Advanced colon polypectomy

Cold Versus Hot Snare Polypectomy for Colorectal Polyps: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

Endoscopic polypectomy is an excellent tool for colon cancer prevention. With the innovation of novel resection techniques, the best method is still being investigated. Hence, we aim to evaluate the efficacy and safety of cold snare polypectomy (CSP) versus hot snare polypectomy (HSP) for colorectal polyp resection.

METHODS

A systematic review and meta-analysis synthesizing evidence from randomized controlled trials retrieved from PubMed, EMBASE, WOS, SCOPUS, and CENTRAL until July 16, 2022. We pooled dichotomous outcomes using risk ratio (RR) with the corresponding CI. This review's protocol was prospectively registered in PROSPERO with ID: CRD42022347496.

RESULTS

We included 18 randomized controlled trials with a total of 4317 patients and 7509 polyps. Pooled RR favored HSP regarding the complete resection rate (RR: 0.96 with 95% CI: 0.95, 1, P = 0.03) and local recurrence incidence (RR: 5.74 with 95% CI: 1.27, 25.8, P = 0.02). Pooled RR favored CSP regarding the colonoscopy time (mean difference: -6.50 with 95% CI: -7.55, -5.44, P = 0.00001) and polypectomy time (mean difference: -57.36 with 95% CI: -81.74, -32.98, P = 0.00001). There was no difference regarding the incidence of immediate bleeding ( P = 0.06) and perforation ( P = 0.39); however, HSP was associated with more incidence of delayed bleeding ( P = 0.01), abdominal pain ( P = 0.007), and postresection syndrome ( P = 0.02).

DISCUSSION

HSP is associated with a higher complete resection and lower recurrence rates; however, HSP is also associated with a higher incidence of adverse events. Therefore, improving the complete resection rate with CSP still warrants more innovation, giving the technique safety and shorter procedure duration.

Efficacy and safety of cold versus hot snare polypectomy for small (5-9 mm) colorectal polyps: a multicenter randomized controlled trial

BACKGROUND

Resection techniques for small polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). This study compared CSP and HSP in 5-9 mm polyps in terms of complete resection and adverse events.

METHODS

This was a multicenter, randomized trial conducted in seven Spanish centers between February and November 2019. Patients with ≥ 1 5-9 mm polyp were randomized to CSP or HSP, regardless of morphology or pit pattern. After polypectomy, two marginal biopsies were submitted to a pathologist who was blinded to polyp histology. Complete resection was defined as normal mucosa or burn artifacts in the biopsies. Abdominal pain was only assessed in patients without < 5 mm or > 9 mm polyps.

RESULTS

496 patients were randomized: 237 (394 polyps) to CSP and 259 (397 polyps) to HSP. Complete polypectomy rates were 92.5 % with CSP and 94.0 % with HSP (difference 1.5 %, 95 % confidence interval -1.9 % to 4.9 %). Intraprocedural bleeding occurred during three CSPs (0.8 %) and seven HSPs (1.8 %) (P = 0.34). One lesion per group (0.4 %) presented delayed hemorrhage. Post-colonoscopy abdominal pain presented similarly in both groups 1 hour after the procedure (CSP 18.8 % vs. HSP 18.4 %) but was higher in the HSP group after 5 hours (5.9 % vs. 16.5 %; P = 0.02). A higher proportion of patients were asymptomatic 24 hours after CSP than after HSP (97 % vs. 86.4 %; P = 0.01).

CONCLUSIONS

We observed no differences in complete resection and bleeding rates between CSP and HSP. CSP reduced the intensity and duration of post-colonoscopy abdominal pain.

The quality of colorectal polypectomy. Is it enough to have just a visual assessment of the site?

INTRODUCTION

Performing a colonoscopy allows the examination of the entire colon and the assessment of polyps.

PATIENTS, MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data from January 2018 until February 2020 (two years), in which we enrolled a number of 210 patients performing colonoscopy in the Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Romania. We performed 326 polypectomies.

RESULTS

We classified the polyps into diminutive (n=169), small (n=103) and large polyps (n=54). Regarding the polypectomy technique, our results indicated that 40 out of 48 (83.3%) polypectomies with the biopsy forceps were complete, as well as 27 out of 31 (87.1%) cold snare polypectomies and 12 out of 14 (85.7%) hot snare polypectomies. The differences were not statistically significant (p=0.116). Regarding the number of incomplete polypectomies, our data suggests that the high expertise endoscopist had two incomplete resections (5.1% of total), the medium expertise endoscopist 1 had also two incomplete resections (11.1% of total), the medium expertise endoscopist 2 had three incomplete resections (15% of total), the limited expertise endoscopist 1 had three incomplete resections (27.27% of total) and the limited expertise endoscopist 2 had four incomplete resections (30.76% of total). Analyzing the data, the differences were statistically significant (p=0.006).

