Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

A novel tool for case selection in endoscopic mucosal resection training

BACKGROUND

 As endoscopic mucosal resection (EMR) of large (≥ 20 mm) adenomatous nonpedunculated colonic polyps (LNPCPs) becomes widely practiced outside expert centers, appropriate training is necessary to avoid failed resection and inappropriate surgical referral. No EMR-specific tool guides case selection for endoscopists learning EMR. This study aimed to develop an EMR case selection score (EMR-CSS) to identify potentially challenging lesions for "EMR-naïve" endoscopists developing competency.

METHODS

 Consecutive EMRs were recruited from a single center over 130 months. Lesion characteristics, intraprocedural data, and adverse events were recorded. Challenging lesions with intraprocedural bleeding (IPB), intraprocedural perforation (IPP), or unsuccessful resection were identified and predictive variables identified. Significant variables were used to form a numerical score and receiver operating characteristic curves were used to generate cutoff values.

RESULTS

 Of 1993 LNPCPs, 286 (14.4 %) were in challenging locations (anorectal junction, ileocecal valve, or appendiceal orifice), 368 (18.5 %) procedures were complicated by IPB and 77 (3.9 %) by IPP; 110 (5.5 %) procedures were unsuccessful. The composite end point of IPB, IPP, or unsuccessful EMR was present in 526 cases (26.4 %). Lesion size, challenging location, and sessile morphology were predictive of the composite outcome. A six-point score was generated with a cutoff value of 2 demonstrating 81 % sensitivity across the training and validation cohorts.

CONCLUSIONS

 The EMR-CSS is a novel case selection tool for conventional EMR training, which identifies a subset of adenomatous LNPCPs that can be successfully and safely attempted in early EMR training.

Polyps seen but not removed during index colonoscopy: an underestimated inefficiency in endoscopy practice

BACKGROUND AND AIMS

In the United Kingdom endoscopists are certified for independent practice once competent in the removal of polyps up to 20 mm in size. Where polyps are detected but not removed during the index colonoscopy, a repeat procedure is required. The aim of this study was to identify the proportion of polyps <20 mm that were not removed at the time of diagnosis.

METHODS

Polyps identified at colonoscopy during a 12-month period in a single institution were included in this study. All polyps were categorized according to the reported size and complexity per the size, morphology, site, access (SMSA) classification. In cases where polyps ≤20 mm were not removed, patient records and endoscopy reports were interrogated to ascertain the reasons for this.

RESULTS

Across 1444 patients, 2442 polyps <20 mm in size were diagnosed. Removal at the time of the index procedure occurred in 1158 patients (80.2%). Nonremoval for a predefined acceptable reason, such as concomitant anticoagulation therapy, accounted for 174 cases (12.0%). Nonremoval without contraindication was noted in 112 cases (7.8%). The mean polypectomy complexity as determined by the SMSA score of these polyps was lower than level 2, denoting low complexity. The requirement for unnecessary repeat procedures equated to 9.3 days of endoscopy capacity per year.

CONCLUSIONS

This study demonstrates that a small but significant proportion of small colorectal polyps are not removed at the time of diagnosis. This practice has implications for both patients and service provision.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video)

BACKGROUND AND AIMS

Colonic endoscopic submucosal dissection (ESD) is particularly challenging and limited to a few expert centers. We recently conducted a pilot study on improvement of colonic ESD with systematic use of a countertraction device (double-clip traction with rubber band [DCT-ESD]).

METHODS

A French prospective multicenter study was conducted between March 2017 and September 2019, including all consecutive cases of naive colonic ESD. Since the first case of DCT-ESD in March 2017, all cases of colonic ESD have been performed using the DCT-ESD strategy in the 3 centers involved in the study.

RESULTS

Five hundred ninety-nine lesions with a mean size of 53 mm were included in this study, resected by 5 operators in 3 centers. The en bloc, R0, and curative resection rates were 95.7%, 83.5%, and 81.1%, respectively. The adverse event rates were 4.9% for perforation and 4.2% for postprocedure bleeding. Between 2017 and 2019, the rates of R0 and curative resections increased significantly from 74.7% in 2017 to 88.4% in 2019 (P = .003) and from 72.6% in 2017 to 86.3% in 2019 (P = .004), respectively. Procedure duration and speed of resection were 62.4 minutes and 39.4 mm²/minute, respectively. No differences were noted between operators.

