoscopic resections during small audience live endoscopy events with endoscopist at their home endoscopy unit. Endosc Int Open 2022; 10:E1386-E1390. [PMID: 36262510 PMCID: PMC9576331 DOI: 10.1055/a-1922-8046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background and study aims Live endoscopy courses are popular. The safety of performing live endoscopy has been questioned. In this study, we compared outcomes of large colorectal polyp resections during live endoscopy events (LEEs) (with a small audience of 2 to 5 physicians) to those removed during standard procedure days (SPDs) (without an audience). All procedures were performed at the endoscopist's home unit. Methods Retrospective assessment of the adverse event (AE) and recurrence rates for large ( ≥ 20 mm) non-pedunculated colorectal lesions removed during LEEs. Logistic regression was used to assess whether presence of an audience predicted worse outcomes. Results From January 2017 to May 2021, 317 lesions were removed with a live audience and 866 were removed on SPDs. Polyp pathology and procedure length were similar in both groups. There were 16 (5.0 %) total adverse events in the LEE group and 30 (3.4 %) in the SPD group ( P = 0.224). The majority in both groups were delayed hemorrhage. There were 2 (0.6 %) perforations in the LEE and 3 (0.3 %) in the SPD group. Increasing polyp size was associated with more AEs and higher recurrence. Increasing patient age predicted higher recurrence, and thermal injury of the resection margin predicted lower recurrence. There were no other predictors of AEs or recurrence, including presence of a live audience. Conclusions Removing large colorectal polyps with a small live audience did not increase adverse outcomes.
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Affiliation(s)
- Ahmed El Rahyel
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Douglas K. Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
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31
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Komanduri S, Dominitz JA, Rabeneck L, Kahi C, Ladabaum U, Imperiale TF, Byrne MF, Lee JK, Lieberman D, Wang AY, Sultan S, Shaukat A, Pohl H, Muthusamy VR. AGA White Paper: Challenges and Gaps in Innovation for the Performance of Colonoscopy for Screening and Surveillance of Colorectal Cancer. Clin Gastroenterol Hepatol 2022; 20:2198-2209.e3. [PMID: 35688352 DOI: 10.1016/j.cgh.2022.03.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 02/23/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
In 2018, the American Gastroenterological Association's Center for GI Innovation and Technology convened a consensus conference, entitled "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The conference participants, which included more than 60 experts in colorectal cancer, considered recent improvements in colorectal cancer screening rates and polyp detection, persistent barriers to colonoscopy uptake, and opportunities for performance improvement and innovation. This white paper originates from that conference. It aims to summarize current patient- and physician-centered gaps and challenges in colonoscopy, diagnostic and therapeutic challenges affecting colonoscopy uptake, and the potential use of emerging technologies and quality metrics to improve patient outcomes.
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Affiliation(s)
- Srinadh Komanduri
- Department of Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System and the Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Linda Rabeneck
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Charles Kahi
- Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, the Regenstrief Institute, the Simon Cancer Center, and the Center for Innovation at Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Michael F Byrne
- Division of Gastroenterology, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey K Lee
- Collaborative Health Outcomes Research in Digestive Diseases (CHORD) Group, Kaiser Permanente Division of Research, Kaiser Permanente San Francisco, San Francisco, California
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aasma Shaukat
- Division of Gastroenterology, Minneapolis Veterans Affairs Health Care System and Department of Medicine, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heiko Pohl
- Veterans Affairs Medical Center White River Junction, Vermont; Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California.
