Endoscopic resection of large colorectal polyps using a clipping method

The Effectiveness of Prophylactic Epinephrine Compared to No Prophylaxis for Postpolypectomy Bleeding in Endoscopic Colorectal Surgery: A Systematic Review and Meta-Analysis

Colorectal cancer prevention has seen significant advancements with colonoscopic polypectomy, a critical technique in clinical practice. However, postpolypectomy bleeding (PPB), particularly in the resection of large pedunculated polyps, remains a major complication. This systematic review and meta-analysis investigates the efficacy of prophylactic epinephrine injections in preventing PPB, addressing inconsistencies in the literature regarding its effectiveness. Employing a comprehensive search strategy, we rigorously selected studies for inclusion, focusing on those comparing prophylactic epinephrine with no intervention. The risk of bias was assessed using the Cochrane Risk of Bias assessment tool, ensuring a robust and reliable analysis. Our findings, based on an analysis of four studies involving 1,062 patients, indicate a significant reduction in early PPB with epinephrine use, with a marked decrease in bleeding incidence compared to the no-prophylaxis group. However, the impact on delayed bleeding was less conclusive, suggesting the need for further research in this area. Our study thus highlights the effectiveness of epinephrine as a preventive tool in colonoscopic polypectomy while underscoring the complexity of bleeding risks and the necessity for ongoing investigation in optimizing patient outcomes.

Evaluation of cold snare polypectomy for small pedunculated (Ip) polyps with thin stalks: a prospective clinical feasibility study

BACKGROUND

Although the use of cold snare polypectomy (CSP) has spread rapidly, no prospective studies evaluating the safety of CSP for pedunculated (Ip) polyps have been carried out.

AIM

We performed this study to provide an accurate evaluation of the safety of CSP for Ip polyps.

METHODS

This is a prospective study (UMIN000035687). From January 2019 to February 2021, the safety of CSP for use on Ip polyps <10 mm with thin stalks was evaluated at our hospital. The primary outcome measure was the incidence of bleeding (delayed post-polypectomy bleeding (DPPB) and immediate bleeding).

RESULTS

During the study period, 89 consecutive patients (including 92 colonoscopies and 114 polyps) were prospectively enrolled. The en-bloc resection rate was 100%. The rate of DPPB after CSP was 0%, however, DPPB after conversion to HSP occurred in 1 case (33.3% (1/3)). The rate of immediate bleeding during CSP was 28.9% (33/114). Polyps with diameters ≥6 mm (OR (95% CI): 2.77 (1.041-7.376); p = .041) were extracted as independent risk factors for immediate bleeding during CSP for Ip polyps. In all, 104 (91.2%) polyps were low-grade adenomas, and the percentage of cases with negative pathological margins was 96.5% (110/114).

CONCLUSIONS

CSP for Ip polyps was safe and had good outcomes. We believe that Ip polyps could be included as an indication for CSP, and that CSP may become the next step in the 'cold revolution.' To confirm our results and verify CSP's inclusion in future guidelines, prospective, randomized studies are necessary.

Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding

BACKGROUND

Although prophylactic clip application before polypectomy may prevent postpolypectomy bleeding (PPB), the usefulness of prophylactic clipping in the treatment of large pedunculated polyps is controversial in some prospective randomized studies. This study was conducted to evaluate the efficacy of prophylactic clip application and to investigate the predictors of PPB in large pedunculated colorectal polyps.

METHODS

A total of 137 pedunculated polyps (size ≥1 cm) in 116 patients were prospectively included and randomized into group A (with clipping) and group B (without clipping), and resected. The occurrences of immediate PPB (graded 1-4) and delayed PPB were compared.

RESULTS

Sixty-seven polyps were allocated in group A and 70 polyps in group B. In both groups, the median polyp diameter was 15 mm (P = 0.173) and the median stalk diameter was 3 mm (P = 0.362). Twenty-eight (20.4%) immediate PPB episodes in 137 polyps occurred, 6 (9.0%) in group A and 22 (31.4%) in group B (P = 0.001). However, the occurrence of delayed PPB was not different between the groups (P = 0.943). Prophylactic clip application decreased the occurrence of immediate PPB (odds ratio 0.215, 95% confidence interval 0.081-0.571). Moreover, polyp size ≥20 mm and stalk diameter ≥ 4 mm increased the risk of immediate PPB.

CONCLUSIONS

Clip application before polypectomy of ≥1 cm pedunculated polyps is effective in decreasing the occurrence of immediate PPB. Thus, clip application should be considered before performing snare polypectomy, especially for large polyps with a thick stalk.

