Postpolypectomy colonic hemorrhage

Endoscopic management of giant colonic polyps: a retrospective Italian study

BACKGROUND/AIMS

Polyps greater than 30 mm are classified as "giants". Their endoscopic removal represents a technical challenge. The choice of the endoscopic removal technique is important because it provides a resection sample for precise histopathological staging. This is pivotal for diagnostic, prognostic, and management purposes.

METHODS

From a retrospective analysis, we obtained a sample of 38 giant polyps. Eighteen polypectomies were performed using the epinephrine volume reduction (EVR) method, nine polypectomies utilized endo-looping or clipping methods, and 11 patients underwent surgery.

RESULTS

We obtained en bloc resection with the EVR method in all cases; histology confirmed the correct indication for endoscopic resection in all cases. Moreover, no early or delayed complications were observed, and no patient required hospitalization. Using endo-looping or clipping methods, we observed advanced histology in 1/9 (11.1%) cases, while another patient (1/9, 11.1%) had delayed bleeding. Among patients who underwent surgery, 5/11 (45.5%) were deemed overtreated and three had post-surgical complications.

CONCLUSIONS

We propose EVR as an alternative technique for giant polyp resection due to its safety, effectiveness, cost-efficiency, and the advantage of avoiding the need to postpone polypectomy to a later time. Further prospective studies might help improve this experience and enhance the technique.

Review article: Advances in the management of lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved.

AIMS

To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion.

RESULTS

The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients.

CONCLUSIONS

The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Suturing techniques with endoscopic clips and special devices after endoscopic resection

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.

Monoclonal gammopathy of undetermined significance (MGUS) characterized by refractory lower gastrointestinal postoperative bleeding with coagulopathy

Bleeding is a common complication after lower gastrointestinal surgery, and cases due to coagulation dysfunction are rare. The current authors encountered a 54-year-old Chinese man with refractory bleeding after endoscopic rectal polypectomy, and multiple endoscopic and surgical interventions failed to control that bleeding. An APTT mixing test could not be corrected and there was no evidence of autoimmune-related disease, so the presence of nonspecific antibodies was considered. After empiric therapy with a cyclophosphamide and glucocorticoid, APTT was corrected and gastrointestinal bleeding stopped. Based on laboratory results and therapeutic results, the patient was ultimately diagnosed with prolonged APTT induced by monoclonal gammopathy of undetermined significance (MGUS). MGUS and coagulopathy characterized by a prolonged APTT has rarely been reported. Here, studies noting elevated monoclonal immunoglobulins and coagulopathy have been reviewed. If a prolonged APTT of undetermined significance cannot be corrected with an APTT mixing test and if autoimmune-related factors are excluded, then plasma cell-related diseases such as MGUS need to be considered.

Endoscopic management of delayed bleeding after polypectomy of small colorectal polyps: two or more clips may be safe

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.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

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.

Biomaterials in Gastroenterology: A Critical Overview

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.

Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis

BACKGROUND

The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes.

AIM

To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm.

METHODS

We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I² were used to test for heterogeneity. Pooling was conducted using a random-effects model.

RESULTS

Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies (I² = 0%, P = 0.67).

CONLUSION

Prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.

Colonoscopy, Polypectomy, and the Risk of Bleeding

Colonoscopy with polypectomy is the means by which the incidence of colon cancer may be reduced; however, polypectomy is not without risk. Physicians must carefully weigh the risks and benefits of colonoscopy, particularly when patients are given prescriptions for antiplatelet agents and anticoagulants. This article discusses the risks of colonoscopy and polypectomy and reviews the most recent data for managing antiplatelet agents and anticoagulants in the periendoscopic period.

Postpolypectomy Bleeding Prevention and More Complete Precancerous Colon Polyp Removal With Endoscopic Mucosal Stripping (EMS)

Background and Aims: Postpolypectomy bleeding and incomplete polyp removal are important complication and quality concerns of colonoscopy for colon cancer prevention. We investigated if endoscopic mucosal stripping (EMS) as a technical modification of traditional cold snare polypectomy to avoid submucosal injury during removal of non-pedunculated colon polyps could prevent postpolypectomy bleeding and facilitate complete polyp removal.

Methods: This is an Internal Review Board exemption-granted retrospective analysis of 5,142 colonoscopies with snare polypectomy performed by one of the authors (ZJC) at Minnesota Gastroenterology ambulatory endoscopy centers during a 12-year period divided into pre-EMS era (2005–2012, n = 2,973) and EMS era (2013–2016, n = 2169) with systemic adoption of EMS starting 2013. Change in postpolypectomy bleeding rate before and after EMS adoption and EMS polypectomy completeness were evaluated.

Results: Zero postpolypectomy bleeding case was found during EMS era (rate 0%) compared with 10 bleeding cases during pre-EMS era (rate 0.336%). This difference was statistically significant (P = 0.0055) and remained so after excluding 2 bleeding cases of pedunculated polyps (P = 0.012). All bleeding cases involved hot snare polypectomy. Histological examination of the involved polyps showed substantial submucosal vascular damage in contrast to a remarkable paucity of submucosa in comparable advanced polyps removed using EMS. Both biopsy and follow-up colonoscopy examination of the polypectomy sites confirmed that EMS more completely removed non-pedunculated advanced polyps.

