Large Sessile Serrated Polyps Can Be Safely and Effectively Removed by Endoscopic Mucosal Resection

Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis

BACKGROUND

There is increasing evidence that cold endoscopic mucosal resection (c-EMR) can effectively treat large colorectal polyps. We aim to appraise the current literature and evaluate outcomes following c-EMR for nonpedunculated colonic polyps ≥20 mm.

METHODS

Major databases were searched. Primary outcomes included recurrence rate and adverse events. Meta-analysis was performed using a random-effects model.

RESULTS

Nine articles were included in the final analysis, which included 817 patients and 1077 colorectal polyps. Average polyp size was 28.8 (±5.1) mm. The pooled recurrence rate of polyps of any histology at 4 to 6 months was 21.0% (95% CI: 9.0%-32.0%, P <0.001, I2 =97.3, P <0.001). Subgroup analysis showed that recurrence was 10% for proximal lesions (95% CI: 0.0%-20.0%, P =0.054, I2 =93.7%, P =0.054) and 9% for distal lesions (95% CI: 2.0%-21.0%, P =0.114, I2 =95.8%, P =0.114). Furthermore, subgroup analysis showed that recurrence was 12% for adenoma (95% CI: 4.0%-19.0%, P =0.003, I2 =98.0%, P =0.003), and 3% for sessile serrated polyps (95% CI: 1.0%-5.0%, P =0.002, I2 =34.4%, P =0.002). Post-polypectomy bleeding occurred in 1% (n=8/817) of patients, whereas abdominal pain occurred in 0.2% (n=2/817) of patients.

CONCLUSIONS

C-EMR for nonpedunculated colorectal polyps ≥20 mm shows an excellent safety profile with a very low rate of delayed bleeding as well as significantly less recurrence for sessile serrated polyps than adenomas.

Cold EMR vs. Hot EMR for the removal of sessile serrated polyps larger than 10 mm: a systematic review and meta-analysis

BACKGROUND

Endoscopic mucosal resection (EMR) appears to be a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. To assess the effectiveness and safety of EMR for removing SSPs ≥ 10 mm, we conducted this systematic review and meta-analysis.

METHODS

We conducted a thorough search of Embase, PubMed, Cochrane, and Web of Science databases for relevant studies reporting on EMR of SSPs ≥ 10 mm, up until December 2023. Our primary endpoints of interest were rates of technical success, residual SSPs, and adverse events (AE).

RESULTS

Our search identified 426 articles, of which 14 studies with 2262 SSPs were included for analysis. The rates of technical success, AEs, and residual SSPs were 100%, 2.0%, and 3.1%, respectively. Subgroup analysis showed that the technical success rates were the same for polyps 10-19 and 20 mm, and en-bloc and piecemeal resection. Residual SSPs rates were similar in en-bloc and piecemeal resection, but much lower in cold EMR (1.0% vs. 4.2%, P = 0.034). AEs rates were reduced in cold EMR compared to hot EMR (0% vs. 2.9%, P = 0.168), in polyps 10-19 mm compared to 20 mm (0% vs. 4.1%, P = 0.255), and in piecemeal resection compared to en-bloc (0% vs. 0.7%, P = 0.169).

CONCLUSIONS

EMR is an effective and safe technique for removing SSPs ≥ 10 mm. The therapeutic effect of cold EMR is superior to that of hot EMR, with a lower incidence of adverse effects.

PROSPERO REGISTRATION NUMBER

CRD42023388959.

Cold Versus Hot Endoscopic Mucosal Resection for Sessile Serrated Colorectal Polyps ≥10 mm: A Systematic Review and Meta-analysis

INTRODUCTION

We performed a systematic review and meta-analysis studying the efficacy and safety of cold versus hot endoscopic mucosal resection (EMR) for resection of sessile serrated polyps (SSPs) ≥10 mm.

METHODS

Multiple databases were searched until January 2023 for studies reporting outcomes of cold versus hot EMR for SSPs ≥10 mm. The primary outcome was the residual SSP rate. Secondary outcomes included technical success rate, R0 resection rate, and adverse events. We used standard meta-analysis methods using the random-effects model, and I2% was used to assess heterogeneity.

RESULTS

Thirteen studies were included in the final analysis. In all, 1896 SSPs were included with a mean polyp size of 23.7 mm (range, 15.9 to 33). A total of 1452 SSPs were followed up for a median follow-up duration of 15.3 months (range, 6 to 37). The pooled residual SSP rate for cold EMR was 4.5% (95% CI: 1.0-17.4), and 5.1% (95% CI: 2.4-10.4) for hot EMR (P=0.9). The pooled rates of technical success, R0 resection, immediate bleeding, and perforation were comparable. Hot EMR was significantly associated with lower piecemeal resection (59.2% vs. 99.3%, P<0.001), higher en-bloc resection (41.4% vs. 1.4%, P<0.001), and delayed bleeding rate (4% vs. 0.7%, P=0.05) compared to cold EMR.

CONCLUSIONS

Cold EMR has similar efficacy compared to hot EMR for resection of SSP ≥ 10 mm, despite limitations in piecemeal R0 resection rate reporting. Although hot EMR was associated with a higher rate of en-bloc resection, it also showed an increased risk of delayed bleeding compared to cold EMR.

Decreasing rates of colectomy for benign neoplasms: A nationwide analysis

BACKGROUND

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms.

METHODS

All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups.

RESULTS

Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001).

CONCLUSIONS

The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice

BACKGROUND AND AIMS

Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice.

METHODS

We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy.

RESULTS

Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P < .001; RR = .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups.

CONCLUSION

TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.

Third Asia-Pacific consensus recommendations on colorectal cancer screening and postpolypectomy surveillance

The Asia-Pacific region has the largest number of cases of colorectal cancer (CRC) and one of the highest levels of mortality due to this condition in the world. Since the publishing of two consensus recommendations in 2008 and 2015, significant advancements have been made in our knowledge of epidemiology, pathology and the natural history of the adenoma-carcinoma progression. Based on the most updated epidemiological and clinical studies in this region, considering literature from international studies, and adopting the modified Delphi process, the Asia-Pacific Working Group on Colorectal Cancer Screening has updated and revised their recommendations on (1) screening methods and preferred strategies; (2) age for starting and terminating screening for CRC; (3) screening for individuals with a family history of CRC or advanced adenoma; (4) surveillance for those with adenomas; (5) screening and surveillance for sessile serrated lesions and (6) quality assurance of screening programmes. Thirteen countries/regions in the Asia-Pacific region were represented in this exercise. International advisors from North America and Europe were invited to participate.