TRIAL REGISTRATION

This research was studied a prospective maneuver and enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT01437631). This study was registered on September 19, 2011.

Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies

Background

Bleeding is the most common major complication following colonoscopic polypectomy. The purpose of this study is to evaluate whether submucosal epinephrine injections could prevent the occurrence of postpolypectomy bleeding.

Method

The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for appropriate randomized controlled studies published before April 2015. A meta-analysis was conducted to investigate the preventative effect of submucosal epinephrine injection for overall, early, and delayed postpolypectomy bleeding.

Results

The final analysis examined the findings of six studies, with data from 1388 patients. The results demonstrated that prophylactic treatment with epinephrine injection significantly reduced the occurrence of overall (OR = 0.38, 95% CI: 0.21, 0.66; p = 0.0006) and early bleeding (OR = 0.38, 95% CI: 0.20, 0.69; p = 0.002). However, for delayed bleeding complications, epinephrine injections were not found to be any more effective than treatment with saline injection or no injection (OR = 0.45, 95% CI: 0.11, 1.81; p = 0.26). Moreover, for patients with polyps larger than 20 mm, mechanical hemostasis devices (endoloops or clips) were found to be more effective than epinephrine injection in preventing overall bleeding (OR = 0.33, 95% CI: 0.13, 0.87; p = 0.03) and early bleeding (OR = 0.29, 95% CI: 0.08, 1.02; p = 0.05). This was not established for delayed bleeding.

Conclusion

The routine use of prophylaxis submucosal epinephrine injection is safe and beneficial preventing postpolypectomy bleeding.

Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps

BACKGROUND AND AIM

Post-polypectomy bleeding (PPB) is the most common adverse event of colonoscopic polypectomy, especially in cases with large pedunculated polyps. To minimize the risk of PPB, several endoscopic preventive methods have been performed. The aim of this prospective, randomized study was to compare the rates of PPB following single (clipping alone) and combined (clipping plus epinephrine-saline injection) methods in prevention of PPB in large pedunculated polyps.

METHODS

Adult patients with pedunculated colorectal polyps with heads ≥ 10 mm were prospectively enrolled from March 2011 to January 2013. Patients were randomized to receive treatment of either clips alone (group A) or clips plus injection of epinephrine-saline (group B) prior to a conventional polypectomy. PPB rate in both groups were compared.

RESULTS

A total of 148 patients with 173 pedunculated colorectal polyps were enrolled. Groups A and B each had 74 patients, with 83 and 90 polyps, respectively. The mean head diameters were 17.2 ± 6.6 and 17.5 ± 6.7 mm in groups A and B, respectively (P = 0.748). Immediate PPB (IPPB) occurred in 10 cases (12.0%) from group A and 13 cases (14.4%) from group B (P = 0.64). There were no cases of delayed PPB or perforation. Multivariate analysis showed that inadequate bowel preparation and large head diameter of polyp were independent risk factors for IPPB.

CONCLUSIONS

The rate of IPPB is relatively high in cases with large pedunculated polyps, but these polyps can be successfully resected by snare polypectomy following use of the single prophylactic clipping method.

Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥ 30 mm) pedunculated colorectal polyp?

BACKGROUND

Snare polypectomy of a giant pedunculated colorectal polyp is sometimes technically demanding, and, therefore, piecemeal resection is inevitable, despite the relative risk of invasive cancer and postpolypectomy bleeding.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection in comparison with conventional snare polypectomy for giant pedunculated polyps

DESIGN AND SETTINGS

We retrospectively reviewed the clinical outcomes and complications of endoscopic polypectomy for giant pedunculated polyps from October 2006 to November 2011.

PATIENTS

All the patients who underwent endoscopic submucosal dissection (n = 23) or snare polypectomy (n = 20) for pedunculated polyps ≥ 3 cm were enrolled consecutively. In the case of a giant pedunculated polyp with 1) poor visualization of the stalk, 2) technical difficulties in snare positioning for en bloc resection, or 3) need for trimming of the head, we did not attempt piecemeal snare polypectomy, and we performed endoscopic submucosal dissection instead. (These were arbitrarily defined as "difficult" giant pedunculated polyps.)

MAIN OUTCOME MEASURES

Data on the patient's demography, endoscopic and histopathologic findings, clinical outcomes, and complications were analyzed.