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32
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Safe, efficient, and effective screening colonoscopy. Curr Opin Gastroenterol 2022; 38:430-435. [PMID: 35894671 DOI: 10.1097/mog.0000000000000860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Colorectal cancer continues to be one of the most common causes of cancer-related death. Widespread dissemination of screening colonoscopy in the United States has led to a significant reduction in the incidence and mortality. Here we review current literature with an aim to highlight recent improvements in the safety, efficiency, and effectiveness of screening colonoscopy. RECENT FINDINGS Colon capsule endoscopy is an emerging noninvasive method to capture images of colonic mucosa for select patients with appreciable sensitivity for polyp detection. Recent literature supports the use of the novel oral anticoagulant apixaban over other anticoagulants to reduce the risk of gastrointestinal bleeding related to colonoscopy. Cold snare polypectomy for smaller lesions and prophylactic clipping following resection of large polyps in the proximal colon may reduce the rate of delayed bleeding. Novel methods and devices for improving bowel preparation continue to emerge. Mechanical attachment devices and artificial intelligence represent recent innovations to improve polyp detection. SUMMARY Clinicians should be aware of relevant data and literature that continue to improve the quality and safety of screening colonoscopy and incorporate these findings into their clinical practice.
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Dixit VK, Sahu MK, Venkatesh V, Bhargav VY, Kumar V, Pateriya MB, Venkataraman J. Gastrointestinal Emergencies and the Role of Endoscopy. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1755303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractMany gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies.
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Affiliation(s)
- Vinod Kumar Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Manoj Kumar Sahu
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Vybhav Venkatesh
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Varanasi Yugandhar Bhargav
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Vinod Kumar
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mayank Bhushan Pateriya
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Lau LHS, Guo CLT, Lee JKK, Chan CST, Mak JWY, Wong SH, Yip TCF, Wong GLH, Wong VWS, Chan FKL, Tang RSY. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in oral anticoagulant users: a propensity-score analysis. Gastrointest Endosc 2022; 96:530-542.e1. [PMID: 35413329 DOI: 10.1016/j.gie.2022.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Evidence of prophylactic clipping is inconsistent except for proximal and large colonic lesions in the general population. Although warfarin and direct oral anticoagulants (DOACs) are significant risk factors of postpolypectomy bleeding (PPB), dedicated studies to examine the benefit of prophylactic clipping in these high-risk patients remain limited. METHODS We performed a propensity score-weighted retrospective cohort study from 2012 to 2020. Patients who received an oral anticoagulant and underwent colonoscopic polypectomy were included. Data were collected on baseline demographics, medications (anticoagulant, antiplatelet, and heparin bridging), and endoscopies (polyp number, location, size, morphology, histopathology, resection method and prophylactic clipping). Propensity-score models with inverse probability of treatment weighting were developed between prophylactic clipping and no clipping groups. Unbalanced variables were included in a doubly robust model with multivariate analysis. The primary outcome was clinically significant delayed PPB, defined as a composite endpoint of hemoglobin drop ≥2 g/dL, blood transfusion, or repeat colonoscopy for hemostasis within 30 days. RESULTS Five hundred forty-seven patients with 1485 polyps were included. Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio [OR], 1.19; 95% confidence interval [CI], .73-1.95; P = .497). The hot resection method was associated with a significantly higher risk of PPB (OR, 9.76; 95% CI, 3.94-32.60; P < .001) compared with cold biopsy or snare polypectomy. In a subgroup analysis, prophylactic clipping was associated with a lower PPB risk in patients on DOACs (OR, .36; 95% CI, .16-.82; P = .015). CONCLUSIONS Prophylactic clipping was not associated with an overall reduced risk of PPB in patients on oral anticoagulants. The use of cold snare polypectomy should be maximized in anticoagulated patients.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Joyce K K Lee
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Clive S T Chan
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Sunny H Wong
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Terry C F Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions. Am J Gastroenterol 2022; 117:1080-1088. [PMID: 35765907 DOI: 10.14309/ajg.0000000000001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/27/2022] [Indexed: 12/11/2022]
Abstract
The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.
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Rex DK, Vemulapalli KC. Response. Gastrointest Endosc 2022; 95:1288-1289. [PMID: 35589217 DOI: 10.1016/j.gie.2022.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/19/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Repici A, Maselli R, Hassan C. How to Incorporate Advanced Tissue Resection Techniques in Your Institution. Gastroenterology 2022; 162:1825-1830. [PMID: 35358510 DOI: 10.1053/j.gastro.2022.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Roberta Maselli
- Department of Gastroenterology, Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cesare Hassan
- Department of Gastroenterology, Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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38
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American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol 2022; 117:542-558. [PMID: 35297395 PMCID: PMC8966740 DOI: 10.14309/ajg.0000000000001627] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 02/07/2023]
Abstract
We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1-7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1-7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.
