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Patel A, Treves G, Samreen I, Vaghani UP. The Effectiveness of Prophylactic Epinephrine Compared to No Prophylaxis for Postpolypectomy Bleeding in Endoscopic Colorectal Surgery: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e56778. [PMID: 38650798 PMCID: PMC11034620 DOI: 10.7759/cureus.56778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
Colorectal cancer prevention has seen significant advancements with colonoscopic polypectomy, a critical technique in clinical practice. However, postpolypectomy bleeding (PPB), particularly in the resection of large pedunculated polyps, remains a major complication. This systematic review and meta-analysis investigates the efficacy of prophylactic epinephrine injections in preventing PPB, addressing inconsistencies in the literature regarding its effectiveness. Employing a comprehensive search strategy, we rigorously selected studies for inclusion, focusing on those comparing prophylactic epinephrine with no intervention. The risk of bias was assessed using the Cochrane Risk of Bias assessment tool, ensuring a robust and reliable analysis. Our findings, based on an analysis of four studies involving 1,062 patients, indicate a significant reduction in early PPB with epinephrine use, with a marked decrease in bleeding incidence compared to the no-prophylaxis group. However, the impact on delayed bleeding was less conclusive, suggesting the need for further research in this area. Our study thus highlights the effectiveness of epinephrine as a preventive tool in colonoscopic polypectomy while underscoring the complexity of bleeding risks and the necessity for ongoing investigation in optimizing patient outcomes.
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Affiliation(s)
- Akash Patel
- Internal Medicine, Eisenhower Health, Rancho Mirage, USA
| | - Guy Treves
- Medicine and Surgery, St. George's University School of Medicine, Irvine, USA
| | - Isha Samreen
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | - Utsav P Vaghani
- Internal Medicine, Smt. N.H.L. Municipal Medical College, Ahmedabad, IND
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2
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Tokuhara M, Shimatani M, Tominaga K, Nakahira H, Ohtsu T, Kouda K, Naganuma M. Evaluation of a new method, "non-injection resection using bipolar soft coagulation mode (NIRBS)", for colonic adenomatous lesions. Clin Endosc 2023; 56:623-632. [PMID: 37524565 PMCID: PMC10565442 DOI: 10.5946/ce.2022.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/21/2022] [Accepted: 12/16/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic resection of all colorectal adenomatous lesions with a low complication rate, simplicity, and negative residuals is challenging. Hence, we developed a new method called "non-injection resection using bipolar soft coagulation mode (NIRBS)" method, adapted for colorectal lesions. In addition, we evaluated the effectiveness of this method. METHODS We performed NIRBS throughout a 12-month period for all colorectal lesions which snare resection was acceptable without cancerous lesions infiltrating deeper than the submucosal layer. RESULTS A total of 746 resected lesions were included in the study, with a 4.5 mm mean size (range, 1-35 mm). The major pathological breakdowns were as follows: 64.3% (480/746) were adenomas, and 5.0% (37/746) were intraepithelial adenocarcinomas (Tis lesions). No residuals were observed in any of the 37 Tis lesions (mean size, 15.3 mm). Adverse events included bleeding (0.4%) but no perforation. CONCLUSIONS NIRBS allowed the resection of multiple lesions with simplicity because of the non-injection and without perforating due to the minimal burn effect of the bipolar snare set in the soft coagulation mode. Therefore, NIRBS can be used to resect adenomatous lesions easily, including Tis lesions, from small to large lesions without leaving residuals.
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Affiliation(s)
- Mitsuo Tokuhara
- Department of Gastroenterology, Japan Community Healthcare Organization Hoshigaoka Medical Center, Osaka, Japan
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Masaaki Shimatani
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Kazunari Tominaga
- Department of Gastroenterology, Japan Community Healthcare Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Hiroko Nakahira
- Department of Gastroenterology, Japan Community Healthcare Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Takuya Ohtsu
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Katsuyasu Kouda
- Department of Hygiene and Public Health, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Makoto Naganuma
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
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3
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Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions. Am J Gastroenterol 2022; 117:1080-1088. [PMID: 35765907 DOI: 10.14309/ajg.0000000000001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/27/2022] [Indexed: 12/11/2022]
Abstract
The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.
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Gupta S, Sidhu M, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Byth K, Brown G, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 7:152-160. [PMID: 34801133 DOI: 10.1016/s2468-1253(21)00384-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. METHODS We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. FINDINGS Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. INTERPRETATION Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. FUNDING None.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Eric Yong Tat Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Stephen John Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Nicholas Graeme Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael John Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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5
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Yang JK, Hyun JJ, Lee TH, Choi JH, Lee YN, Choe JW, Park JS, Kwon CI, Jeong S, Kim HJ, Moon JH, Park SH. Can prophylactic argon plasma coagulation reduce delayed post-papillectomy bleeding? A prospective multicenter trial. J Gastroenterol Hepatol 2021; 36:467-473. [PMID: 32677716 DOI: 10.1111/jgh.15186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. METHODS In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate. RESULTS The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications. CONCLUSION Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).