RESULTS

Among the 43 giant pedunculated polyps, 23 polyps were defined as "difficult" polyps and were removed with endoscopic submucosal dissection. Subpedunculated (stalk <1 cm) type was more common in the "difficult" polyp group (p = 0.01). The overall incidence of cancer was 18.6% (8/43). En bloc resection rates were 100% (23/23) in the endoscopic submucosal dissection group and 90% (18/20) in the snare polypectomy group. The procedure times of snare polypectomy and endoscopic submucosal dissection group did not differ significantly (41.7 ± 13.7 minutes vs 44.9 ± 35.6 minutes, p = 0.70). Postpolypectomy bleeding was noted in 1 case (4.3%) in the endoscopic submucosal dissection group and in 3 cases (15%) in the snare polypectomy group.

CONCLUSIONS

Endoscopic submucosal dissection, as well as the snare polypectomy for giant pedunculated polyps, appeared to be effective without major complications and can be an alternative option to achieve en bloc resection, particularly for difficult cases, such as giant subpedunculated polyps.

Prophylactic clip application before endoscopic resection of large pedunculated colorectal polyps in patients receiving anticoagulation or antiplatelet medications

BACKGROUND

The aim of the present study was to evaluate the safety of prophylactic endoclipping before resection of large pedunculated colorectal polyps in patients with uninterrupted anticoagulation or antiplatelet therapy.

PATIENTS AND METHODS

In a single tertiary referral center, patients with normal coagulation parameters and those with uninterrupted anticoagulation or antiplatelet medications, who underwent prophylactic endoclipping before resection of large pedunculated colorectal polyps (polyp's head diameter >10 mm), were evaluated retrospectively. Demographic, clinical, and laboratory parameters, polyp characteristics, number of clips used for endoclipping, histology of resected polyps, the polypectomy technique, and postpolypectomy complications were recorded and compared.

RESULTS

In 64 patients with large pedunculated colorectal polyps, successful endoclipping before resection was achieved. Eleven patients (17.2%) had uninterrupted anticoagulation (n = 4) or antiplatelet (n = 7) medications. Statistical analysis showed no significant differences in age, sex, indications for colonoscopy, location of polyps, size of polyp head or stalk, coexisting small polyps, histology of resected polyps, and polypectomy techniques among patients with normal coagulation parameters (group A) and patients on uninterrupted anticoagulant or antiplatelet treatment (group B). Coronary artery disease, hypertension, and atrial fibrillation were significantly more prevalent in group B. No immediate or delayed postpolypectomy hemorrhage occurred in either group. One patient (1.9%) in group A developed postpolypectomy coagulation syndrome and was successfully treated conservatively. Follow-up evaluation demonstrated no recurrence of polyps or cancer development.

CONCLUSIONS

According to our experience, uncomplicated polypectomy of large pedunculated colorectal polyps can be performed by prophylactic endoclipping in patients receiving anticoagulation or antiplatelet medications.

Postpolypectomy bleeding: incidence, risk factors, prevention, and management

Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.

Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

BACKGROUND

Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model.

METHODS

Cholecystectomies were attempted in five 88-130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route.

RESULTS

Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present.

CONCLUSIONS

NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.

Evaluating long-term attachment of two different endoclips in the human gastrointestinal tract

AIM: To evaluate the long-term attachment of two types of endoclips in the human gastrointestinal tract.

METHODS: In this prospective observational study, endoclips were placed and followed-up during endoscopies or using fluoroscopic images as part of a prospective feasibility study evaluating external beam radiotherapy (EBRT, wk 1-3) followed by high dose rate brachytherapy (HDRBT with an endoluminal applicator once a week for 3 wk, wk 9-11) in medically inoperablerectal cancer patients. Initially, the type and number of endoclips were chosenrandomly and later refined to 1 Resolution^® clip (Microvasive) proximal and 2 Quickclips^® (Olympus) distal to the tumor. Nine consecutive patients from between September 2007 and August 2008 were analyzed. Retention rates were evaluated over three different observational periods [period 1: pre-HDRBT (wk -2-8), period 2: during HDRBT (wk 9-11) and period 3: post-HDRBT (wk 12-16)].

RESULTS: In this study, a total of 44 clips were placed during endoscopy, either at the beginning or at the end of period 1. The Resolution clip had a higher overall retention rate than the Quickclip (P = 0.01). After a median period of 81 d after placement (in period 1), long-term retention rates for the Resolution clip and Quickclip clip were 67% and 35% respectively.

CONCLUSION: The Resolution clip has a high retention rate and is useful in situations where long-term attachment to the human gastrointestinal mucosa is warranted.

Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome

BACKGROUND

The most common complication of polypectomy is hemorrhage, and various techniques have been used to prevent this complication.