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Management of Patients on Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Peri-Endoscopic Period: A Clinical Practice Guideline Dissemination Tool. Am J Gastroenterol 2022; 117:513-519. [PMID: 35354773 DOI: 10.14309/ajg.0000000000001688] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 12/11/2022]
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40
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Telford JJ, Abraham NS. Management of Antiplatelet and Anticoagulant Agents before and after Polypectomy. Gastrointest Endosc Clin N Am 2022; 32:299-312. [PMID: 35361337 PMCID: PMC9169436 DOI: 10.1016/j.giec.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Antithrombotic medications, including antiplatelet drugs and anticoagulants, are widely prescribed to prevent thromboembolic disease. There is limited evidence informing gastroenterologists of the management of patients on antithrombotic medications undergoing colonoscopy and polypectomy. A patient's risk of thromboembolism versus postpolypectomy bleeding should be carefully considered, incorporating patient preferences concerning benefits and harms of temporary antithrombotic interruption. We will review the available consensus guidelines, current literature, and strategies to mitigate the risk of bleeding following polypectomy. These will be interpreted in the framework of shared decision-making with the patient to arrive at the safest solution best aligned with the patient's preferences.
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Affiliation(s)
- Jennifer J Telford
- Division of Gastroenterology, Department of Medicine, University of British Columbia, 770-1190 Hornby Street, Vancouver, British Columbia V6Z2K5, Canada.
| | - Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
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Abraham NS, Barkun AN, Sauer BG, Douketis J, Laine L, Noseworthy PA, Telford JJ, Leontiadis GI. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. J Can Assoc Gastroenterol 2022; 5:100-101. [DOI: 10.1093/jcag/gwac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1–7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1–7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.
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Affiliation(s)
- Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Alan N Barkun
- Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bryan G Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- Virginia Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Electrophysiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer J Telford
- Division of Gastroenterology, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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SANTOS CEOD, NADER LA, SCHERER C, FURLAN RG, SANMARTIN IDA, PEREIRA-LIMA JC. SMALL AS WELL AS LARGE COLORECTAL LESIONS ARE EFFECTIVELY MANAGED BY ENDOSCOPIC MUCOSAL RESECTION TECHNIQUE. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:16-21. [DOI: 10.1590/s0004-2803.202200001-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/06/2021] [Indexed: 11/21/2022]
Abstract
ABSTRACT Background Endoscopic mucosal resection (EMR) is an easy-to-use treatment option for superficial colorectal lesions, including lesions ≥20 mm. Objective To evaluate the effectiveness of EMR. Methods We evaluated 430 lesions removed by EMR in 404 patients. The lesions were analyzed according to their morphology, size, location, and histology. Lesions <20 mm were resected en bloc, whereas lesions ≥20 mm were removed by piecemeal EMR (p-EMR). Adverse events and recurrence were assessed. Results Regarding morphology, 145 (33.7%) were depressed lesions, 157 (36.5%) were polypoid lesions and 128 (29.8%) were laterally spreading lesions, with 361 (84%) lesions <20 mm and 69 (16%) ≥20 mm. Regarding histology, 413 (96%) lesions were classified as neoplastic lesions. Overall, 14 (3.3%) adverse reactions occurred, most commonly in lesions removed by p-EMR (P<0.001) and associated with advanced histology (P=0.008). Recurrence occurred in 14 (5.2%) cases, more commonly in lesions removed by p-EMR (P<0.001). Conclusion EMR is an effective technique for the treatment of superficial colorectal lesions, even of large lesions.