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Affiliation(s)
- Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Chang-Il Kwon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hong Ja Kim
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
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Turan AS, Moons LMG, Schreuder RM, Schoon EJ, Terhaar Sive Droste JS, Schrauwen RWM, Straathof JW, Bastiaansen BAJ, Schwartz MP, Hazen WL, Alkhalaf A, Allajar D, Hadithi M, van der Spek BW, Heine DGDN, Tan ACITL, de Graaf W, Boonstra JJ, Voogd FJ, Roomer R, de Ridder RJJ, Kievit W, Siersema PD, Didden P, van Geenen EJM. Clip placement to prevent delayed bleeding after colonic endoscopic mucosal resection (CLIPPER): study protocol for a randomized controlled trial. Trials 2021; 22:63. [PMID: 33461579 PMCID: PMC7813164 DOI: 10.1186/s13063-020-04996-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) for large colorectal polyps is in most cases the preferred treatment to prevent progression to colorectal carcinoma. The most common complication after EMR is delayed bleeding, occurring in 7% overall and in approximately 10% of polyps ≥ 2 cm in the proximal colon. Previous research has suggested that prophylactic clipping of the mucosal defect after EMR may reduce the incidence of delayed bleeding in polyps with a high bleeding risk. METHODS The CLIPPER trial is a multicenter, parallel-group, single blinded, randomized controlled superiority study. A total of 356 patients undergoing EMR for large (≥ 2 cm) non-pedunculated polyps in the proximal colon will be included and randomized to the clip group or the control group. Prophylactic clipping will be performed in the intervention group to close the resection defect after the EMR with a distance of < 1 cm between the clips. Primary outcome is delayed bleeding within 30 days after EMR. Secondary outcomes are recurrent or residual polyps and clip artifacts during surveillance colonoscopy after 6 months, as well as cost-effectiveness of prophylactic clipping and severity of delayed bleeding. DISCUSSION The CLIPPER trial is a pragmatic study performed in the Netherlands and is powered to determine the real-time efficacy and cost-effectiveness of prophylactic clipping after EMR of proximal colon polyps ≥ 2 cm in the Netherlands. This study will also generate new data on the achievability of complete closure and the effects of clip placement on scar surveillance after EMR, in order to further promote the debate on the role of prophylactic clipping in everyday clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT03309683 . Registered on 13 October 2017. Start recruitment: 05 March 2018. Planned completion of recruitment: 31 August 2021.
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands.
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Màxima Medical Center, Veldhoven, Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, Netherlands
| | - Daud Allajar
- Department of Gastroenterology and Hepatology, Hospital St. Jansdal, Harderwijk, Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Bas W van der Spek
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Dimitri G D N Heine
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina hospital, Nijmegen, Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leids University Medical Center, Leiden, Netherlands
| | - Fia J Voogd
- Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Wietske Kievit
- IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
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Chen CW, Kuo CJ, Chiu CT, Su MY, Lin CJ, Le PH, Lim SN, Yeh CT, Alison MR, Lin WR. The effect of prophylactic hemoclip placement and risk factors of delayed post-polypectomy bleeding in polyps sized 6 to 20 millimeters: a propensity score matching analysis. BMC Gastroenterol 2020; 20:309. [PMID: 32962643 PMCID: PMC7510104 DOI: 10.1186/s12876-020-01454-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022] Open
Abstract
Background Delayed post-polypectomy bleeding (PPB) is a major complication of polypectomy. The effect of prophylactic hemoclipping on delayed PPB is uncertain. The aim of this study was to evaluate the effectiveness of prophylactic hemoclipping and identify the risk factors of delayed PPB. Methods Patients with polyps sized 6 to 20 mm underwent snare polypectomy from 2015 to 2017 were retrospectively reviewed. The patients with prophylactic hemoclipping for delayed PPB prevention were included in the clipping group, and those without prophylactic hemoclipping were included in the non-clipping group. The incidence of delayed PPB and time to bleeding were compared between the groups. Multivariate analysis was used to identify the risk factors of delayed PPB. Propensity score matching was used to minimize potential bias. Results After propensity score matching, 612 patients with 806 polyps were in the clipping group, and 576 patients with 806 polyps were in the non-clipping group. There were no significant differences in the incidence of delayed PPB and days to bleeding between two groups (0.8% vs 1.3%, p = 0.4; 3.4 ± 1.94 days vs 4.13 ± 3.39 days, p = 0.94). In the multivariate analysis, the polyp size [Odds ratio (OR):1.16, 95% confidence interval (CI):1.01–1.16, p = 0.03), multiple polypectomies (OR: 4.64, 95% CI:1.24–17.44, p = 0.02) and a history of anticoagulant use (OR:37.52, 95% CI:6.49–216.8, p < 0.001) were associated with delayed PPB. Conclusions In polyps sized 6 to 20 mm, prophylactic hemoclip placement did not decrease the risk of delayed PPB. Patients without risk factors including multiple polypectomies and anticoagulant use are no need to performing prophylactic hemoclipping.
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Affiliation(s)
- Chun-Wei Chen
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Gastroenterology and Hepatology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chun-Jung Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Siew-Na Lim
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chau-Ting Yeh
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Liver Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Malcolm R Alison
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Liver Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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8
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Soh JS, Seo M, Kim KJ. Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding. BMC Gastroenterol 2020; 20:68. [PMID: 32164613 PMCID: PMC7069010 DOI: 10.1186/s12876-020-01210-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although prophylactic clip application before polypectomy may prevent postpolypectomy bleeding (PPB), the usefulness of prophylactic clipping in the treatment of large pedunculated polyps is controversial in some prospective randomized studies. This study was conducted to evaluate the efficacy of prophylactic clip application and to investigate the predictors of PPB in large pedunculated colorectal polyps. METHODS A total of 137 pedunculated polyps (size ≥1 cm) in 116 patients were prospectively included and randomized into group A (with clipping) and group B (without clipping), and resected. The occurrences of immediate PPB (graded 1-4) and delayed PPB were compared. RESULTS Sixty-seven polyps were allocated in group A and 70 polyps in group B. In both groups, the median polyp diameter was 15 mm (P = 0.173) and the median stalk diameter was 3 mm (P = 0.362). Twenty-eight (20.4%) immediate PPB episodes in 137 polyps occurred, 6 (9.0%) in group A and 22 (31.4%) in group B (P = 0.001). However, the occurrence of delayed PPB was not different between the groups (P = 0.943). Prophylactic clip application decreased the occurrence of immediate PPB (odds ratio 0.215, 95% confidence interval 0.081-0.571). Moreover, polyp size ≥20 mm and stalk diameter ≥ 4 mm increased the risk of immediate PPB. CONCLUSIONS Clip application before polypectomy of ≥1 cm pedunculated polyps is effective in decreasing the occurrence of immediate PPB. Thus, clip application should be considered before performing snare polypectomy, especially for large polyps with a thick stalk. TRIAL REGISTRATION This research was studied a prospective maneuver and enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT01437631). This study was registered on September 19, 2011.