CONCLUSIONS

Our study is able to suggest that high-definition white-light endoscopy (HD-WLE) macroscopic visualization of the polyp resection site is not enough to assess complete polyp resection and follow-up colonoscopy should be performed for cases with incomplete margins of resection.

Carbon dioxide insufflation during endoscopic resection of large colorectal polyps can reduce post-procedure abdominal pain: A prospective, double-blind, randomized controlled trial

Background

Studies of the use of CO₂ insufflation during endoscopic resection of large colorectal polyps (LCPs) are lacking.

Objective

We evaluated the effect of CO₂ insufflation on pain after endoscopic resection of LCPs.

Methods

In a prospective randomized controlled trial (RCT), 132 patients were randomly assigned to groups who underwent endoscopic resection with CO₂ insufflation (CO₂ group, n = 66) or air insufflation (air group, n = 66). The primary outcome was abdominal pain post-procedure (PP). The secondary outcomes were abdominal distension, rates of technical success, amounts of sedatives prescribed, use of analgesics, and adverse events.

Results

Baseline patient characteristics were similar between the groups. The mean abdominal pain score was 12.3 in the CO₂ group vs. 17.5 in the air group at 1 h PP (p  =  0.047). Also, the proportion of patients without pain was significantly higher in the CO₂ group at 1 h PP (p = 0.008). The pain score differed more in the endoscopic submucosal dissection group and long-time group. The secondary outcomes were not significantly different between the two groups.

Conclusions

The results of this RCT demonstrate the superiority of CO₂ insufflation for endoscopic resection of LCPs in terms of decreasing PP abdominal pain (KCT0001636).

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

Stray energy transfer during endoscopy

INTRODUCTION

Endoscopy is the standard tool for the evaluation and treatment of gastrointestinal disorders. While the risk of complication is low, the use of energy devices can increase complications by 100-fold. The mechanism of increased injury and presence of stray energy is unknown. The purpose of the study was to determine if stray energy transfer occurs during endoscopy and if so, to define strategies to minimize the risk of energy complications.

METHODS AND PROCEDURES

A gastroscope was introduced into the stomach of an anesthetized pig. A monopolar generator delivered energy for 5 s to a snare without contacting tissue or the endoscope itself. The endoscope tip orientation, energy device type, power level, energy mode, and generator type were varied to mimic in vivo use. The primary outcome (stray current) was quantified as the change in tissue temperature (°C) from baseline at the tissue closest to the tip of the endoscope. Data were reported as mean ± standard deviation.

RESULTS

Using the 60 W coag mode while changing the orientation of the endoscope tip, tissue temperature increased by 12.1 ± 3.5 °C nearest the camera lens (p < 0.001 vs. all others), 2.1 ± 0.8 °C nearest the light lens, and 1.7 ± 0.4 °C nearest the working channel. Measuring temperature at the camera lens, reducing power to 30 W (9.5 ± 0.8 °C) and 15 W (8.0 ± 0.8 °C) decreased stray energy transfer (p = 0.04 and p = 0.002, respectively) as did utilizing the low-voltage cut mode (6.6 ± 0.5 °C, p < 0.001). An impedance-monitoring generator significantly decreased the energy transfer compared to a standard generator (1.5 ± 3.5 °C vs. 9.5 ± 0.8 °C, p < 0.001).

CONCLUSION

Stray energy is transferred within the endoscope during the activation of common energy devices. This could result in post-polypectomy syndrome, bleeding, or perforation outside of the endoscopist's view. Decreasing the power, utilizing low-voltage modes and/or an impedance-monitoring generator can decrease the risk of complication.

Laparoscopic colorectal surgery for colorectal polyps: experience of ten years

Background. Laparoscopy or its combination with endoscopy is the next step for “difficult” polyps. The purpose of the paper was to review the outcomes of the laparoscopic approach to the management of “difficult” colorectal polyps.

Materials and methods. From 2006 to 2016, 58 patients who underwent laparoscopic treatment for “difficult” polyps that could not be treated by endoscopy at the National Cancer Institute, Lithuania, were included. The demographic data, the type of surgery, length of post-operative stay, complications, and final pathology were reviewed prospectively.

Results. The mean patient was 65.9 ± 8.9 years of age. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed in 15 (25.9%) patients, laparoscopic segmental bowel resection in 41 (70.7%) cases: anterior rectal resection with partial total mesorectal excision in 18 (31.0%), sigmoid resection in nine (15.5%), left hemicolectomy in seven (12.1%), right hemicolectomies in two (3.4%), ileocecal resection in two (3.4%), resection of transverse colon in two (3.4%), and sigmoid resection with transanal retrieval of specimen in one (1.7%). Two patients (3.4%) underwent laparoscopic-assisted endoscopic polypectomy. The mean post-operative hospital stay was 5.7 ± 2.4 days. There were four complications (6.9%). All patients recovered after conservative treatment. The mean polyp size was 3.5 ± 1.9 cm. Final histopathology revealed hyperplastic polyps (n = 2), tubular adenoma (n = 9), tubulovillous adenoma (n = 31), carcinoma in situ (n = 12), and invasive cancer (n = 4).