Conclusions: EMS polypectomy was effective in preventing postpolypectomy bleeding and facilitated complete polyp removal.

Colonoscopy complications: experience with 8968 consecutive patients in a single institution

OBJECTIVE

to evaluate the incidence, epidemiological characteristics, diagnosis and evolution of patients who returned to the emergency care units of the Albert Einstein Hospital in São Paulo/SP with signs and symptoms suggestive of colonoscopy complications up to 30 days after the procedure.

METHODS

we conducted a retrospective, uni-institutional study of patients submitted to colonoscopy in 2014 who returned to the Emergency department (ED) within 30 days after the procedure.

RESULTS

8968 patients underwent colonoscopies, 95 (1.06%) of whom had complaints related to possible complications. Most of the procedures were elective ones. Minor complications (nonspecific abdominal pain/distension) were frequent (0.49%) and most of the patients were discharged after consultation at the ED. Severe complications were less frequent: perforation (0.033%), lower gastrointestinal bleeding (0.044%), and intestinal obstruction (0.044%). ED consultations in less than 24 hours after the procedure was associated with a higher index of normal colonoscopies (p=0.006), more diagnosis of fever (p=0.0003) and dyspeptic syndrome (p=0.043), and less diagnosis of colitis/ileitis (p=0.015). The observation of fever in patients treated at the ED was associated with the diagnosis of polyps at colonoscopy (p=0.030).

CONCLUSION

the data corroborate the safety of the colonoscopy exam and points to a reduction in major complications rates.

Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications

BACKGROUND AND AIMS

Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy.

METHODS

We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding.

RESULTS

There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001).

CONCLUSION

We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.

Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry

BACKGROUND

Patients receiving direct-acting, non-vitamin K oral anticoagulants (NOAC) frequently undergo gastrointestinal endoscopies (GIE) but little is known on the management and outcome of these interventions.

METHODS

With use of data from an ongoing, prospective, noninterventional registry of NOAC patients, the management and outcome of GIE were evaluated with use of standard event definitions. Patients undergoing GIE were categorized into two subgroups: (1) scheduled GIE (scheduled appointment, no acute bleeding) and (2) unscheduled GIE (unscheduled including management of acute gastrointestinal bleeding). The rates of major bleeding complications, cardiovascular complications, and all-cause death within 30 days after the procedure were evaluated.

RESULTS

Between October 1, 2011, and March 31, 2015, 492 patients underwent a total of 713 GIE (44.5% gastroscopies, 53.0% colonoscopies, 2.5% endoscopic retrograde cholangiopancreatography procedures), with 70.0% being scheduled procedures and 30.0% being unscheduled procedures. Endoscopies were performed within 24 h after the last NOAC intake in 45 of 713 cases (6.3%), between 24 and 48 h after the last intake in 336 cases (47.1%), and after NOAC therapy interruption for more than 48 h in 213 cases (29.9%). Heparin bridging therapy was used in 180 of 713 procedures (25.3%) and predominantly (170/180; 94.4%) in cases of NOAC therapy interruption for longer than 72 h. Until day 30 after the procedure, the event rates were 1.4% for cardiovascular events and 0.7% for major bleeding events.

CONCLUSION

Continuation or short-term interruption of NOAC therapy seems to be a safe strategy for GIE. Heparin bridging therapy is predominantly used in cases of prolonged NOAC therapy interruption.

Prospective analysis of delayed colorectal post-polypectomy bleeding

BACKGROUNDS/AIMS

Although post-polypectomy bleeding is the most frequent complication after colonoscopic polypectomy, only few studies have investigated the incidence of bleeding prospectively. The aim of this study was to investigate the incidence of delayed post-polypectomy bleeding and its associated risk factors prospectively.

METHODS

Patients who underwent colonoscopic polypectomy at Kangbuk Samsung Hospital from January 2013 to December 2014 were prospectively enrolled in this study. Trained nurses contacted patients via telephone 7 and 30 days after polypectomy and completed a standardized questionnaire regarding the development of bleeding. Delayed post-polypectomy bleeding was categorized as minor or major and early or late bleeding. Major delayed bleeding was defined as a > 2-g/dL drop in the hemoglobin level, requiring hospitalization for control of bleeding or blood transfusion; late delayed bleeding was defined as bleeding occurring later than 24 h after polypectomy.

RESULTS

A total of 8175 colonoscopic polypectomies were performed in 3887 patients. Overall, 133 (3.4%) patients developed delayed post-polypectomy bleeding. Among them, 90 (2.3%) and 43 (1.1%) patients developed minor and major delayed bleeding, respectively, and 39 (1.0%) patients developed late delayed bleeding. In the polyp-based multivariate analysis, young age (< 50 years; odds ratio [OR] 2.10; 95% confidence interval [CI] 1.18-3.68), aspirin use (OR 2.78; 95% CI 1.23-6.31), and polyp size of > 10 mm (OR 2.45; 95% CI 1.38-4.36) were significant risk factors for major delayed bleeding, while young age (< 50 years; OR 2.6; 95% CI 1.35-5.12) and immediate bleeding (OR 3.3; 95% CI 1.49-7.30) were significant risk factors for late delayed bleeding.