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Affiliation(s)
- Jae Seung Soh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea
| | - Myeongsook Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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9
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Prophylactic endoscopic coagulation to prevent delayed post-EMR bleeding in the colorectum: a prospective randomized controlled trial (with videos). Gastrointest Endosc 2019; 90:813-822. [PMID: 31175874 DOI: 10.1016/j.gie.2019.05.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Post-EMR bleeding (PEB) is the most common adverse event after EMR. However, there are no established endoscopic methods for the prevention of PEB. This study aimed to investigate whether prophylactic endoscopic coagulation (PEC) using coagulation probes reduces the incidence of overall delayed PEB. METHODS We performed a randomized controlled study of patients undergoing EMR for large (≥10 mm) sessile lesions and laterally spreading tumors. Patients were randomized 1:1 to the EMR with coagulation group (n = 285) or EMR (control) group (n = 285). Immediate bleeding during colon EMR or clean-based ulcer after EMR was excluded. Clinically significant PEB was defined as bleeding requiring endoscopic hemostasis, hospitalization, or a decrease in the hemoglobin level >2 g/dL. RESULTS A total of 569 patients were analyzed. The incidence of overall PEB was significantly lower in the EMR with coagulation group than in the control group (12.6% [36/285] vs 18.7% [53/284], P = .048). However, this was largely because of a reduction in minor bleeding. There was no difference in clinically significant PEB (1.8% [5/285] vs 3.2% [9/284], P = .276). Rectal location was a risk factor associated with overall PEB (odds ratio, 1.256; 95% confidence interval, 1.12-1.41; P < .001). CONCLUSIONS Although this study found reduced PEB with prophylactic cautery of visible vessels, this was largely because of a reduction in minor bleeding with no benefit observed for clinically significant bleeding. Overall, PEB was more frequent with rectal lesions. (Clinical trial registration number: KCT0000779.).
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10
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Albéniz E, Álvarez MA, Espinós JC, Nogales O, Guarner C, Alonso P, Rodríguez-Téllez M, Herreros de Tejada A, Santiago J, Bustamante-Balén M, Rodríguez Sánchez J, Ramos-Zabala F, Valdivielso E, Martínez-Alcalá F, Fraile M, Elosua A, Guerra Veloz MF, Ibáñez Beroiz B, Capdevila F, Enguita-Germán M. Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding. Gastroenterology 2019; 157:1213-1221.e4. [PMID: 31362007 DOI: 10.1053/j.gastro.2019.07.037] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/16/2019] [Accepted: 07/21/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS It is not clear whether closure of mucosal defects with clips after colonic endoscopic mucosal resection (EMR) prevents delayed bleeding, although it seems to have no protective effects when risk is low. We performed a randomized trial to evaluate the efficacy of complete clip closure of large (≥2 cm) nonpedunculated colorectal lesions after EMR in patients with an estimated average or high risk of delayed bleeding. METHODS We performed a single-blind trial at 11 hospitals in Spain from May 2016 through June 2018, including 235 consecutive patients who underwent EMR for large nonpedunculated colorectal lesions with an average or high risk of delayed bleeding (based on Spanish Endoscopy Society Endoscopic Resection Group score). Participants were randomly assigned to groups that received closure of the scar with 11-mm through-the-scope clips (treated, n = 119) or no clip (control, n = 116). The primary outcome was proportion of patients in each group with delayed bleeding, defined as evident hematochezia that required medical intervention within 15 days after colonoscopy. RESULTS In the clip group, complete closure was achieved in 68 (57%) cases, with partial closure in 33 (28%) cases and failure to close in 18 (15%) cases. Delayed bleeding occurred in 14 (12.1%) patients in the control group and in 6 (5%) patients in the clip group (absolute risk difference, reduction of 7% in the clip group; 95% confidence interval, -14.7% to 0.3%). After completion of the clip closure, there was only 1 (1.5%) case of delayed bleeding (absolute risk difference, reduction of 10.6%; 95% confidence interval, -4.3% to 17.9%). CONCLUSIONS In a randomized trial of patients with large nonpedunculated colorectal lesions undergoing EMR, we found that clip closure of mucosal defects in patients with a risk of bleeding can be a challenge, but also reduces delayed bleeding. Prevention of delayed bleeding required complete clip closure. ClinicalTrials.gov ID: NCT02765022.
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Affiliation(s)
| | | | | | | | | | | | | | | | - José Santiago
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | | | | | | | | | | | | | - Berta Ibáñez Beroiz
- Navarrabiomed, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas, Pamplona, Spain
| | - Ferrán Capdevila
- Navarrabiomed, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Mónica Enguita-Germán
- Navarrabiomed, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
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11
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Desomer L, Tate DJ, Bahin FF, Awadie H, Chiang B, Holt B, Byth K, Bourke MJ. A systematic description of the post-EMR defect to identify risk factors for clinically significant post-EMR bleeding in the colon. Gastrointest Endosc 2019; 89:614-624. [PMID: 30503846 DOI: 10.1016/j.gie.2018.11.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Clinically significant post-EMR bleeding (CSPEB) is the most-frequent serious adverse event after EMR of large laterally spreading colonic lesions (LSLs). There is no proven prophylactic therapy, and it remains a significant drawback of EMR. We aimed to systematically describe and evaluate the features of the post-EMR mucosal defect (PED) and their relationship to CSPEB. METHODS A prospective study of LSLs referred for EMR at a tertiary center was performed. PEDs without visible features were recorded as bland blue. Nonbland blue (NBB) PED features included size, number, and herniation of submucosal vessels and presence of submucosal hemorrhage, fibrosis, fat, and exposed muscle. NBB PEDs were analyzed for association with CSPEB, defined as bleeding occurring after completion of the procedure necessitating readmission or reintervention. RESULTS From April 2012 to May 2017, 501 lesions in 501 patients were eligible for analysis. The frequency of CSPEB was 30 of 501 (6.0%). More than or equal to 3 visible vessels was a significant predictor of CSPEB (P = .016). None of the following showed a significant correlation with CSPEB: presence of visible vessels, their diameter, herniation, or other nonvascular PED features. Submucosal vessels were more common in the left-sided colon segment (88.6% vs 78.3%, P = .004) and were significantly larger (20.8% vs 12.1% ≥1 mm, P = .037), more numerous (median 4 vessels [interquartile range, 2-7] vs 2 vessels [interquartile range, 1-4], P < .001), and more often herniated (32% vs 22.2%, P = .022). CONCLUSIONS More than or equal to 3 visible vessels within the PED may be predictive for CSPEB and may define a target group for real-time prophylactic intervention. No other endoscopically visible features of the PEDs were predictive of CSPEB. (Clinical trial registration number: NCT03117400.).