Declining Colectomy Rates for Nonmalignant Colorectal Polyps in a Large, Ethnically Diverse, Community-Based Population

INTRODUCTION

Despite studies showing improved safety, efficacy, and cost-effectiveness of endoscopic resection for nonmalignant colorectal polyps, colectomy rates for nonmalignant colorectal polyps have been increasing in the United States and Europe. Given this alarming trend, we aimed to investigate whether colectomy rates for nonmalignant colorectal polyps are increasing or declining in a large, integrated, community-based healthcare system with access to advanced endoscopic resection procedures.

METHODS

We identified all individuals aged 50-85 years who underwent a colonoscopy between 2008 and 2018 and were diagnosed with a nonmalignant colorectal polyp(s) at the Kaiser Permanente Northern California integrated healthcare system. Among these individuals, we identified those who underwent a colectomy for nonmalignant colorectal polyps within 12 months after the colonoscopy. We calculated annual colectomy rates for nonmalignant colorectal polyps and stratified rates by age, sex, and race and ethnicity. Changes in rates over time were tested by the Cochran-Armitage test for a linear trend.

RESULTS

Among 229,730 patients who were diagnosed with nonmalignant colorectal polyps between 2008 and 2018, 1,611 patients underwent a colectomy. Colectomy rates for nonmalignant colorectal polyps decreased significantly from 125 per 10,000 patients with nonmalignant polyps in 2008 to 12 per 10,000 patients with nonmalignant polyps in 2018 (P < 0.001 for trend). When stratified by age, sex, and race and ethnicity, colectomy rates for nonmalignant colorectal polyps also significantly declined from 2008 to 2018.

DISCUSSION

In a large, ethnically diverse, community-based population in the United States, we found that colectomy rates for nonmalignant colorectal polyps declined significantly over the past decade likely because of the establishment of advanced endoscopy centers, improved care coordination, and an organized colorectal cancer screening program.

Endoscopic Mucosal Resection in Children

OBJECTIVES

Endoscopic mucosal resection (EMR) for removal of large polyps is well established in adults. EMR technique in the pediatric population is less utilized due to lower incidence of large intestinal polyps in pediatric patients and limited EMR training for pediatric gastroenterologists. The aim of this study is to retrospectively review safety and efficacy of pediatric EMR cases at two large, tertiary referral centers with adult and pediatric EMR expertise.

METHODS

A retrospective chart review was conducted at Cedars-Sinai Medical Center and Cincinnati Children's Hospital Medical Center from January 2012 to May 2021. Demographic, clinical, technical and follow up data were collected for patients <18 years of age who underwent EMR during the study period.

RESULTS

Fifteen pediatric EMR procedures were identified in 11 patients (five male, six female) during the study period. Indication was most frequently rectal bleeding. Polyp size removed ranged from 9 to 60 mm and pathology was consistent with juvenile inflammatory polyps in six patients. Technical success was achieved in 14 of 15 (93%) of EMRs with clinical success (desired clinical outcome) in all 13 procedures with clinical follow-up. There were no adverse events.

CONCLUSIONS

This study identifies a case series of pediatric patients who underwent EMR at two tertiary care centers. This series demonstrates successful EMR in children and shows a high technical and clinical success rate with a low complication rate. More investigation into EMR in pediatric patients is necessary, and its use should be isolated to centers with endoscopists with specific experience in EMR techniques.

Management of the colonic polyps referred for surgery: an opportunity for improvement

PURPOSE

To examine local practice for non-malignant polyps and to calculate morbidity and mortality associated with bowel resection for this indication.

METHODS

This retrospective cohort study was conducted by reviewing our local gastrointestinal pathology database over a five-year period to identify colonic resections performed for benign polyps. Using search terms "polyp" and "adenoma," 272 cases were identified. Exclusion criteria included: cancer diagnosis, emergency surgeries, multiple resections, and subtotal colectomies for polyposis. 106 patients were included in the study. Primary outcome was perioperative mortality. Secondary outcomes included patient morbidity, characteristics of polyps requiring surgery, and the number of patients referred for a second endoscopic opinion prior to proceeding with surgery.

RESULTS

64 male and 42 female patients with a mean age of 65.3 years (± 8.6 years) underwent colon resection for benign polyps. The mean polyp size was 32.7 mm (± 19.5 mm). 30 patients (28.6%) had polyps equal to or less than 2 cm. Most of the polyps described were sessile (n = 55, 51.9%) and located in the right colon (n = 84, 79.3%). Endoscopic resection was attempted in 31 patients (29.2%), and five cases (4.7%) were referred for a second endoscopic opinion prior to proceeding with surgery. Endoscopists incorrectly felt that polyps were malignant in 62 cases (58.5%). Using Clavien-Dindo classification, most patients had no complications n = 36 (34.0%) or minor complications n = 41 (38.7%). Twelve patients (11.3%) had complications that required antibiotics, blood transfusions, or total parental nutrition. Nine patients (8.5%) required surgical or endoscopic management. Six patients (5.7%) required ICU admission. Mortality rate was 1.9% (n = 2).

CONCLUSION

Surgery for benign colonic polyps is associated with significant morbidity and mortality. These findings reveal a gap in endoscopic management of benign colonic polyps.

EVALUATION OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION FOR COLORECTAL POLYPS IN AN OUTPATIENT CLINIC IN BRAZIL

BACKGROUND

Since 2012, a new technique for resection of large polyps has been described, the underwater endoscopic mucosal resection (UEMR). Some advantages that emerge from it is the needless of injection in submucosal layer and a greater chance of complete capture of the polyp.

OBJECTIVE

There are few studies of UEMR in Brazil. The aim of this study is to evaluate the safety and efficacy of this technique in one Brazilian center.