CONCLUSIONS

Young age, aspirin use, polyp size, and immediate bleeding were found to be independent risk factors for delayed post-polypectomy bleeding.

Quality indicators in pediatric colonoscopy: an Australian tertiary center experience

OBJECTIVES

Quality indicators for colonoscopy in adults are largely driven by colorectal cancer screening, and include cecal intubation rates, with rates of >90% recommended. In contrast, colorectal cancer is rare in childhood, with paucity of data on relevant quality indicators for pediatric colonoscopy. It is also unclear whether high rates of cecal intubation are achievable in small children. Our aim was to audit all colonoscopies performed in a tertiary pediatric center to examine clinical indications for procedure, completeness of examination with cecal and ileal intubation, significant findings, and complications.

METHODS

Retrospective review of colonoscopies performed between November 2011 and October 2015 was undertaken.

RESULTS

Total colonoscopy was performed in 652 patients, 53% male, with median age 13.0 (range 0.4-18.2) years. The most common indications for colonoscopy were assessment of inflammatory bowel disease (IBD) 57.9% (378/652), rectal bleeding 10% (68/652) and abdominal pain 10% (68/652). Trainees performed 69.8% (452/652) of procedures. Quality of bowel preparation was mentioned in 63% (410/652), of which 22% (90/410) were considered inadequate. Cecal intubation rate was 96.3% (628/652) and ileal intubation rate was 92.4% (603/652). Extent of procedure was confirmed in 99.2% of patients with photographs and/or ileal biopsy. Poor quality of bowel preparation (p = .001) and age <5years (p = .007) were inversely related to successful ileal intubation.

CONCLUSIONS

High rates of cecal and ileal intubation are achievable in pediatric colonoscopy. Ileal intubation should be considered a quality indicator since the main indicator for pediatric colonoscopy is to investigate IBD.

Prospective Analysis of Minor Adverse Events After Colon Polypectomy

BACKGROUND

The risks of minor adverse events (MAEs) such as abdominal pain and bloating after colon polypectomy (CP) are less clearly documented than major adverse events. However, these complications may cause significant discomfort during the performance of normal activities. We aimed to estimate the incidence of MAE, associated risk factors, and healthcare resource utilization after CP.

METHODS

Patients who underwent CP were prospectively enrolled in this study. Trained nurses contacted patients by telephone at 7 and 30 days after the CP and administered a standardized questionnaire to obtain information regarding the development of complications. MAEs were defined as any discomfort the patient experienced after CP excluding major bleeding, perforation, and post-polypectomy coagulation syndrome.

RESULTS

Among a total of 2716 patients, 2253 patients completed the interview at 7 and 30 days. MAEs occurred in 263 patients (11.7%) before day 7, among which the most common were abdominal pain (4.5%), rectal bleeding (2.8%), and bloating (2.6%). Cumulative incidence of MAEs was in 267 patients (11.9%) at 30 days. On multivariate analysis, female sex (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.58-3.18) and use of meperidine (OR 1.54, 95% CI 1.04-2.27) were risk factors for the occurrence of MAEs. Two patients (0.7%) required hospital admission, 117 patients (43.8%) were treated medically in the outpatient clinic, and the majority at 148 patients (55.4%) experienced resolution of symptoms after observation.

CONCLUSIONS

The post-CP MAE rate was as low as 11.8%. The MAEs occurred mainly in the first seven postoperative days and resulted in little use of healthcare resources.

Management of Anticoagulants and Antiplatelet Agents During Colonoscopy

Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.

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.

Endoscopy in Patients on Antiplatelet Agents and Anticoagulants

OPINION STATEMENT

Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.

Clinical outcome of endoscopic management in delayed postpolypectomy bleeding

Background/Aims

The clinical course after endoscopic management of delayed postpolypectomy bleeding (DPPB) has not been clearly determined. This study aimed to assess clinical outcomes after endoscopic hemostasis of DPPB and evaluate risk factors for rebleeding after initial hemostasis.

Methods

We reviewed medical records of 198 patients who developed DPPB and underwent endoscopic hemostasis between January 2010 and February 2015. The performance of endoscopic hemostasis was assessed. Rebleeding negative and positive patients were compared.

Results

DPPB developed 1.4±1.6 days after colonoscopic polypectomy. All patients achieved initial hemostasis. Clipping was the most commonly used technique. Of 198 DPPB patients, 15 (7.6%) had rebleeding 3.3±2.5 days after initial hemostasis. The number of clips required for hemostasis was higher in the rebleeding positive group (3.2±1.6 vs. 4.2±1.9, P=0.047). Combinations of clipping with other modalities such as injection methods were more common in the rebleeding positive group (67/291, 23.0% vs. 12/17, 70.6%; P<0.001). Multivariate analysis showed a large number of clips and combination therapy were independent risk factors for rebleeding. All the rebleeding cases were successfully managed by repeat endoscopic hemostasis.

Conclusions

Endoscopic hemostasis is effective for the management of DPPB because of its high initial hemostasis rate and low rebleeding rate. Endoscopists should carefully observe patients in whom a large number of clips and/or combination therapy have been used to manage DPPB because these may be related to the severity of DPPB and a higher risk of rebleeding.

Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies

BACKGROUND AND AIM

The efficacy of clipping for preventing delayed bleeding after colorectal endoscopic resection is still controversial. To assess the efficacy of prophylactic clipping, we conducted a meta-analysis of randomized controlled trials.

METHODS

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified seven eligible randomized trials from the database search, and compared the effect of clipping versus non-clipping with respect to delayed bleeding and perforation. Data from eligible studies were combined to calculate pooled odds ratios (ORs).

RESULTS

Postoperative bleeding was observed in 41 of 1526 cases (2.7%) without clipping and in 32 of 1533 cases (2.1%) with clipping (OR 0.76, 95% CI: 0.39-1.47, p = 0.414). There was no significant heterogeneity among the trial results (I-Square = 26.7%, p = 0.22). In the subgroup analysis based on small tumor size (<20 mm) and large tumor size (≥20 mm), there were no significant differences. Compared with non-clipping, the pooled OR of developing perforation with clipping was 1.00 (95% CI: 0.14-7.25), indicating no significant difference between the two groups.

CONCLUSIONS

Prophylactic clipping did not decrease the occurrence of delayed bleeding after colorectal endoscopic resection. Clipping could be of interest in patients with a high risk of bleeding (anticoagulation) or large lesions, but with the available trials data to prove this are scarce.

Incidence and risk factors of delayed postpolypectomy bleeding in patients with chronic liver disease

OBJECTIVE

Hepatologists and colonoscopists often hesitate to perform a colonoscopic polypectomy in patients with chronic liver disease (CLD), especially those with cirrhosis, because of the risk of postpolypectomy bleeding (PPB). We aimed to investigate the incidence and risk factors of delayed PPB after a colonoscopic polypectomy in patients with CLD.

MATERIALS AND METHODS

In total, 152 patients with CLD who underwent colonoscopic polypectomy from December 2005 to December 2012 were retrospectively reviewed.

RESULTS

Cirrhosis was identified in 80 (52.6%) patients. During the study period, 442 polyps were removed and delayed PPB developed in 14 (9.2%) patients. The incidence of delayed PPB was significantly higher in patients with cirrhosis than in those without the disease (13.8% [n = 11] vs. 4.2% [n = 3], p = 0.041). The polyp size (odds ratio, 1.087; 95% confidence interval, 1.009-1.172) and cirrhosis (odds ratio, 8.535; 95% confidence interval, 2.417-30.140) were independent risk factors for delayed PPB. In patients with cirrhosis, the optimal cut-off size to identify high-risk polyps for delayed PPB was 10 mm (area under the receiver operating characteristics curve, 0.737; sensitivity, 52%; specificity, 88%).

CONCLUSION

Caution is needed when colonoscopic polypectomy is planned in patients with CLD who have larger polyps and cirrhosis.

Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation).

WARFARIN

The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance.

DIRECT ORAL ANTICOAGULANTS DOAC

For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

Improving the utility of colonoscopy: Recent advances in practice

Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.

Periprocedural management of aspirin during colonoscopy: a survey of practice patterns in the United States

BACKGROUND

The risk of postpolypectomy bleeding for patients taking aspirin is low, and gastroenterology society guidelines state that aspirin is likely safe to continue; however, many practices recommend aspirin discontinuation.

OBJECTIVE

To characterize practice patterns of periprocedural aspirin use with colonoscopy in the United States.

DESIGN

Survey study.

SETTING

Endoscopy units in the United States.

INTERVENTIONS

We reviewed colonoscopy preparation instruction sheets available online to characterize recommendations regarding periprocedural aspirin use. The endoscopy units that recommended discontinuation of aspirin before colonoscopy were contacted to determine their reasons for doing so. We also determined which endoscopy units were recognized by the American Society for Gastrointestinal Endoscopy (ASGE) quality recognition program.

MAIN OUTCOME MEASUREMENTS

Endoscopy unit recommendations regarding aspirin use before colonoscopy.

RESULTS

We reviewed colonoscopy preparation instructions from 317 endoscopy units, of which 138 (43.5%) recommended continuing aspirin, 103 (32.5%) recommended stopping aspirin, and 76 (24%) requested patients to contact a physician. The most common reasons for recommending aspirin discontinuation were concern about bleeding after polypectomy (62%), perceived minimal downside to stopping aspirin (38%), inertia to changing old policies (20%), and concern about medicolegal implications of postpolypectomy bleeding (15%). There was no significant association between endoscopy unit recommendations about periprocedural aspirin use and ASGE quality certification (P = .17) or type of endoscopy facility (ambulatory surgical center vs hospital affiliated) (P = .55).

LIMITATION

Non-response bias.

CONCLUSION

Less than half of the endoscopy units surveyed in the United States routinely continue aspirin before screening colonoscopies despite evidence that benefits outweigh the risks. It is important for gastroenterology and cardiology societies to make a firm statement, educate their members, and give them confidence and support to continue aspirin periprocedurally.

Do We Perform a Perfect Endoscopic Hemostasis Prophylactically with Argon Plasma Coagulation in Colonic Endoscopic Mucosal Resection?

BACKGROUND

Submucosal injection for endoscopic mucosal resection (EMR) may effect performing the prophylactic argon plasma coagulation (APC) of non-bleeding visible vessels on ulcer crater.

AIMS

The purpose of this study was to evaluate the clinical features of visible vessels in iatrogenic ulcers over time after prophylactic APC in colonic EMR.