AIM

This study evaluates the outcomes of endoclip-assisted polypectomy in patients with large pedunculated colorectal polyps, in comparison with a historical control group of patients treated with endoloop-assisted polypectomy.

METHODS

Between January and December 2007, 32 patients with 32 large pedunculated polyps (>or=15 mm) were treated with endoclip-assisted polypectomy (group A). Between January and December 2006, 35 patients with 35 large pedunculated polyps were treated; 33 with endoloop-assisted polypectomy (control, group B) and two cases with endoclips and needle knife, which were included in group A for the analysis.

RESULTS

The mean (+/- standard deviation [SD]) size of polyp head was 26.8 +/- 8.1 mm (range 15-50) in group A and 22.3 +/- 4.1 mm (range 15-30) in group B (P = 0.004). In group A, six polyps had a mean (+/-SD) head size of 40.8 +/- 5.8 mm (range 35-50) and were resected with clips and needle knife. In group A, bleeding occurred in two cases (5.9%), which were associated with the presence of cancer at histology (P = 0.006) and were managed by applying new clips. No bleeding occurred in patients of group B and no perforation and post-polypectomy syndrome occurred in either group. There were three (8.8%) cancerized adenomas in group A and one (3%) in group B. Clip application was possible in all patients, while in two cases, loop placement was impossible.

CONCLUSIONS

In our experience, endoclip-assisted resection is a safe alternative to endoloop for the resection of large pedunculated colorectal polyps when endoloop placement is difficult or impossible.

Prevention of covered enteral stent migration in patients with malignant gastric outlet obstruction: a pilot study of anchoring with endoscopic clips

OBJECTIVE

Placement of a self-expandable metal stent is a palliative treatment of choice for patients with malignant gastric outlet obstruction (GOO). Although covering an enteral stent with a membrane almost solves the problem of tumor ingrowth, stent migration continues to be a major unresolved problem. Our aim was to evaluate the clinical efficacy of endoscopic clipping for prevention of covered stent migration in the treatment of malignant GOO.

MATERIAL AND METHODS

A total of 25 consecutive patients with malignant GOO were evaluated prospectively. After deployment of a double-layered combination stent (comprising an outer uncovered stent and an inner covered stent), three endoscopic clips were applied for fixation of the proximal end of the enteral stent to the gastric or duodenal mucosa.

RESULTS

Technical and clinical success rates were 100% (25/25) and 88% (22/25), respectively. No stent migration was observed in any of the patients. Five patients (20%) experienced complications such as tumor overgrowth and stent compression.

CONCLUSION

Endoscopic clipping for enteral stent placement seems to be effective for prevention of covered stent migration in patients with malignant GOO.

Colonoscopy polypectomy management in Glanzmann’s thrombasthenia

Glanzmann's thrombasthenia (GT) is a rare autosomal recessive bleeding syndrome characterized by abnormal Glycoprotein IIb/IIIa complex (GIIb/IIIa) on platelets with resultant abnormality in platelet aggregation. There is very little information regarding polypectomy management in GT. We report a single patient with this rare disease, who underwent sequential endoscopic management of large colon polyps. Polypectomy in our GT patient was complicated by immediate and delayed bleeding. Multiple clips used after standard cautery polypectomy for a polyp 10 mm or larger in our GT patient, was most effective in preventing immediate and delayed post-polypectomy bleeding than other known therapeutic approaches. We favor preemptive use of multiple clips in large polypectomy defects for GT patients and we may argue the added cost may be offset by the reduction in the need for blood products, and by averting or shortening potential hospitalizations.

Prophylactic argon plasma coagulation ablation does not decrease delayed postpolypectomy bleeding

BACKGROUND

The most common complication of colonoscopic polypectomy is postpolypectomy bleeding (PPB). However, there are no established guidelines for the prevention of delayed PPB. It is possible that submucosal vessels of an artificial ulcer are a potential source of delayed bleeding that occurs several days after polypectomy.

OBJECTIVE

The aim of this randomized, controlled study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) of nonbleeding visible vessels in preventing delayed PPB.

DESIGN

A prospective, randomized, controlled study.

SETTING

A tertiary referral center.

PATIENTS

A total of 987 polyps in 600 consecutive patients were resected by colonoscopic polypectomy.

INTERVENTION

In patients who underwent APC (APC group), all nonbleeding visible vessels on the ulcer crater were targeted and were then coagulated by APC ablation until they disappeared, but not in patients who did not undergo APC (control group).