Conclusions. For the management of endoscopically unresectable polyps, laparoscopic surgery is currently the technique of choice.

Digital Chromoendoscopy With i-Scan for In Vivo Prediction of Advanced Colorectal Neoplasia: A Multicenter Study

BACKGROUND

Recent studies have analyzed the potential of advanced endoscopic imaging techniques for differentiating hyperplastic and adenomatous colorectal lesions. Latest endoscopic resection techniques now also allow for treatment of more advanced staged lesions including treatment of early cancerous lesions.

AIMS

To assess the potential of the i-scan technology to differentiate between adenomatous polyps and advanced staged neoplasia.

METHODS

Consecutive patients undergoing colonoscopy at a tertiary referral center were included. After a dedicated training, participating endoscopists underwent a review of 298 unknown images of colonic lesions to assess colorectal lesion histology.

RESULTS

Overall accuracy for prediction of advanced staged neoplasia was 92.2% (sensitivity: 94.2%, specificity 90.9%). The positive and negative predictive values were calculated as 87.5% and 95.9%, respectively. The κ-value for differentiating adenomatous polyps and advanced staged neoplasia was 0.8193 (0.7894 to 0.8492). Intraobserver agreement was calculated with a κ-value of 0.9301 (0.8875 to 0.9727).

CONCLUSIONS

Accurate interpretation of i-scan images for prediction of advanced colorectal neoplasia can successfully be performed even by nonexpert endoscopists with a high overall accuracy and excellent interobserver agreements.

Endoscopic Therapy in Inflammatory Bowel Diseases

Background

Endoscopy is an essential diagnostic and therapeutic modality in the clinical care of inflammatory bowel disease (IBD) patients. Endoscopic therapy can be used for treatment of disease-related strictures, surveillance and resection of intraepithelial neoplasia, and treatment of fistulas or disease-related complications, and is currently being evaluated regarding its capacity in in vivo molecular imaging procedures.

Methods

A literature search using Medline and Science Citation Index was performed in March 2015. All studies on endoscopic therapy in IBD published from 1980 to 2015 (March) were reviewed. Potential studies were initially screened by title and abstract. The terms ‘endoscopy IBD’, ‘endoscopy therapy IBD’, ‘dilatation IBD’, ‘strictureplasty Crohn's disease’, ‘endoscopy therapy fistula’, ‘endoscopy toxic megacolon’, ‘endoscopy dysplasia IBD’, ‘endoscopy complications IBD’, and ‘molecular imaging IBD’ were used in the search. A total of 115 articles were studied to construct this review.

Results

Dilatation is most useful in short anastomotic strictures, but can be also undertaken in colonic strictures. Strictures in ulcerative colitis are always suspicious for neoplasia and should be evaluated carefully. Lesions with intraepithelial neoplasia can be resected when complete removal can be assured. The finding of carcinoma or high-grade dysplasia in a random biopsy is an indication for colectomy. If intraepithelial neoplasia is present in random biopsy specimens, colectomy should similarly be recommended. Endoscopic therapy of Crohn's fistulas is a possible emerging technology. In vivo molecular imaging is currently being studied in IBD patients and offers promising therapeutic opportunities.

Conclusion

Therapeutic endoscopy is indispensable in the management of IBD. It has to be carefully evaluated against alternative surgical options but often offers an effective therapeutic approach.

© 2015 S. Karger GmbH, Freiburg

Current issues in inflammatory bowel disease neoplasia

Recent histological criteria and developments in the field of endoscopic imaging have led to higher detection rates of neoplasms in ulcerative colitis. Once a lesion is detected, endoscopic resection is recommended to guide subsequent surveillance or therapy and to gain adequate material for histological diagnosis. Further management is based on the grade of neoplasia and on whether the neoplasia is categorized as sporadic or colitis-associated. Nevertheless it may sometimes be difficult to distinguish colitis-associated neoplasms from sporadic neoplasms. A better way to report this may be ultimately classified. Here, we review endoscopic and histological parameters to help to differentiate colitis-associated neoplasia from sporadic lesions and discuss pathogenesis and therapeutic options.