METHODS

This case series was conducted from February to December of 2020. Colorectal polyps greater than 9 mm without features of deep submucosal invasion were resected using UEMR.

RESULTS

Twenty-four large polyps were resected with the UEMR approach from 24 patients. The mean size of the polys was 19 mm, ranging from 12 to 35 mm. All lesions were successful resected and 66% (16/24) were resected en bloc. In histologic analyses, most of them were adenomas (70.8%) and only one had deep submucosal invasion. There were no cases of acute complications, such perforation or acute bleeding.

CONCLUSION

The UEMR is a safe and feasible procedure. With the emerging data on the procedure, it seems to be a wonderful tool in preventing colorectal cancer and its applicability and scope should be encourage to surpass reference centers.

Evolving management of colorectal polyps

Advances in endoscopic technology have led to increased success in colorectal cancer (CRC) screening and polyp management, with reduction of CRC incidence and mortality. Despite these advances, CRC is still one of the leading causes of cancer deaths, and half of all CRC develops from lesions that were missed during colonoscopy while one-fifth of CRC arise from prior incomplete resection. Techniques to improve polyp detection are needed, along with optimization of complete resection of any abnormal lesions that are found. This article will review the currently available endoscopic resection techniques and will discuss where they fit in the management of polyps of different sizes and types, such as pedunculated versus nonpedunculated, and those with or without suspected invasion.

Colonoscopy screening and surveillance guidelines

The Colonoscopy Screening and Surveillance Guidelines were developed by the Japan Gastroenterological Endoscopy Society as basic guidelines based on the scientific methods. The importance of endoscopic screening and surveillance for both detection and post-treatment follow-up of colorectal cancer has been recognized as essential to reduce disease mortality. There is limited high-level evidence in this field; therefore, we had to focus on the consensus of experts. These clinical practice guidelines consist of 20 clinical questions and eight background knowledge topics that have been determined as the current guiding principles.

Circumferential submucosal incision prior to endoscopic mucosal resection versus conventional endoscopic mucosal resection for colorectal lesions with endoscopic features of sessile serrated lesions

BACKGROUND AND AIMS

Sessile serrated lesions (SSLs) are more prone to incomplete resection than conventional adenomas. This study evaluated whether circumferential submucosal incision prior to endoscopic mucosal resection (CSI-EMR) can increase the rate of complete and en bloc resections of colorectal lesions with endoscopic features of SSL.

METHODS

Retrospective analyses and propensity score matching were performed for the resection of colorectal lesions ≥ 10 mm with endoscopic features of SSL.

RESULTS

After 1:1 ratio matching, 127 lesions in the CSI-EMR group and 127 in the EMR group were selected for analysis. The median size of the lesions was 15 mm (IQR 12-16) in both groups. There was no significant difference in either the complete resection rate or en bloc resection rate between CSI-EMR and EMR groups (96.9% vs. 92.9%, P = 0.155; 92.1% vs. 89.0%, P = 0.391). By contrast, the R0 resection rate was significantly higher in the CSI-EMR group than in the EMR group (89.8% vs. 59.8%, P < 0.001). The median procedure time was significantly longer in the CSI-EMR group than in the EMR group (6.28 min vs. 2.55 min, P < 0.001), whereas there was no significant difference between the two groups in the incidence of adverse events or recurrence rate. Multivariate analysis showed that CSI-EMR was the only factor significantly associated with R0 resection (P < 0.001).

CONCLUSIONS

For colorectal lesions with endoscopic features of SSL, CSI-EMR does not increase the complete or en bloc resection rate, but does increase the R0 resection rate. The procedure time is longer for CSI-EMR than EMR. The association of CSI-EMR with R0 resection and non-recurrence should be further evaluated.

Interobserver agreement of the Paris and simplified classifications of superficial colonic lesions: a Western study

Background and study aims  The Paris classification of superficial colonic lesions has been widely adopted, but a simplified description that subgroups the shape into pedunculated, sessile/flat and depressed lesions has been proposed recently. The aim of this study was to evaluate the accuracy and inter-rater agreement among 13 Western endoscopists for the two classification systems. Methods  Seventy video clips of superficial colonic lesions were classified according to the two classifications, and their size estimated. The interobserver agreement for each classification was assessed using both Cohen k and AC1 statistics. Accuracy was taken as the concordance between the standard morphology definition and that made by participants. Sensitivity analyses investigated agreement between trainees (T) and staff members (SM), simple or mixed lesions, distinct lesion phenotypes, and for laterally spreading tumors (LSTs). Results  Overall, the interobserver agreement for the Paris classification was substantial (κ = 0.61; AC1 = 0.66), with 79.3 % accuracy. Between SM and T, the values were superimposable. For size estimation, the agreement was 0.48 by the κ-value, and 0.50 by AC1. For single or mixed lesions, κ-values were 0.60 and 0.43, respectively; corresponding AC1 values were 0.68 and 0.57. Evaluating the several different polyp subtypes separately, agreement differed significantly when analyzed by the k-statistics (0.08-0.12) or the AC1 statistics (0.59-0.71). Analyses of LSTs provided a κ-value of 0.50 and an AC1 score of 0.62, with 77.6 % accuracy. The simplified classification outperformed the Paris classification: κ = 0.68, AC1 = 0.82, accuracy = 91.6 %. Conclusions  Agreement is often measured with Cohen's κ, but we documented higher levels of agreement when analyzed with the AC1 statistic. The level of agreement was substantial for the Paris classification, and almost perfect for the simplified system.

Colorectal EMR outcomes in octogenarians versus younger patients referred for removal of large (≥20 mm) nonpedunculated polyps

BACKGROUND AND AIMS

Data are limited on safety and outcomes of colorectal EMR in octogenarians (≥80 years old). We sought to review outcome data for patients aged ≥80 in a prospectively collected database of patients referred for large polyp removal.

METHODS

We retrospectively evaluated a database of patients referred for large (≥20 mm) nonpedunculated polyp removal. From 2000 to 2019, we compared the rates of follow-up, recurrence, adverse events, and synchronous neoplasia detection between younger patients and patients aged ≥80.