MAIN OUTCOME MEASUREMENT

The incidence of delayed PPB in the APC group was compared with that in the control group.

RESULTS

Delayed PPB occurred in 3.3% (16/475) of all the patients, including 2.5% (6/240) in the APC group and 4.3% (10/235) in the control group. No significant differences were observed between the 2 groups in the rates of delayed PPB, irrespective of the type of delayed bleeding (significant bleeding: 0.8% [2/240] vs 1.3% [3/235], P = .638; minor bleeding: 1.7% [4/240] vs 3% [7/235], P = .378). There were no significant APC-related complications.

LIMITATION

Single-center study.

CONCLUSION

Prophylactic APC ablation does not appear to have an additional advantage in the prevention of delayed PPB.

Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study

BACKGROUND

Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods.

MATERIALS AND METHODS

Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions.

RESULTS

Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04).

CONCLUSION

Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.

Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study

BACKGROUND

Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods.

MATERIALS AND METHODS

Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions.

RESULTS

Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04).

CONCLUSION

Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.

Endoscopic clipping

Endoscopic clips are relatively new devices that have been shown to be effective for the control of acute gastrointestinal hemorrhage. Various different models are available and offer simplicity of use with relatively few complications. Recently, endoscopic clips have been used for a variety of non-hemorrhagic conditions. In this article we review the literature and present current thinking about the indications, efficacy and safety of these devices.

Endoclipping-assisted resection of large colorectal polyps

BACKGROUND

The use of endoclipping may minimize the risk of bleeding after endoscopic polypectomy of large pedunculated polyps. The aim of this study was to assess the safety and efficacy of endoclipping of the stalk before resection of large pedunculated colorectal polyps, drawing particular attention to the cases in which the use of this method could be very useful.

PATIENTS AND METHODS

This retrospective study included 17 patients [10 men, 7 women; median age: 62 y (range 38 to 79)] with 18 large pedunculated colorectal polyps, who underwent endoclipping-assisted endoscopic polypectomy between March 2003 and May 2006. The outcome of the technique and the technique-related complications were evaluated.

RESULTS

Application of the clips was possible in all patients. In 4 patients (23.5%), the endoclipping was performed via the more flexible gastroscope. En bloc resection of colon polyps was achieved in all patients. No immediate or late bleeding or perforation occurred. One patient (5.9%) developed postcoagulation syndrome and was successfully treated conservatively. Histologic examination showed in situ carcinoma in 6 polyps (33.3%). Follow-up colonoscopy demonstrated no recurrence of polyps or cancer development.

CONCLUSIONS

Endoclipping, followed by snare transection, may be safer than conventional polypectomy in large pedunculated colorectal polyps. Special attention is needed not to cut very close to clips to avoid thermal injury of colonic wall.

Comparative study of endoscopic clips: duration of attachment at the site of clip application

BACKGROUND

Several designs of endoscopic clips are now commercially available, and the indications for endoclip application are rapidly expanding. However, very limited data have been published to aid in choosing between the different types of endoclips.

OBJECTIVE

To compare the duration of clip attachment between all commercially available endoclips.

SETTING

Long-term experiments on 50-kg pigs under general anesthesia.

DESIGN AND INTERVENTIONS

Upper endoscope was inserted into the stomach. One clip of each type (Resolution clip, TriClip, and HX-5L clip) was placed along the same gastric fold at a distance of 0.5 to 1 cm from each other. The animals were recovered. In pig nos. 1 and 2, repeat endoscopy was performed after 2 and 4 weeks. In pig nos. 3 to 5, endoscopy was repeated after 1, 2, and 5 weeks.

MAIN OUTCOME MEASUREMENTS

Duration of clip retention at the site of application.

RESULTS

In all animals, only the Resolution endoclip remained attached to the site of application for the entire duration of the study (4-5 weeks). No TriClips or HX-5L clips were attached at the 4- to 5-week follow-up endoscopies. Most of the TriClips (67%) detached within the first week after application. Most of the HX-5L clips (80%) dislodged within the first 2 weeks of follow-up.

LIMITATIONS

The study was performed in a porcine model with a small number of animals.

CONCLUSIONS

The Resolution clip has the longest duration of retention at the site of application (more than 4-5 weeks) and should be preferred when long-term attachment of endoclips is necessary.