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Affiliation(s)
- Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Brian Chiang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Bronte Holt
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Karen Byth
- Medical Statistician, Research and Education Network, Westmead Hospital and Sydney University, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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12
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Nam K, Song TJ, Kim RE, Cho DH, Cho MK, Oh D, Park DH, Lee SS, Seo DW, Lee SK, Kim MH, Baek S. Usefulness of argon plasma coagulation ablation subsequent to endoscopic snare papillectomy for ampullary adenoma. Dig Endosc 2018; 30:485-492. [PMID: 29288506 DOI: 10.1111/den.13008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/25/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Endoscopic snare papillectomy (ESP) is an effective treatment for ampullary adenoma. Argon plasma coagulation (APC) is widely used as an additional method to control bleeding or ablate the residual tumor. However, the efficacy of this procedure has not yet been fully evaluated. This study aimed to evaluate the usefulness of APC as an additional method to ESP. METHODS Patients who underwent ESP for ampullary adenoma between September 2005 and September 2015 were retrospectively reviewed. Using propensity score matching, we compared short- and long-term outcomes between the ESP-with-additional-APC group (ESP + APC group) and the ESP-only group. Primary outcome was early post-ESP adverse events (AE), and secondary outcomes were late AE and recurrence. RESULTS Among 109 patients, additional APC was carried out in 59 (54.1%) patients. After matching, 41 patients were included in both groups, respectively. Bleeding rate was significantly lower in the ESP + APC group than in the ESP-only group (7.3% vs 31.7%, odds ratio = 0.180, P < 0.01). However, there were no significant differences in other procedure-related early AE such as pancreatitis (12.2% vs 19.5%, P = 0.365), cholangitis (2.4% vs 9.8%, P = 0.198), and perforation (2.4% vs 2.4%, P = 1.000) between the ESP + APC group and the ESP-only group. During the follow-up period (mean 904 ± 868 days), papillary stricture (9.8% vs 4.9%, P = 0.405) and recurrence rates (24.4% vs 24.4%, P = 0.797) were not significantly different between the ESP + APC group and the ESP-only group. CONCLUSION Additional APC during ESP may have a beneficial effect by decreasing bleeding rate without harmful effects.
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Affiliation(s)
- Kwangwoo Nam
- Division of Gastroenterology, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, South Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Raymond E Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Dong Hui Cho
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Min Keun Cho
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dongwook Oh
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seunghee Baek
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Jaruvongvanich V, Prasitlumkum N, Assavapongpaiboon B, Suchartlikitwong S, Sanguankeo A, Upala S. Risk factors for delayed colonic post-polypectomy bleeding: a systematic review and meta-analysis. Int J Colorectal Dis 2017; 32:1399-1406. [PMID: 28779355 DOI: 10.1007/s00384-017-2870-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Delayed post-polypectomy bleeding (PPB) is an infrequent but serious adverse event after colonoscopic polypectomy. Several studies have tried to identify risk factors for delayed PPB, with inconsistent results. This meta-analysis aims to identify significant risk factors for delayed PPB. METHODS MEDLINE and EMBASE databases were searched through January 2016 for studies that investigated the risk factors for delayed PPB. Pooled odds ratio (OR) for categorical variables and mean differences (MD) for continuous variables and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity of effect size was quantified using the Q statistic and I 2. RESULTS Twelve articles involving 14,313 patients were included. The pooled delayed PPB rate was 1.5% (95%CI, 0.7-3.4%), I 2 = 96%. Cardiovascular disease (OR = 1.55), hypertension (OR = 1.53), polyp size > 10 mm (OR = 3.41), and polyps located in the right colon (OR = 1.60) were identified as significant risk factors for delayed PPB, whereas age, sex, alcohol use, smoking, diabetes, cerebrovascular disease, pedunculated morphology, and carcinoma histology were not. CONCLUSIONS Cardiovascular disease, hypertension, polyp size, and polyp location were associated with delayed PPB. More caution is needed when removing polyps in patients with these risk factors. Future studies are warranted to determine appropriate preventive hemostatic measures in these patients.
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Affiliation(s)
- Veeravich Jaruvongvanich
- Department of Internal Medicine, University of Hawaii, Honolulu, HI, USA
- Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Narut Prasitlumkum
- Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sakolwan Suchartlikitwong
- Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Department of Internal Medicine, Texas Tech Medical Center, Lubbock, TX, USA
| | - Anawin Sanguankeo
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, 13326, USA
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sikarin Upala
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, 13326, USA.
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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14
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Tullavardhana T, Akranurakkul P, Ungkitphaiboon W, Songtish D. Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies. Ann Med Surg (Lond) 2017; 19:65-73. [PMID: 28652912 PMCID: PMC5476974 DOI: 10.1016/j.amsu.2017.05.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Bleeding is the most common major complication following colonoscopic polypectomy. The purpose of this study is to evaluate whether submucosal epinephrine injections could prevent the occurrence of postpolypectomy bleeding. Method The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for appropriate randomized controlled studies published before April 2015. A meta-analysis was conducted to investigate the preventative effect of submucosal epinephrine injection for overall, early, and delayed postpolypectomy bleeding. Results The final analysis examined the findings of six studies, with data from 1388 patients. The results demonstrated that prophylactic treatment with epinephrine injection significantly reduced the occurrence of overall (OR = 0.38, 95% CI: 0.21, 0.66; p = 0.0006) and early bleeding (OR = 0.38, 95% CI: 0.20, 0.69; p = 0.002). However, for delayed bleeding complications, epinephrine injections were not found to be any more effective than treatment with saline injection or no injection (OR = 0.45, 95% CI: 0.11, 1.81; p = 0.26). Moreover, for patients with polyps larger than 20 mm, mechanical hemostasis devices (endoloops or clips) were found to be more effective than epinephrine injection in preventing overall bleeding (OR = 0.33, 95% CI: 0.13, 0.87; p = 0.03) and early bleeding (OR = 0.29, 95% CI: 0.08, 1.02; p = 0.05). This was not established for delayed bleeding. Conclusion The routine use of prophylaxis submucosal epinephrine injection is safe and beneficial preventing postpolypectomy bleeding.