Coagulation syndrome: Delayed perforation after colorectal endoscopic treatments

Various procedure-related adverse events related to colonoscopic treatment have been reported. Previous studies on the complications of colonoscopic treatment have focused primarily on perforation or bleeding. Coagulation syndrome (CS), which is synonymous with transmural burn syndrome following endoscopic treatment, is another typical adverse event. CS is the result of electrocoagulation injury to the bowel wall that induces a transmural burn and localized peritonitis resulting in serosal inflammation. CS occurs after polypectomy, endoscopic mucosal resection (EMR), and even endoscopic submucosal dissection (ESD). The occurrence of CS after polypectomy or EMR varies according previous reports; most report an occurrence rate around 1%. However, artificial ulcers after ESD are largely theoretical, and CS following ESD was reported in about 9% of cases, which is higher than that for CS after polypectomy or EMR. Most cases of post-polypectomy syndrome (PPS) have an excellent prognosis, and they are managed conservatively with medical therapy. PPS rarely develops into delayed perforation. Delayed perforation is a severe adverse event that often requires emergency surgery. Since few studies have reported on CS and delayed perforation associated with CS, we focused on CS after colonoscopic treatments in this review. Clinicians should consider delayed perforation in CS patients.

Management of polypectomy complications

The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.

Laparoscopic colorectal surgery for colorectal polyps: single institution experience

Introduction

Because of their difficult location or size, some polyps are impossible to remove with a flexible colonoscope and must be surgically removed. Laparoscopy is a great alternative.

Aim

To assess outcomes of a laparoscopic approach for the management of difficult colorectal polyps.

Material and methods

From 2006 to 2014, patients with polyps that could not be treated by endoscopy were included. Demographic data, histology of the biopsy, type of surgery, length of postoperative stay, complications and final pathology were reviewed prospectively.

Results

Forty-two patients with a mean age of 64.9 ±8.4 underwent laparoscopic polypectomy. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed for 12 (28.6%) polyps. Laparoscopic segmental bowel resection was performed in 30 (71.4%) cases: anterior rectal resection with partial total mesorectal excision in 12 (28.6%), left hemicolectomy in 7 (16.6%), sigmoid resection in 6 (14.3%), ileocecal resection in 2 (4.76%), resection of transverse colon in 2 (4.76%) and sigmoid resection with transanal retrieval of specimen in 1 (2.38%). Mean postoperative hospital stay was 5.9 ±2.6 days. There were 4 complications (9.5%). All patients recovered after conservative treatment. Mean polyp size was 3.6 ±2.2 cm. Final pathology revealed polyps (n = 2), tubular adenoma (n = 6), tubulovillous adenoma (n = 20), carcinoma in situ (n = 10) and invasive cancer (n = 4). Two of these patients underwent laparoscopic left hemicolectomies 14 and 10 days after laparoscopic colotomy and polypectomy.

Conclusions

For the management of endoscopically unresectable polyps, laparoscopic polypectomy is currently the technique of choice.

Risk factors for delayed postpolypectomy bleeding

AIM: To identify risk factors for delayed postpolypectomy bleeding (DPPB) and analyze the correlations of these risk factors with DPPB.

METHODS: A total of 2292 polpyectomies performed in 1426 cases between November 2008 and April 2014 were retrospectively reviewed. Polyp-related and procedure-related factors were evaluated as potential risk factors for DPPB.

RESULTS: Delayed bleeding occurred in 20 (1.4%) cases. Multivariate analysis revealed that polyp size > 10 mm [odds ratio (OR) = 1.222, 95% confidence interval (CI): 1.205-1.239, (P = 0.003], location in the right hemicolon (OR = 1.152, 95%CI: 1.137-1.167, (P = 0.049), and inadequate endoscopic experience of endoscopist (OR = 1.307, 95%CI: 1.288-1.326, (P = 0.046) were significant risk factors for DPPB. Right-sided polypectomy by an inexperienced endoscopist (OR = 1.992, 95%CI: 1.975-2.009, (P = 0.000) significantly increased the risk for DPPB.

CONCLUSION: Polyp size, right hemicolon location andinadequate endoscopic experience of endoscopist were identified as potential risk factors for DPPB.

Polypectomy practices of sub-centimeter polyps in the English Bowel Cancer Screening Programme

BACKGROUND

Most colonic polyps are small, and several polypectomy techniques are available. We aimed to describe the variation in polypectomy techniques employed for the removal of sub-centimeter polyps in relation to polyp characteristics, completeness of histological excision and safety.

METHODS

Prospectively collected data relating to the removal of sub-centimeter polyps over a 3-year period (between January 2010 and December 2012) were retrieved from the English Bowel Cancer Screening Programme.