PATIENTS AND METHODS

This study was designed as a prospective study. Between August and November 2013, a total of 40 patients who were admitted underwent prophylactic APC for non-bleeding visible vessels after colonic EMR. After confirming whether visible vessels were completely coagulated or not, the number of visible vessels in ulcers was counted over a specific time period, e.g. 1, 3, 5, or 7 min.

RESULTS

The mean number of visible vessels was significantly higher at 5 min (0.85 ± 1.14) after EMR with prophylactic APC compared to 1 and 3 min (1 min: 0.28 ± 0.60, P < 0.001; 3 min: 0.65 ± 0.87, P = 0.02) and there was no significant difference between 5 and 7 min (P = 0.31). Multivariate analysis showed that the size of the iatrogenic ulcer after EMR was associated with the occurrence of visible vessels (ulcer size >1 vs. ≤0.5 cm: OR 27.32, 95% CI 2.86-infinity).

CONCLUSIONS

A 5-min observation of the ulcer may be advantageous for the assessment of visible vessels after performing colonic EMR with prophylactic APC, and large (>1 cm) iatrogenic ulcers were associated with the occurrence of visible vessels after colonic EMR.

A randomized study on the effectiveness of prophylactic clipping during endoscopic resection of colon polyps for the prevention of delayed bleeding

BACKGROUNDS

The efficacy of clipping for preventing the delayed bleeding after the removal of colon polyps is still controversial. In order to clarify this efficacy, a randomized controlled study was performed.

METHODS

One hundred and fifty-six patients with colon neoplasms (288 lesions) were enrolled in the study. The patients were randomly divided into two groups: clipping or nonclipping groups using a sealed envelope method before the endoscopic resections. Eight specialists and nine residents were invited to perform this procedure. The risk factors and the rates of delayed bleeding after the endoscopic resections in each group were investigated.

RESULTS

There were no significant differences in the bleeding rate between the clipping and nonclipping groups, while the length of the procedure was significantly longer and the cost was higher in the clipping group than in the nonclipping group. The rate of bleeding was significantly higher in cases with polyps 2 cm or larger and with a longer procedure time, while none of the other factors affected the bleeding rate.

CONCLUSIONS

This randomized controlled study revealed no significant effect of prophylactic clipping for preventing delayed bleeding after the endoscopic resection of colon polyps.

Utility of a new reusable clip device for endoscopic treatment

BACKGROUND AND AIM

Existing reusable endoscopic clip devices have some problems regarding opening the device and precise control of clip application. The aim of the present study was to evaluate reusable clip devices for endoscopic treatment.

METHODS

Ability to close a large defect and grip force were evaluated using ex-vivo porcine colon. We assessed clip loading and opening in a non-clinical setting and describe the resulting learning curve. To evaluate clinical utility, data for clip application in 72 post-endoscopic mucosal resection (EMR) defects in 40 patients were retrospectively analyzed.

RESULTS

There was no difference in the ability to close a 20-mm full-thickness defect and the grip force comparing the new clip device (ZEOCLIP®) and a previously used reusable clip device (EZClip®). Although the time to load the ZEOCLIP was almost same as the EZClip, the time to open the ZEOCLIP was significantly shorter than the EZClip (P < 0.001). Opening width of the ZEOCLIP was significantly wider than the EZClip (P < 0.05). We successfully accomplished closure of post-EMR defects by clip application in 72 lesions using ZEOCLIP. Reopening/repositioning and restoring it to the working channel were more frequently carried out in a non-easy location than in an easy location (11/35 [31%] vs 4/37 [11%], P = 0.030; and 21/35 [60%] vs 1/37 [3%], P < 0.001, respectively).

CONCLUSIONS

ZEOCLIP is more quickly and easily opened to its maximum width compared with EZClip, and is feasible for clip application after EMR.

Complications of minimally invasive procedures of the abdomen and pelvis: a comprehensive update on the clinical and imaging features

Minimally invasive gastrointestinal, genitourinary, and gynecological procedures are widely used in the clinical practice for diagnostic and therapeutic purposes. Complications both minor and major are not uncommon with these procedures. Imaging plays an important role in the detection and optimal management of these complications. Familiarity with the clinical and imaging features of these complications by radiologists can help in their timely detection.

Optimal timing for resuming antithrombotic agents and risk factors for delayed bleeding after endoscopic resection of colorectal tumors

Aim. To examine optimal timing for resuming antithrombotic agents and risk factors for delayed bleeding after endoscopic resection of colorectal tumors. Method. Of 1,970 polyps larger than 10 mm removed by polypectomy, endoscopic mucosal resection, or endoscopic submucosal dissection, delayed bleeding, which was designated as bleeding that occurred 6 or more hours after endoscopic treatment, occurred in 52 cases (2.6%); 156 nonbleeding cases matched for age and gender were controls in this single-institution retrospective case-control study. We investigated (1) patient-factors: resuming antithrombotic agents within 5 days following endoscopic resection, hypertension, and diabetes mellitus; and (2) tumor-factors: morphology, size, location, and resection technique by conditional logistic regression. Results. By multivariate analysis resumption of anticoagulants within 5 days was a significant risk factor for delayed bleeding (OR 10.2; 95% CI = 2.7-38.3; P = 0.0006). But resuming a thienopyridine within 5 days was not (OR 0.9; 95% CI = 0.1-2.6; P = 0.40). Other patient- and tumor-factors were not significant. Conclusion. Resuming anticoagulants within 5 days after endoscopic treatment was associated with delayed bleeding whereas resuming thienopyridines was not.

Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study

BACKGROUND/AIM

Delayed bleeding is a serious complication that occurs after polypectomy. Many risk factors for delayed bleeding have been suggested, but there is little analysis of procedure-related risk factors. The purpose of this study is to identify a wide range of risk factors for delayed postpolypectomy bleeding (DPPB) and analyze the correlations of those potential DPPB risk factors.

MATERIALS AND METHODS

In this retrospective cohort study, 5981 polypectomies in 3788 patients were evaluated between January 2010 and February 2012. Patient-related, polyp-related, and procedure-related factors were evaluated as potential DPPB risk factors.

RESULTS

Delayed bleeding occurred in 42 patients (1.1%). Multivariate analysis revealed that polyp size >10 mm [odds ratio (OR), 2.785; 95% confidence interval (CI), 1.406-5.513; P=0.003], location in the right hemi-colon (OR, 2.289; 95% CI, 1.117-4.693; P=0.024), and endoscopist's experience (<300 total cases of colonoscopy performed; OR, 4.803; 95% CI, 2.631-8.766; P=0.001) were significant risk factors for DPPB. Especially protruded type polyps (Ip, Isp) larger than 1 cm in the right-side colon were associated with increased risk. Right-side polypectomy by a nonexpert endoscopist was a significant risk factor for DPPB, especially with procedures in the cecum area. Taking the 1.5% DPPB incidence as cutoff value, the learning curve of colonoscopic polypectomy may be estimated as 400 cases of polypectomy.

CONCLUSIONS

Polyp size, endoscopist's experience, and right hemi-colon location were identified as potential risk factors for DPPB development.

Postpolypectomy haemorrhage following removal of large polyps using mechanical haemostasis or epinephrine: a meta-analysis

BACKGROUND AND AIM

Postpolypectomy haemorrhage (PPH) is a known adverse event that can occur following polypectomy, occurring in 0.3-6.1% of cases. Previous meta-analysis has included small polyps, which are less likely to bleed, and less amenable to some methods of mechanical haemostasis. No comprehensive cost-benefit analysis of this topic is available. The aim of this study was to perform a meta-analysis of randomized trials and a cost-benefit analysis of prophylactic haemostasis in PPH.

METHODS

A total of 3092 abstracts from prospective trials conducted in human colonoscopic polypectomy were screened. Outpatients undergoing polypectomy in seven suitable studies (1426 episodes), without polyposis syndromes or bleeding diathesis, were identified. The interventions of prophylactic haemostatic measures (clips, loops, and/or adrenaline injection) to prevent PPH were assessed. The main outcome measurements were PPH measured by haematochezia or drop in haematocrit >10% or haemoglobin >1 g/dl. Risk ratio and number needed to treat (NNT) were generated using meta-analysis.

RESULTS

Comparing any prophylactic haemostasis to none, the pooled risk ratio for PPH was 0.35 (0.21-0.57; p < 0.0001), NNT was 13.6, and cost to prevent one PPH was USD652. Using adrenaline alone vs. no prophylactic haemostasis revealed a pooled risk ratio of 0.37 (0.20-0.66; p = 0.001), NNT 14.0, cost to prevent one PPH USD382. Any prophylactic mechanical haemostasis compared to adrenaline produced a RR for PPH of 0.28 (0.14-0.57; p < 0.0001), NNT 12.3, and cost to prevent one PPH USD1368.

CONCLUSIONS

Adrenaline injection or mechanical haemostasis reduces the risk of PPH. Routine prophylactic measures to reduce PPH for polyps larger than 10 mm are potentially cost effective, although more thorough cost-benefit modelling is required.

Low rate of postpolypectomy bleeding among patients who continue thienopyridine therapy during colonoscopy

BACKGROUND & AIMS

It is not clear whether the cardiovascular risk of discontinuing treatment with antiplatelet agents, specifically the thienopyridines, before elective colonoscopy outweighs the risks of postpolypectomy bleeding (PPB). We studied the rate of PPB in patients who continue thienopyridine therapy during colonoscopy.

METHODS

We performed a prospective study of 516 patients not taking warfarin who received polypectomies during elective colonoscopies; 219 were receiving thienopyridines, and 297 were not (controls). The occurrence of immediate PPB and delayed PPB was recorded. Delayed PPB was categorized as clinically important if it resulted in repeat colonoscopy, hospitalization, or blood transfusion.

RESULTS

Patients receiving thienopyridines were older and had significantly more comorbid diseases than controls; the mean number of polyps removed per patient was significantly higher (3.9 vs 2.9) in the thienopyridine group. Immediate PPB developed in 16 patients in the thienopyridine group (7.3%) and in 14 in the control group (4.7%, P = .25). Among patients who completed a 30-day follow-up analysis (96% of patients enrolled), clinically important, delayed bleeding occurred in 2.4% of patients receiving thienopyridines and in none of the controls (P = .01). All PPB events in both groups were resolved without surgery, angiography, or death.