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Turan AS, Pohl H, Matsumoto M, Lee BS, Aizawa M, Desideri F, Albéniz E, Raju GS, Luba D, Barret M, Gurudu SR, Ramirez FC, Lin WR, Atsma F, Siersema PD, van Geenen EJM. The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis. Clin Gastroenterol Hepatol 2022; 20:362-371.e23. [PMID: 33991691 DOI: 10.1016/j.cgh.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. METHODS An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. RESULTS Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52). CONCLUSIONS Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.).
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Heiko Pohl
- Section of Gastroenterology and Hepatology, VA White River Junction, White River Junction, Vermont
| | - Mio Matsumoto
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | - Brian S Lee
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, California
| | - Masato Aizawa
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Aizuwakamatsu, Japan
| | - Federico Desideri
- Digestive and Liver Disease Department, Endoscopy Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; Gastroenterology Department, San Maurizio Hospital, Bolzano, Italy
| | - Eduardo Albéniz
- Department of Gastroenterology, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | | | - Daniel Luba
- Monterey Bay Gastroenterology Consultants, Monterey, California
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, AP-HP, Université de Paris, Paris, France
| | | | | | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Femke Atsma
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Bendall O, James J, Pawlak KM, Ishaq S, Tau JA, Suzuki N, Bollipo S, Siau K. Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients. Clin Exp Gastroenterol 2022; 14:477-492. [PMID: 34992406 PMCID: PMC8714413 DOI: 10.2147/ceg.s282699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022] Open
Abstract
Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3–1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.
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Affiliation(s)
- Oliver Bendall
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Joel James
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Katarzyna M Pawlak
- Endoscopy Unit, Department of Gastroenterology, Ministry of Interior and Administration, Szczecin, Poland
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, UK.,Medicine, Birmingham City Hospital, Birmingham, UK
| | - J Andy Tau
- Austin Gastroenterology, Austin, TX, USA
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St. Mark's Hospital, London, UK
| | - Steven Bollipo
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Gupta S, Sidhu M, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Byth K, Brown G, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 7:152-160. [PMID: 34801133 DOI: 10.1016/s2468-1253(21)00384-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. METHODS We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. FINDINGS Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. INTERPRETATION Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. FUNDING None.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Eric Yong Tat Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Stephen John Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Nicholas Graeme Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael John Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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Guo XF, Yu XA, Hu JC, Lin DZ, Deng JX, Su ML, Li J, Liu W, Zhang JW, Zhong QH. Endoscopic management of delayed bleeding after polypectomy of small colorectal polyps: two or more clips may be safe. Gastroenterol Rep (Oxf) 2021; 10:goab051. [PMID: 35382164 PMCID: PMC8972999 DOI: 10.1093/gastro/goab051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/14/2022] Open
Abstract
Background The resection of small colorectal polyps (≤10 mm) is routine for endoscopists. However, the management of one of its main complications, namely delayed (within 14 days) postpolypectomy bleeding (DPPB), has not been clearly demonstrated. We aimed to assess the role of coloscopy in the management of DPPB from small colorectal polyps and identify the associated factors for initial hemostatic success. Methods We conducted a retrospective study of 69 patients who developed DPPB after the removal of colorectal polyps of ≤10 mm and underwent hemostatic colonoscopy at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between April 2013 and June 2021. Demographics, clinical variables, and colonoscopic features were collected independently. We applied univariate and multivariate analyses to assess factors associated with initial hemostatic success. Results General colonoscopy without oral bowel preparation was successfully performed in all the patients, with a median duration of 23.9 (12.5–37.9) minutes. Among 69 patients, 62 (89.9%) achieved hemostasis after initial hemostatic colonoscopy and 7 (10.1%) rebled 2.7 ± 1.1 days after initial colonoscopic hemostasis and had rebleeding successfully controlled by one additional colonoscopy. No colonoscopy-related adverse events occurred. Multivariate analysis showed that management with at least two clips was the only independent prognostic factor for initial hemostatic success (odds ratio, 0.17; 95% confidence interval, 0.03–0.91; P = 0.04). All the patients who had at least two clips placed at the initial hemostatic colonoscopy required no further hemostatic intervention. Conclusions Colonoscopy is a safe, effective, and not too time-consuming approach for the management of patients with DPPB of small colorectal polyps and management with the placement of at least two hemoclips may be beneficial.