RESULTS

A total of 147,174 sub-centimeter polyps were removed during 62,679 procedures. For pedunculated polyps, hot snare was most common in the left (median 92 %, IQR 83.3-97.0 %) and right colon (median 75 %, IQR 3-92 %). For non-pedunculated polyps, cold snare was most common in the right colon (median 24 %, IQR 9-47 %); whereas hot snare remained most common in the left colon (median 32 %, IQR 19-49 %). Surgeons were more likely than physicians to use diathermy-assisted techniques (65.6 vs. 56.5 %, p < 0.001). Twelve (0.03 %) bleeding episodes required transfusion with no polypectomy technique dominating and 16 (0.04 %) perforations with 81 % of polypectomies performed using diathermy-assisted techniques. There was substantial variation between screening centers for the completeness of histological excision. For non-pedunculated polyps, histologically confirmed complete excision was more after EMR (23.4 %) compared with other techniques (cold biopsy forceps 17.7 %, cold snare 15.1 %, hot biopsy forceps 19.1 %, hot snare 21.5 %). The use of cold techniques and EMR has increased over time, whereas the use of hot biopsy forceps and hot snare has decreased (p < 0.001).

CONCLUSIONS

The removal of sub-centimeter polyps within the BCSP is safe despite wide variations in practice. The use of cold resection techniques and EMR has increased over time. The histological assessment for completeness of excision is limited and should be confirmed endoscopically at the time of polypectomy.

Advanced colonoscopic imaging using endocytoscopy

Optical biopsy techniques were recently introduced to luminal gastrointestinal endoscopy. These include confocal laser endomicroscopy, spectroscopic imaging techniques and endocytoscopy. Optical biopsy techniques allow on demand in vivo histology during ongoing endoscopy, thereby potentially accelerating clinical diagnosis and specific therapy. In the present review, we focus on endocytoscopy as one of the rapidly emerging optical biopsy techniques. We provide technical details of currently available endocytoscopy systems and give tips on their use in clinical practice. We also summarize applications of endocytoscopy for colorectal pathologies.

Management of bleeding and perforation after colonoscopy

Bleeding is a relatively rare complication occurring mainly after snare polypectomy. The majority of cases can be managed successfully by endoscopic means leaving very few cases which will ultimately need an operation. Colonic perforation, on the other hand is a serious complication that requires intensive and careful management. Prompt recognition of the perforation during the procedure allows, in selected cases, immediate endoscopic closure with an uneventful and full recovery followed by close monitoring and surgical management in case of clinical deterioration. The criteria for the right selection of perforation cases amenable to endoscopic treatment do still need to be confirmed by prospective studies and further experience is required before a standard algorithm on the endoscopic management of perforations is developed.

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.

Imaging findings post colorectal endoscopic mucosal resection

Endoscopic mucosal resection is commonly the treatment regime of choice for large sessile colonic polyps. We describe the computed tomography findings of a 51 year old female who presented with transient severe abdominal pain without systemic upset post endoscopic mucosal polyp resection, which resolved with conservative management. This is the second case in the literature that demonstrates 'normal' appearances post endoscopic mucosal resection. The clinical team and radiologist need to be aware of these findings when making management decisions in patients who present with acute pain post endoscopic mucosal resection.

Successful endoscopic strategies for difficult polypectomy

PURPOSE OF REVIEW

Standard endoscopic polypectomy is a powerful technique to remove most polyps found in the gastrointestinal tract. However, a small percentage of polyps can be classified as difficult, based on size, location, and/or configuration. Traditionally, these difficult polyps were referred for surgical segmental colectomy. Recently, with advancements in endoscopic techniques and accessories, a majority of these difficult polyps are now able to be completely resected using entirely endoscopic techniques.

RECENT FINDINGS

Endoscopic techniques and accessories have been evolving during recent years, including increased dissemination of techniques of endoscopic submucosal dissection to the western hemisphere. In addition to refinement of endoscopic techniques, there has been increased interest in developing improved endoscopic accessories, including novel submucosal injectate with auto-dissecting properties, to improve safety and efficiency of endoscopic resection of difficult polyps.

SUMMARY

This article will review currently available techniques and strategies for successful endoscopic resection for difficult polyps.

Colon polypectomy: a review of routine and advanced techniques

The value of performing comprehensive screening colonoscopy with complete colon polypectomy is widely accepted. Colon cancer is a significant cause of worldwide mortality and prospective studies have proven that colonoscopic polypectomy reduces both the incidence and mortality related to this disease. Over the past few decades the array of instruments and techniques have greatly expanded to assist with the safe endoscopic removal of colon polyps. This article will review the published literature regarding efficacy and safety of standard polypectomy techniques such as snare polypectomy, electrocautery, and endoscopic mucosal resection along with newer techniques such as endoscopic submucosal dissection and combined laparoscopic techniques.

Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation

Postpolypectomy electrocoagulation syndrome is a rare complication of polypectomy with electrocautery and is characterized by a transmural burn of the colon wall. Patients typically present within 12 hours after the procedure with symptoms mimicking colonic perforation. Presented is the case of a 56-year-old man who developed abdominal pain six hours after colonoscopy during which polypectomy was performed using snare cautery. CT imaging of the abdomen revealed circumferential thickening of the wall of the transverse colon without evidence of free air. The patient was treated conservatively as an outpatient and had resolution of his pain over the following four days. Recognition of the diagnosis and understanding of the treatment are important to avoid unnecessary exploratory laparotomy or hospitalization.