RESULTS

There were 167 patients aged ≥80 years and 1686 <80 years. Patients in the elderly group returned for surveillance less often (67.1% vs 75.1%, P = .024), had greater first follow-up recurrence rates (27.5% vs 13.8%, P < .001), but had similar adverse event rates (1.8% vs 2.8%, P = .619) compared with younger patients. Rates of synchronous neoplasia were similar and high in both groups.

CONCLUSIONS

EMR is safe and well tolerated for large polyp removal in patients over 80 years old. Patients aged ≥80 years are less likely to present for follow-up after EMR. They had a higher recurrence rate and a similarly high prevalence of synchronous precancerous lesions. Follow-up after EMR should be encouraged in the elderly, and an attempt to clear the colon of synchronous disease at the time of the initial EMR may be warranted.

Adverse events and residual lesion rate after cold endoscopic mucosal resection of serrated lesions ≥10 mm

BACKGROUND AND AIMS

Cold EMR is being increasingly used for large serrated lesions. We sought to measure residual lesion rates and adverse events after cold EMR of large serrated lesions.

METHODS

In a single academic center, we retrospectively examined a database of serrated class lesions ≥10 mm removed with cold EMR for safety and efficacy.

RESULTS

Five hundred sixty-six serrated lesions ≥10 mm in size were removed from 312 patients. We successfully contacted 223 patients (71.5%) with no reported serious adverse events that required hospitalization, repeat endoscopy, or transfusion. The residual lesion rate per lesion at first follow-up colonoscopy was 18 of 225 (8%; 95% confidence interval, 5-12.1). Lesions with residual were larger at polypectomy compared with lesions without recurrence (median, 23 mm versus 16 mm, P = .017).

CONCLUSION

Cold EMR appears to be safe and effective for the removal of large serrated lesions.

Personalizing Polypectomy Techniques Based on Polyp Characteristics

Polypectomy is an essential skill for all endoscopists performing lower gastrointestinal endoscopy. Different polypectomy tools and techniques have evolved and it is important that endoscopists are familiar with these so they can select the most appropriate technique for each polyp. This narrative review updates the different concepts in tailoring polypectomy technique to the characteristics of polyps. Effective polypectomy requires different components, including the following: careful evaluation of the polyp; decision making about optimal polyp management; actual polypectomy, which includes careful positioning of the endoscope and polyp; and postpolypectomy evaluation of the results (for completeness of resection and prophylaxis of complications).

Efficacy and Safety of Endoscopic Resection of Sessile Serrated Polyps 10 mm or Larger: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

The best method for endoscopic resection of sessile serrated polyps (SSP) 10 mm or larger is unclear; studies report variable outcomes in comparison to conventional adenomas. We performed a systematic review and meta-analysis to assess the efficacy and safety of resection of SSPs 10 mm or larger in size.

METHODS

We searched the PubMed/MEDLINE, Google Scholar, Embase, and Cochrane databases for studies reporting data on endoscopic resection of SSPs 10 mm or larger, through May 31st, 2019. The primary outcome was rate of residual SSP, which was the rate of residual SSP found at the polypectomy site during the first follow-up colonoscopy. Secondary outcomes were: technical success (rate of complete macroscopic resection), R0 resection rate (complete histological resection with absence of any polyp tissue at the lateral and deep margins after en-bloc resection), and adverse events (immediate or delayed bleeding and perforation). We performed IQR,group analyses for outcomes based on polyp size and resection techniques. Pooled proportion rates (%) or odds ratio with 95% CIs with heterogeneity (I²) and P < .05.

RESULTS

A total of 14 studies met the inclusion criteria: 911 patients (50.2% male; mean age, 62.8 ± 4.9 years) who underwent resection of 1137 SSPs (574 SSPs ≥ 20 mm) with a median polyp size of 19.4 mm (interquartile range, 15.9-29.6 mm). Follow-up information was available for 832 SSPs with a median follow-up duration of 12 months (interquartile range, 6-22.5 months). Piecemeal resection was performed in 58.5% SSPs. The pooled residual SSP rate was 4.3% (95% CI, 2%-6.5%). There was a higher residual SSP rate for polyps ≥ 20 mm compared to 10-19 mm (5.9% vs 1.2%; odds ratio, 3.02; 95% CI, 1-9.2; P = .049). Cold endoscopic mucosal resection (EMR) had significantly lower rates of delayed bleeding (0 vs 2.3%; P = .03) and residual polyp rate (0.9% vs 5%; P=.01) compared to hot EMR, based on univariate analysis. In multi-variate analysis there was no difference in residual polyp rate. There was no significant difference in other outcomes based on the size or method of resection.

CONCLUSIONS

In a systematic review and meta-analysis, we found that SSPs ≥ 10 mm can be safely resected with low residual polyp rates. Polyp size ≥ 20 mm is a significant factor for residual polyp. Compared to hot EMR, cold EMR is associated with a lower rate of delayed bleeding. Randomized controlled trials comparing hot and cold resection are needed to standardize techniques and optimize outcomes.

Polypectomy During Both Insertion and Withdrawal Phase Versus During Withdrawal Phase Only: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: This study aimed to compare polypectomy during both insertion and withdrawal phase versus during withdrawal phase only. Method: We performed literature searching in PubMed and Ovid for randomized clinical trials (RCTs) that compared polypectomy during both insertion and withdrawal phase versus during withdrawal phase only on April 3, 2020. The primary outcome was adenoma detection rate (ADR). Results: Five RCTs published between 2012 and 2020 with a total of 2694 individuals were included in this meta-analysis. No significant difference was observed between the two groups for ADR (P = .99, odds ratio = 1.00, 95% confidence interval [CI] 0.84-1.19, I² = 0%), or average number of adenomas per individuals (P = .53, weighted mean difference [WMD] = 0.04, 95% CI -0.09 to 0.17, I² = 30%). Besides, polypectomy during both insertion and withdrawal group showed significantly longer time for insertion phase (P = .01, WMD = 2.16, 95% CI 0.47-3.84, I² = 95%), and shorter time for withdrawal phase (P = .010, WMD = -2.32, 95% CI -4.09 to -0.56, I² = 94%), although the total procedure time was not significantly different between the two groups. Conclusion: No obvious advantages were observed for polypectomy during both insertion and withdrawal phase. We are looking forward to the long-term outcomes of these studies. More studies are warranted in the future for further exploration, especially the detection rate of small lesions.