A novel technique for the treatment of a symptomatic giant colonic lipoma

Submucosal lipomas are usually harmless neoplasms arising from submucosal adipocytes. They are found most commonly in the colon, but may develop in any part of the gastrointestinal tract. Most colonic lipomas are asymptomatic and need no treatment, whereas larger ones (>2 cm) may present with abdominal pain, changes in bowel habits, rectal bleeding, and intussusception or prolapse. The literature on the endoscopic resection of colonic lipomas is limited owing to the increased risk of colonic perforation. In this paper, we describe a novel technique for the treatment of colonic obstruction resulting from a giant lipoma by placing two large clips at the narrow base of the lipoma and performing multiple cuttings on the mucosa covering the fatty tissue by using a needle-knife to facilitate the fat's discharge into the colon's lumen. Our case showed that the endoclipping of semi- or pedunculated large colonic lipomas not amenable for endoloop ligation and associated with cuttings of the mucosa covering the fat is a promising new technique, which avoids the risk of perforation or bleeding of the snare cautery, especially in high-risk patients.

Minimizing endoscopic complications: colonoscopic polypectomy

Current polypectomy tools and techniques are inadequate to prevent all postpolypectomy bleeding, perforation, and postpolypectomy syndrome; however, adherence to certain principles can substantially reduce the risk of these complications. This review does not focus on technical aspects of colonoscopy that are directed toward preventing complications of failed eradication. Rather, the authors focus on the classic complications of bleeding, perforation, and their prevention. New technologies that could further reduce or eliminate perforation and bleeding after polypectomy are sorely needed.

Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy

BACKGROUND

The most common complication of endoscopic polypectomy is hemorrhage. Several factors have been reported to increase the risk of hemorrhage after polypectomy, but controversies still exist. Additionally, the pathomechanism of this complication is not well understood.

OBJECTIVE

To investigate the risk factors of colonoscopic postpolypectomy bleeding in patients without bleeding disorders and the blood supply of resected polyps.

PATIENTS

Two hundred forty-five patients (147 men, 98 women; median age, 62.8 +/- 9.5 years [SD]) with 283 colorectal polyps, measuring > or =1 cm in diameter, were included in this prospective study.

INTERVENTIONS

The polypectomies were performed using the conventional endoscopic method. Data on the patients' age and sex, as well as polyp location, size, shape, and pathology findings were recorded. The patients were observed for bleeding complications. Microscopic examination of the vascular supply of the removed polyps was performed.

RESULTS

Twenty-nine postpolypectomy hemorrhages (10.2%) occurred. The bleeding rate correlated with the size, shape, and pathology results of resected polyps. The microscopic analysis revealed that sessile and thick-stalked pedunculated polyps are supplied with more vessels than other polyps.

CONCLUSIONS

Patients with polyps larger than 17 mm, pedunculated polyps with a stalk diameter >5 mm, sessile polyps, and malignant lesions of the colorectal region are at high risk of hemorrhage after endoscopic excision. Moreover, on the basis of microscopic study, broad-based polyps are supplied with a considerable number of blood vessels.

Endoscopic resection with hypertonic saline-solution-epinephrine injection plus band ligation for large pedunculated or semipedunculated gastric polyp

BACKGROUND

Endoscopic resection of pedunculated polyps with heads 1 cm or greater in diameter presents a risk of bleeding. To minimize this complication, we performed endoscopic resection with hypertonic saline-solution-epinephrine injection plus band ligation and evaluated its safety and effectiveness.

METHODS

Seventeen patients with 20 pedunculated or semipedunculated polyps with heads 1 cm or greater in diameter were treated with this technique. Conventional upper-GI endoscope, hypertonic saline-solution and epinephrine, sclerotherapy needle, and endoscopic band ligator device are needed for the procedure.

OBSERVATIONS

All lesions were easily and safely resected. During this procedure, a band ligation chamber proved to be satisfactory for accurate recognition of a postpolypectomy ulcer under good visual control. No hemorrhage, perforation, or other complication occurred as a result of the use of this technique. The histologic resection margin was affected by nonneoplastic components in 6 of 20 lesions. Follow-up endoscopy 1 week later revealed a small, shallow ulcer without residual polyp in all lesions.

CONCLUSIONS

This preliminary study suggests that endoscopic resection with hypertonic saline-solution-epinephrine injection plus band ligation is a simple and effective method for the prevention of polypectomy-associated bleeding. Prospective trials, including randomized controlled studies, are required to evaluate the suitability of this modality for wide clinical use.