CONCLUSION

DCT-ESD is a safe and reproducible technique, with results comparable with those of the large Japanese teams with speed of resection twice as high as previously reported studies. The DCT strategy is promising, cheap, and seems to be reproducible. Physicians performing colonic ESD should be aware of this promising tool to improve their results in ESD.

Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update

BACKGROUND

One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities.

METHODS

As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined).

RESULTS

The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition.

CONCLUSIONS

Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.

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).

The risk of residual or recurring adenoma after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps is predictable

INTRODUCTION/OBJECTIVE

Piecemeal endoscopic mucosal resection is a safe and effective procedure for the management of large non-pedunculated colorectal polyps. Its major limitation is the possibility of residual or recurrent adenoma and the consequent need for scheduled surveillance colonoscopies, with the implied burden for the patient and health systems. We aimed to evaluate if the Size/Morphology/Site/Access (SMSA) and Sydney EMR Recurrence Tool (SERT) scores are effective in predicting residual/recurrent adenoma after piecemeal endoscopic resection of large non-pedunculated colorectal polyps.

METHODS

Prospective observational cohort study of piecemeal endoscopic mucosal resection of large non-pedunculated colonic polyps performed in a tertiary center. SMSA and SERT scores were calculated in the index colonoscopy and evaluated regarding the ability to predict residual/recurrent adenoma.

RESULTS

One hundred fifty-eight procedures were included. Lesions mean size was 31.6 ± 10.1 mm. 65.8% were flat and 61.4% were located in the right colon. Residual/recurrent adenoma was present in 17 (10.8%) cases. SMSA 2 and SERT 0 lesions had 0.0% and 5.7% of residual/recurrent adenoma rate at 6 months, respectively, while SMSA 3-4 and SERT 1-4 lesions had a 11.5% and 14.8% rate, respectively, at 6 months. SMSA grade 2 and SERT grade 0 had a negative predictive value of 100% and 94%, respectively, for residual/recurrent adenoma. SMSA score had an area under the receiver-operating characteristics curve of 0.732 (P = 0.003), while SERT score had a value of 0.730 (P = 0.002) for residual/recurrent adenoma.

CONCLUSION

SMSA and SERT scores are effective tools to identify lesions with a low risk of residual/recurrent adenoma.

Validation of the size morphology site access score in endoscopic mucosal resection of large polyps in a district general hospital

BACKGROUND

Polyp assessment is multimodal and is vital prior to endoscopic mucosal resection. The size, morphology, site and access (SMSA) score has been validated in specialist endoscopic institutions. this study investigated the ability of this score to predict incomplete endoscopic resection of large colorectal polyps in a district general hospital.

METHODS

Consecutive patients undergoing endoscopic mucosal resection of large (≥ 20 mm) colorectal polyps at Worthing Hospital. Clinical, endoscopic and histological data were taken from prospective databases. The primary outcome of the study was to investigate the correlation of the SMSA score with incomplete endoscopic resection.

RESULTS

Between February 2015 and August 2018, 114 patients underwent colorectal endoscopic mucosal resection. Of these, 67 (59%) were male. The median (interquartile range) age of the study population was 72 years (65-78 years). Some 17 lesions (15%) were pedunculated, 76 (67%) were sessile and 21 were (18%) flat; 84 polyps (77%) were located in the left colon/rectum, with the remainder in the right colon; 51 lesions (45%) were 20-30 mm, 27 (24%) were 30-40 mm and 36 (31%) were greater than 40 mm in diameter. When reclassified into the SMSA score, 9 of the polyps (8%) were level 2, 64 (56%) were level 3 and 41 (36%) were level 4. Incomplete resection was clinically diagnosed in 9/114 (8%). The SMSA score was positively correlated with incomplete endoscopic resection, but not with additional procedure usage, complications or advanced histology.