Optimal Endoscopic Treatment and Surveillance of Serrated Polyps

Serrated polyps are considered precursor lesions that account for 15% to 30% of colorectal cancers, and they are overrepresented as a cause of interval cancers. They are difficult to detect and resect comprehensively; however, recent data suggest that high definition endoscopy, chromoendoscopy (via spray catheter, pump or orally), narrow band imaging, split-dose bowel preparation and a slower withdrawal (>6 minutes) can all improve detection. Cold snare resection is effective and safe for these lesions, including cold snare piecemeal endoscopic mucosal resection, which is likely to become the standard of care for lesions >10 mm in size. Sessile serrated lesions ≥10 mm in size, those exhbiting dysplasia, or traditional serrated adenomas increase the chance of future advanced neoplasia. Thus, a consensus is emerging: a surveillance examination at 3 years should be recommended if these lesions are detected. Serrated lesions likely carry equivalent risk to adenomas, so future guidelines may consider serrated class lesions and adenomas together for risk stratification. Patients with serrated polyposis syndrome should undergo surveillance every 1 to 2 years once the colon is cleared of larger lesions, and their first degree relatives should undergo screening every 5 years starting at age 40.

Colorectal Cancer Screening for the Serrated Pathway

Serrated polyps are classified into hyperplastic polyps, sessile serrated adenomas/polyps, and traditional serrated adenomas. Although all serrated polyps share characteristic colonic crypts serrations, distinguishing hyperplastic polyps from sessile serrated adenomas/polyps is challenging. Traditional serrated adenomas are cytologically dysplastic lesions; sessile serrated adenomas/polyps develop cytologic dysplasia as they progress to colorectal cancer. A flat and pale appearance of serrated polyps may make detection difficult. Endoscopic mucosal resection has higher rates of complete resection. Close surveillance is recommended for sessile serrated adenomas/polyps, sessile serrated adenomas/polyp with dysplasia, hyperplastic polyps ≥10 mm, and traditional serrated adenomas.

The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study

Background

Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions.

Method

This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage.

Results

A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893.

Conclusion

Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.

Impact of observational training on endoscopic mucosal resection outcomes and competency for large colorectal polyps: single endoscopist experience

Background and study aims  Endoscopic mucosal resection (EMR) is standard treatment for large colorectal polyps. However, it is a specialized technique with limited data on the effectiveness of training methods to acquire this skill. The aim of this study was to evaluate the impact of observational training on EMR outcomes and competency in an early-stage endoscopist. Patients and methods  A single endoscopist completed comprehensive EMR training, which included knowledge acquisition and direct observation of EMR cases, and proctored supervision, during the third year of gastroenterology fellowship. After training, EMR was independently attempted on 142 consecutive, large (i. e., ≥ 20 mm), non-pedunculated colorectal polyps between July 2014 and December 2017 (mean age 61.7 years; mean polyp size 30.4 mm; en-bloc resection 55 %). Surveillance colonoscopy for evaluation of residual neoplasia was available for 86 % of the cases. Three primary outcomes were evaluated: endoscopic assessment of complete resection, rate of adverse events (AEs), and rate of residual neoplasia on surveillance colonoscopy. Results  Complete endoscopic resection was achieved in 93 % of cases, the rates of AEs and residual neoplasia were 7.8 % and 7.3 %, respectively. The rate of complete resection remained stable (at 85 % or greater) with increasing experience while rates of AEs and residual neoplasia peaked and decreased after 60 cases. Conclusions  An early-stage endoscopist can acquire the skills to perform effective EMR after completing observational training. At least 60 independent EMRs for large colorectal polyps were required to achieve a plateau for clinically meaningful outcomes.

Trends in EMR for nonmalignant colorectal polyps in the United States

BACKGROUND AND AIMS

Although most large nonpedunculated colorectal lesions can be safely and efficaciously removed using EMR, the use of colectomy for benign colorectal lesions appears to be increasing. The reason(s) is unclear. We aimed to determine the use and adverse events of EMR in the United States.

METHODS

We used Optum's de-identified Clinformatics Data Mart Database (2003-2016), a database from a large national insurance provider, to identify all colonoscopies performed with either EMR or simple polypectomy on adult patients from January 1, 2011 to December 31, 2015. We measured time trends, regional variation, and adverse event rates. We assessed risk factors for adverse events using multivariate logistic regression.

RESULTS

The rate of EMR use in the US increased from 1.62% of all colonoscopies in 2011 to 2.48% of colonoscopies in 2015 (P < .001). There were, however, significant regional differences in the use of EMRs, from 2.4% of colonoscopies in the western United States to 2.0% of colonoscopies in the southern United States. Between 2011 and 2015, we found stable rates of perforation, GI bleeding (GIB), infections, and cardiac adverse events and decreasing rates of admissions after EMR. In our multivariate model, EMR was an independent risk factor for adverse events, albeit the rates of adverse events were low (1.35% GIB, .22% perforation).

CONCLUSIONS

Use of EMR is rising in the United States, although there is significant regional variation. The rates of adverse events after EMR and polypectomies were low and stable, confirming the continued safety of EMR procedures. A better understanding of the regional barriers and facilitators may improve the use of EMR as the standard management for benign colorectal lesions throughout the United States.

Morbidity and Mortality After Surgery for Nonmalignant Colorectal Polyps: A 10-Year Nationwide Analysis

OBJECTIVES

Rates of surgery for nonmalignant colorectal polyps are increasing in the United States despite evidence that most polyps can be managed endoscopically. We aimed to determine nationally representative estimates and to identify predictors of in-hospital mortality and morbidity after surgery for nonmalignant colorectal polyps.

METHODS

Data were analyzed from the National Inpatient Sample for 2005-2014. All discharges for adult patients undergoing surgery for nonmalignant colorectal polyps were identified. Rates of in-hospital mortality and postoperative wound, infectious, urinary, pulmonary, gastrointestinal, or cardiovascular adverse events were calculated. Multivariable logistic regression using survey-weighted data was used to evaluate covariables associated with postoperative mortality and morbidity.