Learning curve of virtual chromoendoscopy for the prediction of hyperplastic and adenomatous colorectal lesions: a prospective 2-center study

BACKGROUND

Computed virtual chromoendoscopy (CVC) enables high-definition imaging of mucosal lesions with improved tissue contrast. Previous studies have shown that CVC yields an improved detection rate of colorectal lesions. However, the learning curve for interpretation of CVC images is unknown.

OBJECTIVE

To examine the learning curve of correctly identifying hyperplastic and adenomatous colorectal lesions by using CVC.

DESIGN

Prospective, 2-center study.

PATIENTS

Consecutive patients undergoing screening colonoscopy were included. CVC images were analyzed by using corresponding polypectomies as the reference standard followed by a prospective, double-blind review of i-scan images.

METHODS

A training set containing 20 images with known histology was reviewed to standardize image interpretation, followed by a blind review of 110 unknown images. Overall, 4 endoscopists from 2 different endoscopy centers evaluated the images, which were obtained by 1 endoscopist using high-definition endoscopy with CVC.

RESULTS

Patients were included in a prospective fashion. Seventy-seven of 110 colorectal lesions were adenomas and 33 were hyperplastic lesions. Mean diameter of colonic polyps was 4 mm (range, 2-20 mm). Overall accuracy for the group was 73.9% for lesions 1 to 22, 79.6% for lesions 23 to 44, 84.1% for lesions 45 to 66, 87.5% for lesions 67 to 88, and 94.3% for lesions 89 to 110. Accuracy of i-scan for prediction of polyp histology was not dependent on polyp size (≤5 mm, 6-10 mm, or > 10 mm). The ability to obtain high-quality images was stable over time, and high-quality images were constantly produced.

LIMITATION

Post-hoc assessment.

CONCLUSION

Accurate interpretation of CVC images for prediction of hyperplastic and adenomatous colorectal lesions follows a learning curve but can be learned rapidly.

Description of a new, endoscopic technique to remove the over-the-scope-clip in an ex vivo porcine model (with video)

BACKGROUND

Various studies have demonstrated the usefulness of the over-the-scope-clip (OTSC) to treat perforations, anastomotic leaks, and fistulae. Endoscopic removal of the OTSC was previously described in a series of 3 patients by using the Nd:YAG laser.

OBJECTIVE

To evaluate a new endoscopic technique to remove the OTSC.

DESIGN

Prospective, single-arm, pilot study in an ex vivo porcine model.

INTERVENTIONS

Perforations were created by using a surgical scalpel and a blunt trocar. Then they were endoscopically closed with the OTSC. Next, the OTSC was removed under endoscopic control by inserting a 0.035-inch straight hydrophilic tip guidewire into the oval hole on the side of the OTSC jaw. Afterward, the OTSC clip was removed by pulling on the wire.

RESULTS

Fifteen perforations were closed: with the OTSC. In all of the cases, the endoscopic closure of the defects was feasible and effective. Successful visualization of the oval hole of the OTSC was possible in 12 cases (80%), and guidewire cannulation was possible in all of these 12 cases (100%). Advancement of the guidewire through the OTSC and then the lumen of the stomach was accomplished in 8 cases (53.3%). In all of the cases with successful cannulation of the orifice, removal of the OTSC was managed safely. The result was an overall success rate of 53.3% (8 of 15 cases).

LIMITATIONS

Ex vivo porcine model.

CONCLUSIONS

Guidewire removal is a new and feasible technique to remove the OTSC. Future studies should refine the technique to enhance visualization and cannulation of the oval hole of the OTSC.

Developing an endoscopic mucosal resection service in a district general hospital

OBJECTIVE

To describe the implementation of a formal single-operator led endoscopic mucosal resection (EMR) service in a district general hospital, and the effect on patient outcome of this service development.

DESIGN

Prospective audit during initiation and subsequent development of EMR service.

SETTING

District general hospital.

PATIENTS

All patients referred to EMR service between 1 January 2008 and 31 December 2011.

INTERVENTIONS

Nil in addition to clinical care.

MAIN OUTCOMES MEASURED

The number of EMRs per year including polyp size and histology, recurrence of polyp tissue at 3 months following EMR, and complications including early/delayed bleeding and perforation.

RESULTS

Following service implementation, the number of EMRs rose from 11 in 2008 to 35 in 2011, with the number of large polyps (>30 mm) rising from four in 2008 to 24 in 2011. Recurrent or residual adenomatous tissue fell from 75% in 2008 to 4.76% in 2011. Only one perforation occurred over the 4 years (0.8% perforation rate: 1 in 120 polypectomies). A reduction in surgical intervention for adenomatous polyp removal was observed during the audit period.