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Affiliation(s)
- Thawatchai Tullavardhana
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Prinya Akranurakkul
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Withoon Ungkitphaiboon
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Dolrudee Songtish
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
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15
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Kim DH. Prediction and Prevention of Postpolypectomy Bleeding: Necessity of a Different Approach for Patients Using Antithrombotic Agents. Clin Endosc 2017; 50:217-218. [PMID: 28609814 PMCID: PMC5475518 DOI: 10.5946/ce.2017.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 04/14/2017] [Accepted: 04/21/2017] [Indexed: 12/16/2022] Open
Affiliation(s)
- Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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16
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Park CH, Jung YS, Nam E, Eun CS, Park DI, Han DS. Comparison of Efficacy of Prophylactic Endoscopic Therapies for Postpolypectomy Bleeding in the Colorectum: A Systematic Review and Network Meta-Analysis. Am J Gastroenterol 2016; 111:1230-43. [PMID: 27402502 DOI: 10.1038/ajg.2016.287] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/09/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although various endoscopic therapies have been suggested for preventing bleeding after colorectal polypectomy, the optimal therapy has yet to be fully clarified. We assessed the comparative efficacy of prophylactic therapies for postpolypectomy bleeding through a network meta-analysis combining direct and indirect comparisons. METHODS We searched for all relevant randomized controlled trials published up until January 2016 examining the effects of prophylactic therapy for bleeding after colorectal polypectomy. The types of prophylactic therapy were classified as mechanical therapy, epinephrine-saline injection therapy, coagulation therapy, combined therapy, or no prophylactic therapy. Combined therapy was defined as a combination of two or more types of therapy including mechanical therapy, epinephrine-saline injection therapy, and coagulation therapy. We performed a Bayesian network meta-analysis for all prophylactic therapies. RESULTS Fifteen studies with 3,462 patients were included in the meta-analysis. Compared with no prophylactic therapy, both epinephrine-saline injection and mechanical therapy showed superiority for preventing early postpolypectomy bleeding with a moderate quality of evidence (injection therapy, risk ratio (RR; 95% credible interval (CrI))=0.32 (0.11-0.67); mechanical therapy, RR (95% CrI)=0.13 (0.03-0.37)). Combined therapy did not show a statistically significant difference for decreasing the risk of early bleeding compared with injection or mechanical therapies, respectively (combined vs. injection therapy: RR (95% CrI)=0.35 (0.10-1.00); combined vs. mechanical therapy: RR (95% CrI)=0.88 (0.23-3.00)). In cases of delayed bleeding, no type of prophylactic therapy decreased the risk of bleeding compared with no prophylactic therapy. CONCLUSIONS Either mechanical therapy or injection therapy reduced the risk of early postpolypectomy bleeding. As for delayed bleeding, none of the prophylactic therapies was associated with a lower risk of bleeding compared with no prophylactic therapy.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yoon Suk Jung
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Dong Il Park
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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17
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Gómez EJ, Izcovich A. Should prophylactic measures to prevent postpolypectomy bleeding after resection of large colorectal polyps be used? Medwave 2016; 16 Suppl 3:e6496. [PMID: 27513877 DOI: 10.5867/medwave.2016.6496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Post-polypectomy bleeding after colonoscopy with resection of large colorectal polyps can cause significant morbidity (readmission for monitoring, transfusion, repeat endoscopy and therapy) and a significant cost to hospitals and insurers. Nevertheless prophylactic endoscopic measures could reduce risk of post-polypectomy bleeding. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified two systematic reviews including 10 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded prophylactic endoscopic measures could be effective in reducing post-polypectomy bleeding after resection of large colorectal polyps.
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Affiliation(s)
- Estanislao J Gómez
- Servicios de Gastroenterología y Endoscopía Digestiva, Hospital Alemán, Buenos Aires, Argentina; Programa de Medicina Basada en Pruebas, Hospital Alemán, Buenos Aires, Argentina Address: Hospital Alemán de Buenos Aires, Av. Pueyrredon 1640, CP C118AAT, +54114827700.
| | - Ariel Izcovich
- Servicios de Gastroenterología y Endoscopía Digestiva, Hospital Alemán, Buenos Aires, Argentina; Programa de Medicina basada en pruebas, Hospital Alemán, Buenos Aires, Argentina
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18
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Albéniz E, Fraile M, Ibáñez B, Alonso-Aguirre P, Martínez-Ares D, Soto S, Gargallo CJ, Ramos Zabala F, Álvarez MA, Rodríguez-Sánchez J, Múgica F, Nogales Ó, Herreros de Tejada A, Redondo E, Pin N, León-Brito H, Pardeiro R, López-Roses L, Rodríguez-Téllez M, Jiménez A, Martínez-Alcalá F, García O, de la Peña J, Ono A, Alberca de Las Parras F, Pellisé M, Rivero L, Saperas E, Pérez-Roldán F, Pueyo Royo A, Eguaras Ros J, Zúñiga Ripa A, Concepción-Martín M, Huelin-Álvarez P, Colán-Hernández J, Cubiella J, Remedios D, Bessa I Caserras X, López-Viedma B, Cobian J, González-Haba M, Santiago J, Martínez-Cara JG, Valdivielso E, Guarner-Argente C. A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions. Clin Gastroenterol Hepatol 2016; 14:1140-7. [PMID: 27033428 DOI: 10.1016/j.cgh.2016.03.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. METHODS We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. RESULTS Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. CONCLUSIONS The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.