RESULTS

An estimated 262,843 surgeries for nonmalignant colorectal polyps were analyzed. In-hospital mortality was 0.8% [95% confidence interval: 0.7%-0.9%] and morbidity was 25.3% [95% confidence interval: 24.2%-26.4%]. Postoperative mortality was associated with open surgical technique (vs laparoscopic), older age, black race (vs non-Hispanic white), Medicaid use, and burden of comorbidities. Female sex and private insurance were associated with lower risk. Patients developing a postoperative adverse event had a 106% increase in mean hospital length of stay (10.3 vs 5.0 days; P < 0.0001) and 91% increase in mean hospitalization cost ($77,015.24 vs $40,258.30; P < 0.0001).

DISCUSSION

Surgery for nonmalignant colorectal polyps is associated with almost 1% mortality and common morbidity. These findings should inform risk vs benefit discussions for clinicians and patients, and although confounding by patient selection cannot be excluded, the risks associated with surgery support consideration of endoscopic resection as a potentially less invasive therapeutic option.

Intra-procedural and delayed bleeding after resection of large colorectal lesions: The SCALP study

Background and aim

The safety of endoscopic resection of large colorectal lesions (LCLs) (≥20 mm) is clinically relevant. The aim of the present study was to assess the rate of post-resection adverse events (AEs) in a real-life setting.

Patients and methods

In a prospective, multicentre, observational study, data from consecutive resections of LCLs over a 6-month period were collected in 24 centres. Patients were followed up at 15 days from resection for AEs. The primary endpoint was intra-procedural bleeding according to lesion morphology. Secondary endpoints were delayed bleeding and perforation. Patient and polyp characteristics, and polypectomy techniques were analysed with respect to the bleeding events.

Results

In total, 1504 patients (female/male: 633/871, mean age, 66.1) with 1648 LCLs (29.1% pedunculated and 70.9% non-pedunculated lesions) were included. Overall, 168 (11.2%) patients had post-resection bleeding (8.5 and 2.0% immediate and delayed, respectively), while 15 (1.0%) cases of perforation occurred. Independent predictors of immediate bleeding for pedunculated lesions were bleeding prophylaxis (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.13-0.62), simple polypectomy (versus endoscopic mucosal resection, OR 0.38, 95% CI 0.17-0.88) and inpatient setting (OR 2.21, 95% CI 1.07-5.08), while bleeding prophylaxis (OR 0.37, 95% CI 0.30-0.98), academic setting (OR 0.27, 95% CI 0.12-0.54) and size (OR 1.03, 95% CI 1.00-1.05) were predictors for those non-pedunculated. Indication for colonoscopy (screening versus diagnostic (OR 0.33, 95% CI 0.12-0.86)), antithrombotic therapy (OR 3.12, 95% CI 1.54-6.39) and size (OR 2.34, 95% CI 1.12-4.87) independently predicted delayed bleeding.

Conclusions

A low rate of post-resection AEs was observed in a real-life setting, reassuring as to the safety of endoscopic resection of ≥2 cm colorectal lesions. Bleeding prophylaxis reduced the intra-procedural bleeding risk, while antithrombotic therapy increased delayed bleeding.CLINICALTRIAL: (NCT02694120).

Role of interventional inflammatory bowel disease in the era of biologic therapy: a position statement from the Global Interventional IBD Group

Interventional (or therapeutic) inflammatory bowel disease (IBD) endoscopy has an expanding role in the treatment of disease and surgical adverse events. Endoscopic therapy has been explored and used in the management of strictures, fistulas/abscesses, colitis-associated neoplasia, postsurgical acute or chronic leaks, and obstructions. The endoscopic therapeutic modalities include balloon dilation, stricturotomy, stent placement, fistulotomy, fistula injection and clipping, sinusotomy, EMR, and endoscopic submucosal dissection. With a better understanding of the disease course of IBD, improved long-term impact of medical therapy, and advances in endoscopic technology, we can foresee interventional IBD becoming an integrated part of the multidisciplinary approach to patients with complex IBD.

Serrated Lesions of the Colon-Rectum: A Focus on New Diagnostic Tools and Current Management

Prompt diagnosis and correct management of the so called "serrated lesions" (SLs) of the colon-rectum are generally considered of crucial importance in the past years, mainly due to their histological heterogeneity and peculiar clinical and molecular patterns; sometimes, they are missed at conventional endoscopy and are possibly implicated in the genesis of interval cancers. The aim of this review is to focus on the diagnostic challenges of serrated lesions, underlying the role of both conventional endoscopy and novel technologies. We will show how an accurate and precise diagnosis should immediately prompt the most appropriate therapy other than defining a proper follow-up program. It will be emphasized how novel endoscopic techniques may provide better visualization of mucosal microsurface structures other than enhancing the microvascular architecture, in order to better define and characterize specific patterns of mucosal lesions of the gastrointestinal tract. Standard therapy of SLs of the colon-rectum is still very debated, also due to the relatively lack of studies focusing on treatment issues. The high risk of incomplete resection, together with the high rate of postcolonoscopy interval cancers, suggests the need of an extra care when facing this kind of lesions. Given this background, we will outline useful technical tips and tricks in the resection of SLs, taking aspects such as the size and location of the lesions, as well as novel available techniques and technologies, other than future perspectives, including confocal laser endomicroscopy into consideration. Follow-up of SLs is another hot topic, also considering that their clinical impact has been misunderstood for a long time. The incidence of the so called interval colorectal cancer underlines how some weaknesses exist in current screening and follow-up programs. Considering the lack of wide consensus for the management of some SLs, we will try to summarize and clarify the best strategies for their optimal management.

Incidence and risk factors of advanced neoplasia after endoscopic mucosal resection of colonic laterally spreading lesions

PURPOSE

To investigate advanced neoplasia (AN) after endoscopic mucosal resection (EMR) of colonic laterally spreading lesions (LSLs).