CONCLUSIONS

Professional engagement and support by medical, surgical and nursing members of the endoscopy team promoted development of skill and confidence in EMR. Exposure to higher volumes of EMR procedures allowed successful removal of larger lesions, while maintained patient safety and reduced the need for surgical removal of benign polyps.

Difficult colon polypectomy

Colorectal cancer (CRC) is one of the leading causes of death from cancer in the world. We now know that 90% of CRC develop from adenomatous polyps. Polypectomy of colon adenomas leads to a significant reduction in the incidence of CRC. At present most of the polyps are removed endoscopically. The vast majority of colorectal polyps identified at colonoscopy are small and do not pose a significant challenge for resection to an appropriately trained and skilled endoscopist. Advanced polypectomy techniques are intended for the removal of difficult colon polyps. We have defined a “difficult polyp” as any lesion that due to its size, shape or location represents a challenge for the colonoscopist to remove. Although many “difficult polyps” will be an easy target for the advanced endoscopist, polyps that are larger than 15 mm, have a large pedicle, are flat and extended, are difficult to see or are located in the cecum or any angulated portion of the colon should be always considered difficult. Although very successful, advanced resection techniques can potentially cause serious, even life-threatening complications. Moreover, post polypectomy complications are more common in the presence of difficult polyps. Therefore, any endoscopist attempting advanced polypectomy techniques should be adequately supervised by an expert or have an excellent training in interventional endoscopy. This review describes several useful tips and tricks to deal with difficult polyps.

Quality of polyp resection during colonoscopy: are we achieving polyp clearance?

BACKGROUND AND STUDY AIM

Currently colonoscopy quality indicators emphasize our ability to improve polyp detection (e.g., preparation quality, withdrawal times of ≥6 min). The completeness of a polyp resection may also be an important determinant of quality and efficient colonoscopy. The primary aim of this study was to determine the incidence of an incomplete polyp resection despite a perceived complete polypectomy.

PATIENTS AND METHODS

This was a retrospective quality assurance project conducted at the San Diego Veterans Affair Medical Center and University of California San Diego Medical Center from July 2007 to April 2008. The patients recruited to this study were undergoing surveillance and screening colonoscopy. The resection quality was evaluated in 65 polyps of 47 patients. Twenty-two polyps were removed with standard biopsy forceps, jumbo forceps (18), hot snare (18), and cold snare (7). Biopsies were taken from the post-polypectomy site base and perimeter for histologic examination in order to confirm histologic absence of all polypoid appearing mucosa.

RESULTS

The post-polypectomy sites of ten polyps (15%) were found to have residual polypoid tissue. Six were removed by standard biopsy forceps, jumbo forceps (2), hot snare (1), and cold snare (1). When compared to other polypectomy devices, standard biopsy forceps were more likely to result in an incomplete resection (27 vs. 9%; P = 0.076).

CONCLUSIONS

The endoscopist may not be visually accurate in determining when a polyp is completely resected, and alternative devices and techniques for polyp resection should be considered.

Complication rates of colonic polypectomy in relation to polyp characteristics and techniques: a district hospital experience

BACKGROUND: Colonic polypectomy reduces the subsequent rate of development of colonic cancer but is not without its risks. We aimed to examine our complication rates in relation to the characteristics of polyps and techniques employed. METHODS: A database for all colonic polypectomies performed over a 3½-year period between 2006 and 2009 was matched against all patients readmitted after an endoscopy. Serious complications post-polypectomy were defined as events leading to readmission within 14 days. RESULTS: We performed 2106 polypectomies on 1252 patients in this period. Fourteen patients or 24 (1.1%) polypectomies experienced complications. Two patients (0.09%) experienced perforation, 10 (0.47%) had bleeding and 3 (0.14%) had post-polypectomy syndromes. Our bleeding rate was 1:211, lower than the national standard of 1:100. No deaths were reported. Complication rates rose from 1% in the smallest group (1-10 mm) to 4.9% in the largest (>31 mm) but the difference was not statistically significant (p=0.067). Right-colon polypectomies had a higher tendency of developing post-polypectomy syndrome and bleeding (p=0.002). Complication rates in snare polypectomies were not significantly different from that of hot biopsies (p=0.64). However, endoscopic mucosal resections (EMR) had significantly more complications compared to snares (p=0.045) and hot biopsies (p=0.026). CONCLUSION: We achieved lower bleeding rates than that published nationally. Hot biopsies did not carry a higher risk unlike EMRs. Although polyp size may be an important risk factor, statistical significance was not met. Ascending and transverse colon polypectomies carried the highest risks of complications.

The submucosal cushion does not improve the histologic evaluation of adenomatous colon polyps resected by snare polypectomy

BACKGROUND & AIMS

Although the "submucosal cushion" technique or injection-assisted polypectomy (IAP) is often used to resect colon polyps, little is known on the influence of this technique on histologic interpretation. We aimed to evaluate whether the use of a submucosal cushion improves the histologic and margin evaluation of colon polyps.