CONCLUSIONS

Although a significantly higher percentage of patients who continue thienopyridine therapy during colonoscopy and polypectomy develop clinically important delayed PPB than patients who discontinue therapy, the rate of PPB events is low (2.4%), and all are resolved without sequelae. The risk for catastrophic cardiovascular risks among patients who discontinue thienopyridine therapy before elective colonoscopies could therefore exceed the risks of PPB. ClinicalTrials.gov, Number NCT01647568.

Risk factors for delayed post-polypectomy hemorrhage: a case-control study

BACKGROUND AND AIM

Delayed post-polypectomy hemorrhage is a rare but serious complication. The aim of this study was to identify risk factors for the development of delayed post-polypectomy hemorrhage.

METHODS

This was a retrospective case-control study of patients who developed delayed hematochezia after receiving colonoscopic polypectomy. The control patients underwent uneventful polypectomy and were selected at a 4:1 ratio.

RESULTS

Of the 7447 lesions examined from the 3253 patients who received colonoscopic polypectomy, 53 lesions (0.7%) of 42 patients (1.3%) developed delayed hemorrhage, and 168 patients were selected as controls. According to multivariate logistic regression analysis, a polyp larger than 10 mm (odds ratio [OR] 2.355, 95% confidence interval [CI] 1.225-4.528, P = 0.010), a pedunculated polyp (OR 3.473, 95% CI 1.576-7.657, P = 0.002), and a polyp located in the right hemi-colon (OR 2.690, 95% CI 1.465-4.940, P = 0.001) were significant risk factors for delayed post-polypectomy hemorrhage. The presence of comorbidities did not increase the risk of delayed hemorrhage.

CONCLUSION

Polyp size (large), shape (pedunculated), and location (right hemi-colon) represented substantial risk factors for the development of delayed hemorrhage after colonoscopic polypectomy.

A blinded comparison of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy in a porcine model

BACKGROUND

Although linked with perforation, serositis, delayed bleeding, and incomplete resection, hot biopsy forceps electrocauterization (HBF) is still widely used for diminutive colonic polypectomy.

OBJECTIVE

To evaluate the safety and efficacy of HBF in comparison with conventional snare polypectomy (CSP).

DESIGN

Randomized, blinded, controlled trial.

SETTING

Academic endoscopy unit.

SUBJECTS

Ten swine.

INTERVENTION

Eighty-two paired polypectomies (41 HBF, 41 CSP) of small, minimally elevated, artificial lesions. Standardized technique using coagulating current at 25 W. HBF: the tissue was avulsed after 1 to 2 seconds of current caused blanching of the artificial pedicle. CSP: the polyp was removed by snare diathermy.

MAIN OUTCOME MEASUREMENTS

Histopathology of resected specimens and polypectomy sites in colectomy specimens at necropsy (lateral mucosal and depth of ulceration, necrosis and inflammation).

RESULTS

Some (21%) of the HBF specimens were ablated and uninterpretable. All CSP specimens yielded interpretable specimens. Mucosal necrosis adjacent to HBF resection sites varied widely, between 1.5 and 9 mm (mean 5.7 mm, standard deviation ± 2). There was visible mucosa under the HBF ulcer in 14% of cases. The depth of necrosis in the colon wall was significantly different between the two techniques, with partial muscularis propria (MP) necrosis in 14 of 41 lesions (34%) with HBF, compared with 1 of 41 (2%) of CSP (P < .001), and full-thickness MP necrosis in 9 of 41 lesions (22%) with HBF, compared with 1 of 41 (2%) of CSP (P = .014). There was full-thickness MP inflammation in 13 of 41 lesions (32%) with HBF compared with 5 of 41 (12%) of CSP (P = .06). Transmural subserosal inflammation was seen in 13 of 41 lesions (32%) with HBF compared with 4 of 41 (10%) of CSP (P = .027). There was no relationship between visible lateral mucosal injury and depth of injury (rs = -0.07).

LIMITATIONS

Animal study.

CONCLUSION

Despite use of the standardized HBF technique, there is a wide range of lateral mucosal and deep thermal injury as well as residual target mucosa. HBF also results in a significantly greater depth of tissue injury, with a high proportion of transmural necrosis. Ensuring minimal blanching of the mucosa during the procedure does not protect from deep injury. In comparison to conventional snare polypectomy, HBF is imprecise, potentially ineffective, and hazardous.

Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?

BACKGROUND

Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.

METHODS

Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.

RESULTS

A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.

CONCLUSIONS

The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.

Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors

OBJECTIVE

Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures.

METHODS

This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection.

RESULTS

The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04).

CONCLUSIONS

Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.

The risk of postpolypectomy bleeding during colonoscopy in patients with early liver cirrhosis

BACKGROUND

Colonoscopists are often hesitant to perform endoscopic polypectomy in patients with liver cirrhosis (LC) because of the risk for postpolypectomy bleeding (PPB). However, little is known about the risk of PPB in these patients.

METHODS

We performed a retrospective study of patients with early LC who underwent colonoscopic polypectomy at a single center between September 2006 and May 2011. We investigated the incidence of immediate PPB (IPPB) and delayed PPB (DPPB) in these patients. In addition, we investigated which LC-related and polyp-related factors were associated with IPPB.