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Affiliation(s)
| | - María Fraile
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Berta Ibáñez
- NavarraBiomed-Fundación Miguel Servet and Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Pamplona, Spain
| | | | | | | | | | | | | | | | - Fernando Múgica
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - Óscar Nogales
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Noel Pin
- Hospital Juan Canalejo, La Coruña, Spain
| | | | | | | | | | | | | | | | | | - Akiko Ono
- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | | | | | | | | | | | | | | | - Mar Concepción-Martín
- Hospital de la Santa Creu y Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Colán-Hernández
- Hospital de la Santa Creu y Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Julyssa Cobian
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | | | - José Santiago
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | - Carlos Guarner-Argente
- Hospital de la Santa Creu y Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Saunders BP, Tsiamoulos ZP. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 2016; 13:486-96. [PMID: 27353401 DOI: 10.1038/nrgastro.2016.96] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.
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Affiliation(s)
- Brian P Saunders
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
| | - Zacharias P Tsiamoulos
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
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20
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Do We Perform a Perfect Endoscopic Hemostasis Prophylactically with Argon Plasma Coagulation in Colonic Endoscopic Mucosal Resection? Dig Dis Sci 2015; 60:3100-7. [PMID: 26065369 DOI: 10.1007/s10620-015-3725-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/15/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Submucosal injection for endoscopic mucosal resection (EMR) may effect performing the prophylactic argon plasma coagulation (APC) of non-bleeding visible vessels on ulcer crater. AIMS The purpose of this study was to evaluate the clinical features of visible vessels in iatrogenic ulcers over time after prophylactic APC in colonic EMR. PATIENTS AND METHODS This study was designed as a prospective study. Between August and November 2013, a total of 40 patients who were admitted underwent prophylactic APC for non-bleeding visible vessels after colonic EMR. After confirming whether visible vessels were completely coagulated or not, the number of visible vessels in ulcers was counted over a specific time period, e.g. 1, 3, 5, or 7 min. RESULTS The mean number of visible vessels was significantly higher at 5 min (0.85 ± 1.14) after EMR with prophylactic APC compared to 1 and 3 min (1 min: 0.28 ± 0.60, P < 0.001; 3 min: 0.65 ± 0.87, P = 0.02) and there was no significant difference between 5 and 7 min (P = 0.31). Multivariate analysis showed that the size of the iatrogenic ulcer after EMR was associated with the occurrence of visible vessels (ulcer size >1 vs. ≤0.5 cm: OR 27.32, 95% CI 2.86-infinity). CONCLUSIONS A 5-min observation of the ulcer may be advantageous for the assessment of visible vessels after performing colonic EMR with prophylactic APC, and large (>1 cm) iatrogenic ulcers were associated with the occurrence of visible vessels after colonic EMR.
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Abstract
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.
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Affiliation(s)
- Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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22
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Bahin FF, Naidoo M, Williams SJ, Hourigan LF, Ormonde DG, Raftopoulos SC, Holt BA, Sonson R, Bourke MJ. Prophylactic endoscopic coagulation to prevent bleeding after wide-field endoscopic mucosal resection of large sessile colon polyps. Clin Gastroenterol Hepatol 2015; 13:724-30.e1-2. [PMID: 25151254 DOI: 10.1016/j.cgh.2014.07.063] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/19/2014] [Accepted: 07/21/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clinically significant postendoscopic mucosal resection bleeding (CSPEB) is the most frequent significant complication of wide-field endoscopic mucosal resection (WF-EMR) of advanced mucosal neoplasia (sessile or laterally spreading colorectal lesions > 20 mm). CSPEB requires resource-intensive management and there is no strategy for preventing it. We investigated whether prophylactic endoscopic coagulation (PEC) reduces the incidence of CSPEB. METHODS We performed a prospective randomized controlled trial of 347 patients (mean age, 67.1 y; 55.3% with proximal colonic lesions) undergoing WF-EMR for advanced mucosal neoplasia at 3 Australian tertiary referral centers. Patients were assigned randomly (1:1) to groups receiving PEC (n = 172) or no additional therapy (n = 175, controls). PEC was performed with coagulating forceps, applying low-power coagulation to nonbleeding vessels in the resection defect. CSPEB was defined as bleeding requiring admission to the hospital. The primary end point was the proportion of CSPEB. RESULTS Patients in each group were similar at baseline. CSPEB occurred in 9 patients receiving PEC (5.2%) and 14 controls (8.0%; P = .30). CSPEB was associated significantly with proximal colonic location on multivariate analysis (odds ratio, 3.08; P = .03). Compared with the proximal colon, there was a significantly greater number (3.8 vs 2.1; P = .002) and mean size (0.5-1 vs 0.3-0.5 mm; P = .04) of visible vessels in the distal colon. CONCLUSIONS PEC does not significantly decrease the incidence of CSPEB after WF-EMR. There were significantly more and larger vessels in the WF-EMR mucosal defect of distal colonic lesions, yet CSPEB was more frequent with proximal colonic lesions. ClinicalTrials.gov NCT01368731.
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Affiliation(s)
- Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mahendra Naidoo
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Donald G Ormonde
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Spiro C Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Bronte A Holt
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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Abstract
The major role of colonoscopy with polypectomy in reducing the incidence of and mortality from colorectal cancer has been firmly established. Yet there is cause to be uneasy. One of the most striking recent findings is that there is an alarmingly high incomplete polyp removal rate. This phenomenon, together with missed polyps during screening colonoscopy, is thought to be responsible for the majority of interval cancers. Knowledge of serrated polyps needs to broaden as well, since they are quite often missed or incompletely removed. Removal of small and diminutive polyps is almost devoid of complications. Cold snare polypectomy seems to be the best approach for these lesions, with biopsy forcep removal reserved only for the tiniest of polyps. Hot snare or hot biopsy forcep removal of these lesions is no longer recommended. Endoscopic mucosal resection and endoscopic submucosal dissection have proven to be effective in the removal of large colorectal lesions, avoiding surgery in the majority of patients, with acceptably low complication rates. Variants of these approaches, as well as new hybrid techniques, are being currently tested. In this paper, we review the current status of the different approaches in removing polypoid and nonpolypoid lesions of the colon, their complications, and future directions in the prevention of colorectal cancer.