METHODS

Consecutive patients undergoing polypectomy with and without IAP were included. An experienced blinded gastrointestinal pathologist evaluated the specimens using standardized criteria.

RESULTS

One hundred eleven sessile colon adenomas were analyzed (IAP, n = 65, standard, n = 46). Two-thirds of polyps ranged in size from 10 to 20 mm; the average polyp size was 13.2 mm for IAP and 9.9 mm for standard snare polypectomy (P = .001). The cautery degree, cautery amount, and margin evaluability, did not differ substantially with regard to the resection technique. For polyps ≥10-20 mm, the overall architecture quality was better in polyps resected with standard technique as compared with IAP.

CONCLUSIONS

The utilization of IAP did not result in a better margin evaluability of the resected polyp. Overall, IAP does not result in a better histologic polyp evaluability.

Cancer risk in IBD: How to diagnose and how to manage DALM and ALM

The risk of developing neoplasia leading to colorectal cancer is significantly increased in ulcerative colitis (UC) and most likely in Crohn’s disease. Several endoscopic surveillance strategies have been implemented to identify these lesions. The main issue is that colitis-associated neoplasms often occurs in flat mucosa, often being detected on taking random biopsies rather than by identification of these lesions via endoscopic imaging. The standard diagnostic procedure in long lasting UC is to take four biopsies every 10 cm. Image enhancement methods, such as chromoendoscopy and virtual histology using endomicroscopy, have greatly improved neoplasia detection rates and may contribute to reduced random biopsies by taking targeted “smart” biopsies. Chromoendoscopy may effectively be performed by experienced endoscopists for routine screening of UC patients. By contrast, endomicroscopy is often only available in selected specialized endoscopic centers. Importantly, advanced endoscopic imaging has the potential to increase the detection rate of neoplasia whereas the interplay between endoscopic experience and interpretation of histological biopsy evaluation allows the physician to make a proper diagnosis and to find the appropriate therapeutic approach. Colitis-associated intraepithelial neoplasms may occur in flat mucosa of endoscopically normal appearance or may arise as dysplasia-associated lesion or mass (DALM), which may be indistinguishable from sporadic adenomas in healthy or non-colitis mucosa [adenoma-like mass (ALM)]. The aim of this review was to summarize endoscopic and histological characteristics of DALM and ALM in the context of therapeutic procedures.

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.

Colonoscopic polypectomy and associated techniques

Polypectomy of colonic polyps has been shown to reduce the risk of colon cancer development and is considered a fundamental skill for all endoscopists who perform colonoscopy. A variety of polypectomy techniques and devices are available, and their use can vary greatly based on local availability and preferences. In general, cold forceps and cold snare have been the polypectomy methods of choice for smaller polyps, and hot snare has been the method of choice for larger polyps. The use of hot forceps has mostly fallen out of favor. Polypectomy for difficult to remove polyps may require the use of special devices and advanced techniques and has continued to evolve. As a result, the vast majority of polyps today can be removed endoscopically. Since electrocautery is frequently used for polypectomy, endoscopists should be thoroughly familiar with the basic principles of electrosurgery as it pertains to polypectomy. Tattooing of a polypectomy site is an important adjunct to polypectomy and can greatly facilitate future surgery or endoscopic surveillance. The two most common post-polypectomy complications are bleeding and perforation. Their incidence can be decreased with the use of meticulous polypectomy techniques and the application of some prophylactic maneuvers. This review will examine the technique of polypectomy and its complications from the perspective of the practicing gastroenterologist.

Development of expertise in the detection and classification of non-polypoid colorectal neoplasia: Experience-based data at an academic GI unit

At its core, quality improvement in gastrointestinal (GI) practice relies on continuous training, education, and information among all health care providers, whether gastroenterologists, GI trainees, endoscopy nurses, or GI pathologists. Over the past few years, it became clear that objective criteria are needed to assess the quality of colonoscopy, such as cecum intubation rate, quality of bowel preparation, withdrawal time, and adenoma detection rate. In this context, development of competence among practicing endoscopists to adequately detect and treat non-polypoid colorectal neoplasms (NP-CRNs) deserves special attention. We describe a summary of the path to develop expertise in detection and management of NP-CRNs, based on experience at our academic GI unit.

An advanced chromocolonoscopic picture is worth a thousand words, but is it worth the effort?

Chromocolonoscopy is a commonly used advanced or multimodal colon imaging method to interrogate the colon mucosa and colon polyps. The two main objectives of chromocolonosopy are to (a) detect a colon polyp and (b) define (differentiate) the lesion. Although data supporting the use of chromocolonoscopy for colon polyp detection are not strongly founded, this technique may be helpful in differentiating colon polyps and may aid in their endoscopic resection.