METHODS

A retrospective study of patients who underwent injection-assisted EMR of colonic LSLs ≥ 10 mm was performed. Primary outcome was overall rate of AN at initial surveillance colonoscopy. Secondary outcomes were the rates of residual AN (rAN) at the EMR site and metachronous AN (mAN), and analysis of risk factors for AN, including effect of surveillance guidance.

RESULTS

Three hundred seventy-four patients underwent successful EMR for 388 LSLs. AN occurred in 66/374 (17.6%) patients on initial surveillance colonoscopy at median follow-up of 364.5 days. Two patients had both rAN and mAN, for a total of 68 instances of AN, including 30/374 (8.0%) cases of rAN and 38/374 (10.2%) cases of mAN. On multivariate analysis, use of piecemeal resection was associated with increased likelihood of residual AN (P = 0.003, OR 9.2, 95% CI 2.1-33.3). Twenty-nine out of thirty cases (96.7%) of rAN were successfully endoscopically managed at surveillance colonoscopy.

CONCLUSIONS

AN occurred in 17.6% of all patients at initial surveillance colonoscopy at a median of 1 year after EMR. Roughly half of the instances of AN were metachronous lesions. Our data support a 1-year surveillance interval after EMR of LSLs ≥ 10 mm with careful inspection of the entire colon, not just the prior resection site.

Sessile Serrated Adenomas: How to Detect, Characterize and Resect

Serrated polyps are important contributors to the burden of colorectal cancers (CRC). These lesions were once considered to have no malignant potential, but currently up to 30% of all CRC are recognized to arise from the serrated neoplasia pathway. The primary premalignant lesions are sessile serrated adenomas/polyps (SSA/Ps), although traditional serrated adenomas are relatively uncommon. Compared to conventional adenomas, SSA/Ps are morphologically subtle with indistinct borders, may be difficult to detect endoscopically, are more prevalent than previously thought, are associated with synchronous and metachronous advanced neoplasia, and have a higher risk of incomplete resection. Although many lesions remain “dormant,” progressive disease is associated with the development of dysplasia and more rapid progression to CRC. As a result, SSA/Ps are strongly implicated in the development of interval cancers. These factors represent unique challenges that require a meticulous approach to their management. In this review, we summarize the contemporary literature on the characterization, detection and resection of SSA/Ps.

Advances in CRC Prevention: Screening and Surveillance

Colorectal cancer (CRC) is among the most commonly diagnosed cancers and causes of death from cancer across the world. CRC can, however, be detected in asymptomatic patients at a curable stage, and several studies have shown lower mortality among patients who undergo screening compared with those who do not. Using colonoscopy in CRC screening also results in the detection of precancerous polyps that can be directly removed during the procedure, thereby reducing the incidence of cancer. In the past decade, convincing evidence has appeared that the effectiveness of colonoscopy as CRC prevention tool is associated with the quality of the procedure. This review aims to provide an up-to-date overview of recent efforts to improve colonoscopy effectiveness by enhancing detection and improving the completeness and safety of resection of colorectal lesions.

Increasing Rates of Surgery for Patients With Nonmalignant Colorectal Polyps in the United States

BACKGROUND & AIMS

Despite the availability of endoscopic therapy, many patients in the United States undergo surgical resection for nonmalignant colorectal polyps. We aimed to quantify and examine trends in the use of surgery for nonmalignant colorectal polyps in a nationally representative sample.

METHODS

We analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample for 2000 through 2014. We included all adult patients who underwent elective colectomy or proctectomy and had a diagnosis of either nonmalignant colorectal polyp or colorectal cancer. We compared trends in surgery for nonmalignant colorectal polyps with surgery for colorectal cancer and calculated age, sex, race, region, and teaching status/bed-size-specific incidence rates of surgery for nonmalignant colorectal polyps.

RESULTS

From 2000 through 2014, there were 1,230,458 surgeries for nonmalignant colorectal polyps and colorectal cancer in the United States. Among those surgeries, 25% were performed for nonmalignant colorectal polyps. The incidence of surgery for nonmalignant colorectal polyps has increased significantly, from 5.9 in 2000 to 9.4 in 2014 per 100,000 adults (incidence rate difference, 3.56; 95% confidence interval 3.40-3.72), while the incidence of surgery for colorectal cancer has significantly decreased, from 31.5 to 24.7 surgeries per 100,000 adults (incidence rate difference, -6.80; 95% confidence interval -7.11 to -6.49). The incidence of surgery for nonmalignant colorectal polyps has been increasing among individuals age 20 to 79, in men and women and including all races and ethnicities.

CONCLUSIONS

In an analysis of a large, nationally representative sample, we found that surgery for nonmalignant colorectal polyps is common and has significantly increased over the past 14 years.

Cold EMR of large sessile serrated polyps at colonoscopy (with video)

BACKGROUND AND AIMS

The optimal technique for the resection of sessile serrated polyps (SSPs) is unknown, with established limitations and risks with conventional polypectomy. Although cold snare polypectomy is safe, the efficacy of piecemeal resection for large lesions is untested. In this study we evaluate the safety and efficacy of cold EMR for large SSPs.

METHODS

Patients presenting for elective colonoscopy at an academic endoscopy center with 1 or more SSPs ≥10 mm in size were enrolled, excluding those on anticoagulant or antiplatelet therapy other than aspirin. Lesions were resected with a cold EMR technique comprising submucosal injection of succinylated gelatin and dilute methylene blue before piecemeal cold snare resection of all visible polyp with a margin of normal tissue. Outcomes were the presence of residual serrated neoplasia in biopsy specimens from the defect margin and findings on surveillance colonoscopy.

RESULTS

Cold EMR was performed on 163 SSPs during 105 procedures in 99 patients (97% women; median age, 57 years). The mean size was 17.5 mm: 61 SSPs were ≥20 mm and 13 SSPs ≥30 mm, and 97.5% were in the proximal colon. Cytologic dysplasia was present in 2 (1.2%). Margin biopsy specimens were positive in 2 lesions (1.2%). Surveillance colonoscopy for 82% of lesions (median, 5 months) showed residual serrated tissue in 1, treated with cold snare, but no evidence of recurrence in the remainder. Minor adverse events were seen in 3 patients; no delayed bleeding was observed.