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Affiliation(s)
- Xue-Feng Guo
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiang-An Yu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jian-Cong Hu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - De-Zheng Lin
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Xin Deng
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Ming-Li Su
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Juan Li
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei Liu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Wei Zhang
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qing-Hua Zhong
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Corresponding author. Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-20-38254166; Fax: +86-20-38254166;
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47
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Ortiz O, Rex DK, Grimm IS, Moyer MT, Hasan MK, Pleskow D, Elmunzer BJ, Khashab MA, Sanaei O, Al-Kawas FH, Gordon SR, Mathew A, Levenick JM, Aslanian HR, Antaki F, von Renteln D, Crockett SD, Rastogi A, Gill JA, Law R, Wallace MB, Elias PA, MacKenzie TA, Pohl H, Pellisé M. Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps. Endoscopy 2021; 53:1150-1159. [PMID: 33291159 DOI: 10.1055/a-1332-6727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIM : Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of nonpedunculated polyps larger than 20 mm reduces the incidence of severe delayed bleeding, especially in proximal polyps. This study aimed to evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. METHODS : This is a post hoc analysis of the CLIP study (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when no remaining mucosal defect was visible and clips were less than 1 cm apart. Factors associated with complete closure were evaluated in multivariable analysis. RESULTS : In total, 458 patients (age 65, 58 % men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4 %); closure was not complete for 156 (31.6 %). Factors associated with complete closure in adjusted analysis were smaller polyp size (odds ratio 1.06 for every millimeter decrease [95 % confidence interval 1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]). CONCLUSIONS : Complete clip closure was not achieved for almost one in three resected large nonpedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. This highlights the need for alternative closure options and measures to prevent bleeding.
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Affiliation(s)
- Oswaldo Ortiz
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Douglas Pleskow
- Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Firas H Al-Kawas
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Sibley Memorial Hospital, Washington, DC, USA
| | - Stuart R Gordon
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA.,Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John M Levenick
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Harry R Aslanian
- Section of Digestive Diseases, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Fadi Antaki
- Division of Gastroenterology, John D. Dingell Veterans Affairs Medical Center and Wayne State University, Detroit, Michigan, USA
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Medical Center (CHUM) and Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey A Gill
- Division of Gastroenterology, James A. Haley VA, University of South Florida, Tampa, Florida, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Pooja A Elias
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Todd A MacKenzie
- The Dartmouth Institute, Department for Biomedical Data Science, Lebanon, New Hampshire, USA
| | - Heiko Pohl
- Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Section of Gastroenterology and Hepatology, VA White River Junction, Vermont, USA
| | - Maria Pellisé
- Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universitat de Barcelona, Barcelona, Spain
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48
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Albéniz E. Further new evidence regarding clipping following colorectal endoscopic mucosal resection. Endoscopy 2021; 53:1160-1161. [PMID: 34293813 DOI: 10.1055/a-1408-3146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, Navarra, Spain
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49
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Chua TY, Kyanam Kabir Baig KR, Leung FW, Ashat M, Jamidar PA, Mulki R, Singh A, Yu JX, Lightdale JR. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020. Gastrointest Endosc 2021; 94:441-451. [PMID: 34147512 DOI: 10.1016/j.gie.2021.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.
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Affiliation(s)
- Tiffany Y Chua
- Division of Digestive Diseases, Harbor-University of California Los Angeles, Torrance, California, USA
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Felix W Leung
- VA Sepulveda Ambulatory Care Center, North Hills, California, USA
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ajaypal Singh
- Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica X Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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50
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Keswani RN, Crockett SD, Calderwood AH. AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review. Gastroenterology 2021; 161:701-711. [PMID: 34334168 DOI: 10.1053/j.gastro.2021.05.041] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 12/23/2022]
Abstract
The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.
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Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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