Use of a Homemade Nylon Loop for the Prevention of Postpolypectomy Bleeding of Large Pedunculated Polyps

To avoid bleeding after colonoscopic polypectomy, several procedures are being used. We describe a new method that consists of a homemade nylon loop that is applied and tied to the stalk of the pedunculated polyp and after which a conventional polypectomy is done. We have used this method in 15 patients and no complication was observed. The procedure is simple; the loop may be opened to large diameters to make it easier to use for large polyps. It has a low cost and seems to be safe and effective to prevent bleeding after endoscopic polypectomy.

Endoscopic mucosal resection for colonic non-polypoid neoplasms

BACKGROUND

Colonic neoplastic lesions can be classified morphologically into polypoid and non-polypoid types. Non-polypoid lesions have a higher malignant potential than polypoid lesions. Removing these lesions and obtaining integral specimen for histopathology evaluation during colonoscopy examination is an important task. Endoscopic mucosal resection (EMR) is an alternative to surgery for removing of non-polypoid lesions of the GI tract. This study assessed the safety, efficacy, and clinical outcomes of EMR.

PATIENTS AND METHODS

From October 2000 to October 2003 during the routine colonoscopy performed at one medical center, identified 152 non-polypoid colonic neoplasms in 149 patients (92 males, 57 females) were found. The mean patient age was 57.8 +/- 15.5 yr (range 32-80 yr). EMR was performed for lesions suspected of being neoplastic tumors via magnification colonoscopy with the indigo carmine dye spray method. The lesions were removed via EMR with pure cutting current after which hemoclips were applied to the resected wounds.

RESULTS

The study identified 40 flat type lesions, 106 lateral spreading tumors, and 6 depressed lesions that were completely resected. The mean size of lesions was 19.4 +/- 10.3 mm (range 6-60 mm). Histological findings were 4 adenocarcinomas, 59 with high-grade adenoma/dysplasia, and 89 with low-grade adenoma/dysplasia. Two patients experienced bleeding immediately following EMR, while adequate hemostasis was achieved using hemoclips. Neither delayed bleeding nor perforation developed following EMR.

CONCLUSION

EMR by using pure cutting current and hemoclip is a useful method for obtaining integral specimen for accurate pathologic assessment. This method provides a safe and minimally invasive technique managing of colonic non-polypoid lesions.

Handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps

BACKGROUND

Colonoscopic polypectomy of giant pedunculated polyps has an increased risk of bleeding and is technically difficult. To facilitate the removal of the polyps, we handcrafted a two-channel colonoscope and applied it for grasping-forceps-assisted resection.

METHODS

We easily handcrafted a two-channel colonoscope by taping a plastic tube along the shaft of a standard colonoscope and used it for the technique in 10 patients with 12 giant pedunculated polyps.

OBSERVATIONS

The colonoscope with forceps assistance proved to be satisfactory for handling detachable and polypectomy snares. Immediate bleeding occurred in one patient because the detachable snare could not be maneuvered over the polyp. In 3 patients, the plastic tube became mobile during the procedure because the tape that attached the tube became loose. No other complications occurred.

CONCLUSIONS

A handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps is effective for the prevention of postpolypectomy bleeding and the reduction of technical difficulties.

N/A

N/A

Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy

BACKGROUND

The most common major complication of colonoscopic polypectomy is postpolypectomy hemorrhage. Although several factors have been implicated in the occurrence of hemorrhage, accurate prediction of delayed bleeding remains difficult. This randomized controlled trial evaluated the efficacy of prophylactic clip application for prevention of delayed postpolypectomy bleeding.

METHODS

Postpolypectomy ulcers created by colonoscopic removal of polyps (mean size 7.8 [4.0] mm) with the endoscopic mucosal resection technique were randomly assigned to prophylactic clip placement (n = 205) or no clip (n = 208). Baseline characteristics of the patients and polyps excised were comparable between the groups. Delayed bleeding was defined as the postprocedure passage of bloody stool or massive hematochezia. The site of delayed bleeding was identified at emergent colonoscopy.

RESULTS

Delayed bleeding was identified from 2 ulcers in each group from 1 to 4 days after resection (mean 2.3 days). Delayed bleeding occurred from 0.98% of ulcers in the clip group and 0.96% in the non-clip group (p > 0.9999). No patient with delayed bleeding required transfusion or surgery.

CONCLUSIONS

Prophylactic clip placement did not decrease the occurrence of delayed bleeding after colonoscopic polypectomy.

Colonoscopic polypectomy with cutting current: is it safe?

BACKGROUND

Coagulation and blended electrosurgical current are currently recommended for colonoscopic polypectomy, whereas pure cut current is believed to be associated with a higher risk of bleeding. However, the outcome of polypectomy performed with a cut current has not been evaluated in a large case series. Our objective was to study the incidence and nature of complications when polypectomy is performed with a pure cut current.