RESULTS

Thirty patients with LC were included in our study, and 29 (96.7 %) of them were classified in Child-Pugh class A or B. The mean prothrombin time was 1.27 ± 0.23, and the mean platelet count was 136.77 ± 106.49 × 10(3)/L. A total of 66 polyps in 30 patients were removed. In terms of IPPB, only 2 (3.03 %) of the 66 removed polyps presented with mild oozing and were controlled by hemostatic procedures using hemoclips. DPPB did not occur in any of the patients in the IPPB or the non-IPPB group. Although the IPPB polyp group was too small to detect statistical significance, the IPPB polyps were larger than the non-IPPB polyps (22.5 ± 10.61 vs. 7.22 ± 3.01 mm), and the gross morphology of both IPPB polyps was the pedunculated type. However, LC-related variables such as platelet counts and Child-Pugh scores did not significantly differ between the IPPB and non-IPPB groups.

CONCLUSIONS

In patients with early LC, the risk of postpolypectomy bleeding was acceptably low and there was no case with DPPB. Therefore, polypectomy can be performed with caution. IPPB was associated with the size and the gross morphology of the polyps. However, LC-related variables in patients with early LC did not impact IPPB.

Management of delayed postpolypectomy bleeding: a decision analysis

OBJECTIVES

The benefit of repeat colonoscopy in managing delayed postpolypectomy bleeding is unknown. This study aimed to assess the outcome of repeat colonoscopy to achieve hemostasis.

METHODS

Endoscopic management of postpolypectomy bleeding is modeled as a decision tree, measuring the expected overall fraction of patients who benefit from therapeutic hemostasis and the number of patients needed to treat (NNT) in order to achieve one beneficial hemostasis.

RESULTS

A repeat colonoscopy to identify and treat postpolypectomy bleeding is beneficial in about 22% of patients, corresponding to an NNT of 4.5 patients. The outcome of the model is sensitive to assumptions underlying the fractions of patients who need treatment and would benefit from successful endoscopic hemostasis. Varying these probabilities over a broad range changes the fraction of patients benefiting from endoscopy between 3% and 33% and the NNT between 28 and 3 patients, respectively.

CONCLUSIONS

The expected outcome of repeat colonoscopy justifies the endoscopic attempts at therapeutic hemostasis. The results also suggest that in many patients expectant management aimed at spontaneous resolution of the bleeding remains a valid option.

Endoscopic complications--avoidance and management

The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.

A meta-analysis and systematic review of prophylactic endoscopic treatments for postpolypectomy bleeding

PURPOSE

The aim of this meta-analysis and systematic review was to determine whether bleeding prophylaxis benefits patients after colonoscopic polypectomy.

METHODS

A systematic review of the literature was performed to find prospective randomized controlled trials of postpolypectomy hemorrhage prophylaxis. Studies were selected according to specific criteria and analyzed to generate pooled data.

RESULTS

Eight studies encompassing 2,595 polyps met the criteria for the meta-analysis. The rate of early bleeding was significantly decreased relative to the control when a single prophylactic technique was used [2.58% vs. 8.15%, OR = 0.34 (95% CI, 0.20-0.58), P < 0.0001]. The use of multiple prophylactic techniques resulted in a lower early postpolypectomy hemorrhage rate compared with the use of a single prophylactic technique [0% vs. 8.41%, OR = 0.12 (95% CI, 0.03-0.47), P = 0.002]. The late bleeding rate did not differ significantly between the monotherapy and control groups [0.61% vs. 1.39%, OR = 0.37 (95% CI, 0.11-1.28), P = 0.12], and the use of combined preventative techniques did not significantly decrease the late postpolypectomy bleeding (PPB) rate compared with use of a single prophylactic method [1.43% vs. 2.05%, OR = 0.70 (95% CI, 0.32-1.55), P = 0.38].

CONCLUSION

Prophylactic endoscopic treatments are effective at reducing early PPB after colonoscopic polypectomy. However, patients with late PPB may not benefit from bleeding prophylaxis.

Iatrogenic perforation at colonic imaging

AIM

Adequate colonic imaging is generally an invasive procedure with attendant risks, particularly perforation. Endoscopy, barium enema and computed tomographic colonography (CTC) are the main techniques for investigating patients with symptoms of, or screening for, colorectal cancer. The potential complications of these investigations have to be weighed against the benefits. This article reviews the literature on the incidence, presentation and management of iatrogenic colonic perforation at colonic imaging.

METHOD

A literature review of relevant studies was undertaken using PubMed, Cochrane library and personal archives of references. Manual cross-referencing was performed, and relevant references from selected articles were reviewed. Studies reporting complications of endoscopy, barium enema and CT colonography were included in this review.

RESULTS

Twenty-four studies were identified comprising 640,433 colonoscopies, with iatrogenic perforation recorded in 585 patients (0.06%). The reported perforation rate with double-contrast barium enema was between 0.02 and 0.24%. Serious complications with CTC were infrequent, though nine perforations were reported in a case series of 24,365 patients (0.036%) undergoing CTC.

CONCLUSION

Perforation remains an infrequent and almost certainly under-reported, complication of all colonic imaging modalities. Risk awareness, early diagnosis and active management of iatrogenic perforation minimizes an adverse outcome.