CONCLUSIONS

Many patients with large polyps can be managed outside of specialist units. This study has validated that the SMSA score was associated with incomplete endoscopic mucosal resection for large polyps in a district general hospital setting.

Size of colorectal polyps determines time taken to remove them endoscopically

BACKGROUND AN STUDY AIMS

 Polypectomy and endoscopic mucosal resection (EMR) are effective and safe ways of removing polyps from the colon at endoscopy. Guidelines exist for advising the time allocation for diagnostic endoscopy but not for polypectomy and EMR. The aim of this study was to identify if time allocated for polypectomy and EMR at planned therapeutic lists in our endoscopy unit is sufficient for procedures to be carried out. We also wanted to identify factors that might be associated with procedures taking longer than the allocated time and to identify factors that might predict duration of these procedures.

PATIENTS AND METHODS

 A retrospective case study of planned 100 lower gastrointestinal EMR and polypectomy procedures at colonoscopy and sigmoidoscopy was performed and analyzed with quantitative analysis.

RESULTS

 The mean actual procedural time (APT) for 100 procedures was 52 minutes and the mean allocated time (AT) was 43.05 minutes. Hence the mean APT was 9 minutes longer than the mean AT. Factors that were significantly associated with procedures taking longer than the allocated time were patient age ( P  = 0.029) and polyp size ( P  = 0.005). Factors that significant changed the actual procedure time were patient age ( P  = 0.018), morphology ( P  = 0.002) and polyp size ( P  < 0.001). Procedures involving flat and lateral spreading tumor (LST) type polyps took longer than the protruding ones. On multivariate analysis, polyp size was the only factor that associated with actual procedure time. Number of polyps, quality of bowel preparation, and distance of polyp from insertion did significantly change procedure duration.

CONCLUSION

 Factors that significantly contribute to duration of polypectomy and EMR at lower gastrointestinal endoscopy include patient age and polyp size and morphology on univariate analysis, with polyp size being the factor with a significant association on multivariate analysis. We recommend that endoscopy units take these factors into consideration locally when allocating time for these procedures to be safe and effective.

Risk stratification of colorectal polyps for predicting residual or recurring adenoma using the Size/Morphology/Site/Access score

Background and Aims

Endoscopic mucosal resection is an effective and safe procedure to manage large non-pedunculated colonic polyps for which residual/recurrent adenoma is the main drawback. Size/Morphology/Site/Access score determines polypectomy difficulty. We aimed to describe residual/recurrent adenoma rate according to Size/Morphology/Site/Access and to select the ize/Morphology/Site/Access cut-off to predict low residual/recurrent adenoma.

Methods

This was a retrospective cohort study of endoscopic mucosal resection for large non-pedunculated colonic polyps performed in a tertiary centre.

Results

Three hundred and sixteen procedures were included. The mean size of lesions was 34.5 ± 17.1 mm, 59.5% were sessile, 60.4% were in the right colon and in 17.7% (n = 56) the access was difficult. Of the lesions, 83.6% were Size/Morphology/Site/Access 3-4. Residual/recurrent adenoma at first and second follow-up was significantly lower in Size/Morphology/Site/Access 2 (1.9% and 0.0%, respectively) when compared to Size/Morphology/Site/Access 3 (18.2%, p = 0.004 and 6.7%, p = 0.049) and Size/Morphology/Site/Access 4 (30.8%, p < 0.001 and 22.7%, p = 0.030). The negative predictive value of Size/Morphology/Site/Access 2 for residual/recurrent adenoma at second follow-up was 86.1%. On multivariate analyses, Size/Morphology/Site/Access 3-4 predicted residual/recurrent adenoma at first (odds ratio 11.96, 95% confidence interval 1.57-91.13) and second follow-up (odds ratio 2.47, 95% confidence interval 1.51-4.22) and had higher cumulative incidence of residual/recurrent adenoma compared to Size/Morphology/Site/Access 2 (p ≤ 0.003).

Conclusion

Use of the Size/Morphology/Site/Access score allows cases to be identified with a low risk of residual/recurrent adenoma.