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Affiliation(s)
- Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Manol Jovani
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
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24
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Moon HS, Park SW, Kim DH, Kang SH, Sung JK, Jeong HY. Only the size of resected polyps is an independent risk factor for delayed postpolypectomy hemorrhage: a 10-year single-center case-control study. Ann Coloproctol 2014; 30:182-5. [PMID: 25210687 PMCID: PMC4155137 DOI: 10.3393/ac.2014.30.4.182] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 03/24/2014] [Indexed: 02/06/2023] Open
Abstract
Purpose A colonoscopic polypectomy is an important procedure for preventing colorectal cancer, but it is not free from complications. Delayed hemorrhage after a colonoscopic polypectomy is one infrequent, but serious, complication. The aim of this study was to identify the risk factors for delayed hemorrhage after a colonoscopic polypectomy. Methods This was a retrospective case-control study based on medical records from a single gastroenterology center. The records of 7,217 patients who underwent a colonoscopic polypectomy between March 2002 and March 2012 were reviewed, and 92 patients and 276 controls were selected. Data collected included comorbidity, use of antiplatelet agents, size and number of resected polyps, histology and gross morphology of resected polyps, resection method, and use of prophylactic hemostasis. Results The average time between the procedure and bleeding was 2.71 ± 1.55 days. Univariate and multivariate analyses revealed that the size of the polyps was the only and most important predictor of delayed hemorrhage after a colonoscopic polypectomy (odds ratio, 2.06; 95% confidence interval, 1.12-1.27; P = 0.03). Conclusion The size of resected polyps was the only independent risk factor for delayed bleeding after a colonoscopic polypectomy. The size of a polyp, as revealed by the colonoscopic procedure, may aid in making decisions, such as the decision to conduct a prophylactic hemostatic procedure.
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Affiliation(s)
- Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Wook Park
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Dong Hwan Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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25
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Kaimakliotis PZ, Chandrasekhara V. Endoscopic mucosal resection and endoscopic submucosal dissection of epithelial neoplasia of the colon. Expert Rev Gastroenterol Hepatol 2014; 8:521-31. [PMID: 24661135 DOI: 10.1586/17474124.2014.902305] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic mucosal resection (EMR) with curative intent has evolved into a safe and effective technique and is currently the gold standard for management of large colonic epithelial neoplasms. Piecemeal EMR is associated with a high risk of local recurrence requiring vigilant surveillance and repeat interventions. Endoscopic submucosal dissection (ESD) was introduced in Japan for the management of early gastric cancer, and has recently been described for en bloc resection of colonic lesions greater than 20 mm. En bloc resection allows accurate histological assessment of the depth of invasion, minimizes the risk of local recurrence and helps determine additional therapy. Morphologic classification of lesions prior to resection allows prediction of depth of invasion and risk of nodal metastasis, allowing selection of the appropriate intervention. This review provides an overview of the assessment of epithelial neoplasms of the colon and the application of EMR and ESD techniques in their management.
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Affiliation(s)
- Pavlos Z Kaimakliotis
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, PA, USA
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26
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Manejo de la hemorragia digestiva baja aguda: documento de posicionamiento de la Societat Catalana de Digestologia. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:534-45. [DOI: 10.1016/j.gastrohep.2013.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/11/2013] [Indexed: 12/16/2022]
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27
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Kim JH, Lee HJ, Ahn JW, Cheung DY, Kim JI, Park SH, Kim JK. Risk factors for delayed post-polypectomy hemorrhage: a case-control study. J Gastroenterol Hepatol 2013; 28:645-9. [PMID: 23369027 DOI: 10.1111/jgh.12132] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Delayed post-polypectomy hemorrhage is a rare but serious complication. The aim of this study was to identify risk factors for the development of delayed post-polypectomy hemorrhage. METHODS This was a retrospective case-control study of patients who developed delayed hematochezia after receiving colonoscopic polypectomy. The control patients underwent uneventful polypectomy and were selected at a 4:1 ratio. RESULTS Of the 7447 lesions examined from the 3253 patients who received colonoscopic polypectomy, 53 lesions (0.7%) of 42 patients (1.3%) developed delayed hemorrhage, and 168 patients were selected as controls. According to multivariate logistic regression analysis, a polyp larger than 10 mm (odds ratio [OR] 2.355, 95% confidence interval [CI] 1.225-4.528, P = 0.010), a pedunculated polyp (OR 3.473, 95% CI 1.576-7.657, P = 0.002), and a polyp located in the right hemi-colon (OR 2.690, 95% CI 1.465-4.940, P = 0.001) were significant risk factors for delayed post-polypectomy hemorrhage. The presence of comorbidities did not increase the risk of delayed hemorrhage. CONCLUSION Polyp size (large), shape (pedunculated), and location (right hemi-colon) represented substantial risk factors for the development of delayed hemorrhage after colonoscopic polypectomy.