CONCLUSIONS

Cold EMR is a safe and effective method for the removal of large SSPs.

Management of Serrated Polyps of the Colon

PURPOSE OF REVIEW

The purpose of this review is to summarize the management of serrated colorectal polyps (SPs), with a particular focus on the most common premalignant SP, sessile serrated adenoma or polyp (SSA/P). These lesions present a challenge for endoscopists with respect to detection and resection, and are also susceptible to pathologic misdiagnosis.

RECENT FINDINGS

Patients with SSA/Ps are at an increased risk of future colorectal neoplasia, including advanced polyps and cancer. Reasonable benchmarks for SP detection rates are 5-7% for SSA/Ps and 10-12% for proximal SPs. Certain endoscopic techniques such as chromoendoscopy, narrow band imaging, water immersion, and wide-angle viewing may improve SSA/P detection. Emerging endoscopic techniques such as underwater polypectomy, suction pseudopolyp technique, and piecemeal cold snare polypectomy are helpful tools for the endoscopist's armamentarium for removing SSA/Ps. Proper orientation of SSA/P specimens can improve the accuracy of pathology readings. Patients with confirmed SSA/Ps and proximal HPs should undergo surveillance at intervals similar to what is recommended for patients with conventional adenomas. Patients with SSA/Ps may also be able to lower their risk of future polyps by targeting modifiable risk factors including tobacco and alcohol use and high-fat diets. NSAIDs and aspirin appear to be protective agents. SPs and SSA/Ps in particular are important colorectal cancer precursors that merit special attention to ensure adequate detection, resection, and surveillance.

Morbidity and mortality after surgery for nonmalignant colorectal polyps

BACKGROUND AND AIMS

Despite evidence that most nonmalignant colorectal polyps can be managed endoscopically, a substantial proportion of patients with a nonmalignant colorectal polyp are still sent to surgery. Risks associated with this surgery are not well characterized. We describe 30-day postoperative morbidity and mortality and explore risk factors for adverse events in patients undergoing surgical resection for nonmalignant colorectal polyps.

METHODS

We analyzed data collected prospectively as part of the National Surgical Quality Improvement Program. Our analysis included 12,732 patients who underwent elective surgery for a nonmalignant colorectal polyp from 2011 through 2014. We report adverse events within 30 days of the index surgery. Modified Poisson regression was used to estimate risk ratios and 95% confidence intervals.

RESULTS

Thirty-day mortality was .7%. The risk of a major postoperative adverse event was 14%. Within 30 days of resection, 7.8% of patients were readmitted and 3.6% of patients had a second major surgery. The index surgery resulted in a colostomy in 1.8% and ileostomy in .4% of patients. Patients who had surgical resection of a nonmalignant polyp in the rectum or anal canal compared with the colon had a risk ratio of 1.58 (95% confidence interval, 1.09-2.28) for surgical site infection and 6.51 (95% confidence interval, 4.97-8.52) for ostomy.

CONCLUSIONS

Surgery for a nonmalignant colorectal polyp is associated with significant morbidity and mortality. A better understanding of the risks and benefits associated with surgical management of nonmalignant colorectal polyps will better inform discussions regarding the relative merits of management strategies.

Optimizing Resection of Large Colorectal Polyps

OPINION STATEMENT

Polypectomy reduces the incidence and mortality of colorectal cancer (CRC). The widespread adoption of CRC screening, more rigorous colonoscopy techniques, and advancements in endoscopic imaging have led to a greater awareness of complex polyps. Whereas surgery was once considered necessary for many large sessile or laterally spreading lesions (LSLs) in the colorectum, the majority can now be removed endoscopically. Endoscopic mucosal resection (EMR) is an established technique for treatment of colorectal LSLs. When performed by experts, EMR is highly effective and safe and can be completed in an outpatient or day-stay setting. Advancements in EMR effectiveness encompass a better understanding of the factors leading to post-EMR recurrence, protocols to recognize and treat it, and interventions that prevent recurrent or residual adenoma. New techniques for treating intra-procedural bleeding and a novel classification system to identify and inform proactive management of deep mural injury enhance the safety profile of EMR. However, each of these incremental advancements necessitates a meticulous and systematic approach that only committed and properly trained endoscopists can master. While alternative interventions such as endoscopic submucosal dissection (ESD) offer potential advantages over EMR, the added procedural complexity, risks, and costs limit the relevance of ESD to a minority of lesions in the colorectum. This article reviews the expanding body of evidence supporting EMR as the first-line treatment of colorectal LSLs ≥20 mm.

Safety of endoscopic mucosal resection (EMR) of large non-pedunculated colorectal adenomas in the elderly

BACKGROUND

Endoscopic mucosal resection (EMR) has been proven to be safe and effective for the treatment of colorectal adenomas. However, data are limited on the safety of this technique for large polyps and in elderly patients. Aims of our study were to examine the bleeding and perforation rates in patients with large non-pedunculated adenomas (≥20mm) and to evaluate the influence of size (≥40mm) and age (≥75 years) on the complication rates.

METHODS

In this multicenter retrospective study, patients who underwent EMR of non-pedunculated adenomas ≥20mm between January 2012 and March 2016 were included. The demographics of the patients, the use of antithrombotic drugs, size of the polyps, type of resection, pathology report, occurrence of post-polypectomy bleeding, and perforation- and recurrence rate were collected.

RESULTS

In 343 patients, 412 adenomas were removed. Eighty patients (23.3%) were ≥75 years of age, 138 polyps (33.5%) were ≥40mm. Bleeding complications were observed in 28 cases (6.8%) and were found significantly more frequent in adenomas ≥40mm, independent of the use of antithrombotic therapy. Five perforations (1.2%) were described, not related to the size of the polyp. There was no significant difference in complication rates between patients <75 years and patients ≥75 years. Bleeding complications rates were significantly higher in patients receiving double antithrombotic therapy.

CONCLUSION

EMR is safe in elderly patients. EMR of adenomas of ≥40mm was associated with more bleeding complications. Future studies should address how the bleeding rates can be reduced in these patients, especially in those who use double antithrombotic treatment.