METHODS

Among 9555 colonoscopic examinations, polypectomy cases were retrospectively reviewed for complications. The electrosurgical current applied was always the cutting waveform.

RESULTS

Electrosurgical polypectomy using pure cut current was performed to remove 4735 lesions. Hemoclips were applied to the excision site after polypectomy to prevent bleeding in 12% of the cases. Hemorrhage occurred in 1.1% of the polypectomies (3.1% of patients). The incidence of bleeding with the different methods was snare polypectomy 0.9%, endoscopic mucosal resection 1.6%, "hot" biopsy 0.4%, and piecemeal polypectomy 7.3%. Bleeding was immediate in 66.1% of episodes and delayed in 33.9%. Patients with delayed postpolypectomy bleeding were significantly younger than those with immediate bleeding (50.5 and 64.7 years, respectively, p < 0.001). There was 1 case of transmural burn, but no perforations.

CONCLUSION

Polypectomy can be performed with pure cut current with a bleeding rate comparable to that seen with the use of coagulation or blended current, provided that hemoclip placement can be used readily. Expertise in hemoclip placement is advisable if this method of polypectomy is to be used.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Endoclip-assisted resection of large pedunculated colon polyps

BACKGROUND

Large pedunculated colorectal polyps are often difficult to remove endoscopically.

METHODS

Four patients with giant pedunculated polyps (>3 cm) underwent an endoscopic procedure in which the polyp stalk was ligated with multiple clips and resected with a needle-knife papillotome.

RESULTS

No complications occurred either during or immediately after the procedure. Mean size of the resected polyps was 4.8 +/- 1.2 cm (range 3 to 6 cm). Mean time for the entire procedure was 31 +/- 5 minutes (range 25 to 45). No bleeding was found after a mean follow-up period of 4.3 +/- 1.1 months (range 3 to 6 months).

CONCLUSIONS

Although technical refinements are necessary to make the procedure easier and faster, this approach might represent the only option for selected patients who would otherwise need surgical resection of large pedunculated colonic polyps.

Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps

BACKGROUND

Colonoscopic polypectomy of large polyps may be associated with complications such as bleeding. Use of a detachable snare may reduce the risk of bleeding. We describe several instances in which the use of such a device proved to be ineffective.

METHODS

A detachable snare was used for colonoscopic polypectomy of large polyps in 18 patients (20 polyps), also applied at the residual stalk after conventional polypectomy in 5 patients (5 polyps), and evaluated retrospectively.

RESULTS

Sixteen of the 20 polyps were pedunculated, and 4 were semi-pedunculated. In 3 of the 4 semi-pedunculated lesions, the loop slipped off after polypectomy because the lesions were cut close to the site of encirclement. Bleeding occurred in 4 cases because of transection by the loop of a thin stalk (4 mm) before polypectomy (1), slipping of the loop in a semi-pedunculated lesion (1), or insufficient tightening of the loop (2). After conventional polypectomy, we could not effectively snare the residual stalk because of flattening in 3 of the 5 lesions.

CONCLUSIONS

Use of the detachable snare for polypectomy of thin stalked or semi-pedunculated lesions may result in technical failure of this technique. The stalk should be fully encircled with the snare before polypectomy. The detachable snare is difficult to apply at the residual stalk after conventional polypectomy.

Endoscopic resection of large pedunculated colorectal polyps using a detachable snare

BACKGROUND

Colonoscopic resection of pedunculated polyps with heads 1 cm or greater in diameter is difficult because of the risk of bleeding. To minimize this complication, we used a detachable snare that allowed endoscopic ligation of the stalk of a large pedunculated polyp and evaluated its safety and effectiveness in comparison with conventional endoscopic snare polypectomy.

METHODS

Patients with pedunculated polyps with heads 1 cm or greater in diameter were randomly assigned to colonoscopic polypectomy with (N = 47) or without (N = 42) a detachable snare. Arterial pumping bleeding immediately after colonoscopic polypectomy or hematochezia resulting in a 10% or greater drop in hematocrit was defined as "bleeding."

RESULTS

No bleeding occurred during or after polypectomy with a detachable snare, but bleeding occurred significantly more frequently (five patients, 12%) without a snare. Moreover, the use of a detachable snare reduced the duration of hospitalization after polypectomy.

CONCLUSIONS

Colonoscopic polypectomy with a detachable snare may be safer than conventional polypectomy without a detachable snare for resection of large, pedunculated polyps.