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Affiliation(s)
- Jeong Ho Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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28
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Bae GH, Jung JT, Kwon JG, Kim EY, Park JH, Seo JH, Kim JY. [Risk factors of delayed bleeding after colonoscopic polypectomy: case-control study]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:423-7. [PMID: 22735875 DOI: 10.4166/kjg.2012.59.6.423] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND/AIMS Colonoscopic polypectomy is a valuable procedure for preventing colorectal cancer, but is not without complications. Delayed bleeding after colonoscopic polypectomy is a rare, but serious complication. The aim of this study was to identify risk factors of delayed bleeding after colonoscopic polypectomy. METHODS A retrospective case-control study was conducted in a single university hospital. Forty cases and 120 controls were included. Data collected included comorbidity, use of antiplatelet agents, size and number of resected polyps, histology and gross morphology of resected polyps, endoscopist's experience, resection method, use of sedation, and use of prophylactic hemostasis. RESULTS In univariate analysis, size, histology and number of resected polyps, endoscopist's experience, resection method and use of prophylactic hemostasis were significant risk factors for delayed bleeding after colonoscopic polypectomy. In multivariate analysis, risk of delayed bleeding increased by 11.6% for every 1 mm increase in resected polyp diameter (OR, 1.116; 95% CI 1.041-1.198; p=0.002). Number of resected polyps (OR, 1.364; 95% CI, 1.113-1.671; p=0.003) and endoscopist's experience (OR, 6.301; 95% CI, 2.022-19.637; p=0.002) were significant risk factors for delayed bleeding after colonoscopic polypectomy. CONCLUSIONS Size and numbers of resected polyps, and endoscopist's experience were independent risk factors for delayed bleeding after colonoscopic polypectomy. More caution would be necessary when removing polyps with these factors.
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Affiliation(s)
- Gyu Hwan Bae
- Division of Gastroenterology, Department of Internal Medicine, Catholic University, Daegu College of Medicine, 33, Dooryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea
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29
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Lee SH, Shin SJ, Park DI, Kim SE, Hong SP, Hong SN, Yang DH, Lee BI, Kim YH, Kim HS, Yang SK, Kim HJ, Kim SH, Kim HJ. [Korean guidelines for colonoscopic polypectomy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:85-98. [PMID: 22387834 DOI: 10.4166/kjg.2012.59.2.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There are indirect evidences to suggest that 80% of colorectal cancers (CRC) develop from adenomatous polyps and that, on average, it takes 10 years for a small polyp to transform into invasive CRC. In multiple cohort studies, colonoscopic polypectomy has been shown to significantly reduce the expected incidence of CRC by 76% to 90%. Colonoscopic polypectomy is performed frequently in primary, secondary and tertiary and medical centers in Korea. However, there are no evidence-based, procedural guidelines for the appropriate performance of this procedure, including the technical aspects. For the guideline presented here, Pubmed, Medline, and Cochrane Library literature searches were performed. When little or no data from well-designed prospective trials were available, an emphasis was placed on the results from large series and reports from recognized experts. Thus, these guidelines for colonoscopic polypectomy are based on a critical review of the available data as well as expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data become available. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions for any particular case involve a complex analysis of the patient's condition and the available courses of action.
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Affiliation(s)
- Suck-Ho Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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Postpolypectomy bleeding: incidence, risk factors, prevention, and management. Surg Laparosc Endosc Percutan Tech 2012; 22:102-7. [PMID: 22487620 DOI: 10.1097/sle.0b013e318247c02e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.
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31
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Endoscopic management of gastrointestinal bleeding from multifocal lymphangioendotheliomatosis with thrombocytopenia: limited efficacy and complications. J Pediatr Gastroenterol Nutr 2012; 54:822-4. [PMID: 21788915 DOI: 10.1097/mpg.0b013e31822aa2db] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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32
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Lee SH, Shin SJ, Park DI, Kim SE, Jeon HJ, Kim SH, Hong SP, Hong SN, Yang DH, Lee BI, Kim YH, Kim HS, Kim HJ, Yang SK, Kim HJ. Korean guideline for colonoscopic polypectomy. Clin Endosc 2012; 45:11-24. [PMID: 22741130 PMCID: PMC3363129 DOI: 10.5946/ce.2012.45.1.11] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 02/15/2012] [Accepted: 02/15/2012] [Indexed: 02/07/2023] Open
Abstract
There is indirect evidence to suggest that 80% of colorectal cancers (CRC) develop from adenomatous polyps and that, on average, it takes 10 years for a small polyp to transform into invasive CRC. In multiple cohort studies, colonoscopic polypectomy has been shown to significantly reduce the expected incidence of CRC by 76% to 90%. Colonoscopic polypectomy is performed frequently in primary outpatient clinics and secondary and tertiary medical centers in Korea. However, there are no evidence-based, procedural guidelines for the appropriate performance of this procedure, including the technical aspects. For the guideline presented here, PubMed, Medline, and Cochrane Library literature searches were performed. When little or no data from well-designed prospective trials were available, an emphasis was placed on the results from large series and reports from recognized experts. Thus, these guidelines for colonoscopic polypectomy are based on a critical review of the available data as well as expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data become available. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions for any particular case involve a complex analysis of the patient's condition and the available courses of action.
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Affiliation(s)
- Suck-Ho Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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Abstract
The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.
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Affiliation(s)
- Daniel Blero
- ISPPC, 1 Boulevard Zoé Drion, 6000 Charleroi, Belgium.
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34
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Li LY, Liu QS, Li L, Cao YJ, Yuan Q, Liang SW, Qu CM. A meta-analysis and systematic review of prophylactic endoscopic treatments for postpolypectomy bleeding. Int J Colorectal Dis 2011; 26:709-19. [PMID: 21311892 DOI: 10.1007/s00384-011-1141-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2011] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- L Y Li
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China.
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35
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Raju GS. Complications of endoscopic mucosal resection and endoscopic submucosal dissection. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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36
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Chou KC, Yen HH. Combined endoclip and endoloop treatment for delayed postpolypectomy hemorrhage. Gastrointest Endosc 2010; 72:218-9. [PMID: 20226454 DOI: 10.1016/j.gie.2009.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 11/01/2009] [Indexed: 12/10/2022]
Affiliation(s)
- Kun-Ching Chou
- Department of Gastroenterology, Changhua Christian Hospital, Changhua City, Taiwan
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37
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Treatment of bleeding ulcer. J Clin Gastroenterol 2010; 44:384; author reply 384. [PMID: 20142754 DOI: 10.1097/mcg.0b013e3181ce6071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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38
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Argon Plasma Coagulation in High-risk Bleeding Ulcers. J Clin Gastroenterol 2010. [DOI: 10.1097/mcg.0b013e3181d406f4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
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