The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection

Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial

BACKGROUND AND AIMS

Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR.

METHODS

Flat, 15-50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success.

RESULTS

177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034).

CONCLUSION

Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique.

TRIAL REGISTRATION NUMBER

NCT04138030.

Incomplete mucosal layer excision during EMR: a potential source of recurrent adenoma (with video)

BACKGROUND AND AIMS

Residual or recurrent adenoma (RRA) detected during surveillance is the major limitation of EMR. The pathogenesis of RRA is unknown, although thermal ablation of the post-endoscopic resection defect (PED) margin reduces RRA. We aimed to identify a feature within the PED that could be associated with RRA.

METHODS

Between January 2017 and July 2020, detailed prospective procedural data on all EMR procedures performed at a single center were retrospectively analyzed. At the completion of EMR, the PED was systematically examined for features of incomplete mucosal layer excision (IME). This was defined as a demarcated area within the PED bordered by a white electrocautery ring and containing endoscopically identifiable features suggesting incomplete resection of the mucosa including lacy capillaries and/or visible fibers of the muscularis mucosae. Areas of IME were reinjected and re-excised by snare and submitted separately for blinded specialist GI pathologist review.

RESULTS

EMR was performed for 508 large nonpedunculated colorectal polyps (LNPCPs) (median size, 35 mm). In 10 PEDs (2.0%), an area of IME was identified and excised. Histopathologic examination of areas of suspected IME demonstrated muscularis mucosae in 9 of 10 (90%), residual lamina propria in 9 of 10 (90.0%), and residual adenoma in 5 of 10 (50.0%). No RRA was detected during follow-up after re-excision of IME.

CONCLUSIONS

We report the novel finding of IME within the PED after EMR of LNPCPs. IME may contain microscopic residual adenoma and therefore is a risk for RRA during follow-up. After completion of EMR, the PED should be carefully evaluated. If IME is found, it should be excised. (Clinical trial registration number: NCT01368289 and NCT02000141.).

Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm

Background

Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors.

Summary

A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection.

Key Messages

Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

Short‐term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions

Objectives

Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients.

Methods

Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events.

Results

A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors.

Conclusions

No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.

Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study

BACKGROUND

Iatrogenic colorectal perforation is a rare event with a relevant mortality and the need for surgical therapy in around ¾ of cases.

METHODS

In this retrospective multicentric cohort study iatrogenic colorectal perforations from 2004 to 2021 were analyzed. Primary outcome parameters were incidence and clinical success of 1st line endoscopic treatment. Comparative analysis of interventional and non-interventional perforations was performed and predictors for clinical success of endoscopic therapy were identified.

RESULTS

From 103,570 colonoscopies 213 (0.2%) iatrogenic perforations were identified. 68.4% were interventional (80 during polypectomy/EMR, 54 during ESD and 11 for other reasons) and 31.6% non-interventional perforations (39 by the tip, 19 by the shaft, 7 by inversion, two by biopsy and one by distension). Incidence of 1st line endoscopic therapy was 61.0% and clinical success 81.5%. Other non-surgical therapies were conducted in 8.9% with clinical success in 94.7% of cases. In interventional perforations both incidence and clinical success of 1st line endoscopic therapy were significantly higher compared to non-interventional perforations [71.7% vs. 38.2% (p < 0.01) resp. 86.5% vs. 61.5% (p < 0.01)]. Mortality was 2.3% and significantly lower in the group of interventional perforations (0.7% vs. 5.9%, p = 0.037). Multivariable analysis revealed perforation size < 5 mm as only independent predictor for clinical success of 1st line endoscopic treatment [OR 14.85 (1.57-140.69), p = 0.019].

CONCLUSIONS

Endoscopic therapy is treatment of choice in the majority of iatrogenic colorectal perforations. In case of interventional perforations it is highly effective but only a minority of non-interventional perforations are good candidates for endoscopic treatment.

Colonic Wall Injuries After Endoscopic Resection: Still a Major Complication? A Retrospective Analysis of 3782 Endoscopic Resections

BACKGROUND

Colonic wall injuries are the most feared adverse events of endoscopic resections among endoscopists. The implementation of endoscopic closure has offered a reliable way to treat such injuries and, thus, has decreased their overall morbidity and mortality.

OBJECTIVES

The aim of our study is to assess the characteristics and outcomes of colonic wall injuries after endoscopic resection, focusing on the endoscopic treatment of these injuries.

DESIGN

This was a retrospective cohort study.

SETTINGS

Patients treated in the Central Endoscopy Unit of the Medical Centre Mannheim were included.

PATIENTS

We retrospectively analyzed all patients who underwent endoscopic mucosal resection and snare polypectomy in our center between 2004 and 2019 and isolated the resection-related colonic wall injuries. These were divided into 3 groups: group A, endoscopically treated early colonic wall injuries; group B, nonendoscopically treated early colonic wall injuries; and group C, late perforations.

MAIN OUTCOME MEASURES

Periprocedural factors and treatment outcomes were analyzed and compared among the 3 groups.

RESULTS

Of 3782 endoscopic resections, we identified 177 cases of colonic wall injuries, of which 148 were identified and treated endoscopically (group A), 9 were identified during the procedure but could not be treated endoscopically (group B), and 20 were late perforations (group C). Endoscopic treatment with use of clips had a technical success rate of 94.3%, while the clinical success rate of technically complete endoscopic closure was 92.6%. Twenty-two percent of all colonic wall injuries required surgical treatment; the type and outcomes of surgery were similar in all groups. Overall hospital stay was significantly lower in group A.

LIMITATIONS

The main limitation of the study is its retrospective design.

CONCLUSIONS

Endoscopic closure with the use of clips is a safe and feasible treatment for intraprocedurally identified colonic wall injuries and is associated with significantly decreased necessity of surgery, morbidity, and hospital stay. See Video Abstract at http://links.lww.com/DCR/B755.

LESIONES DE PARED COLNICA POSTERIOR A RESECCIN ENDOSCPICA ES AN UNA COMPLICACIN IMPORTANTE ANLISIS RETROSPECTIVO DE RESECCIONES ENDOSCPICAS

ANTECEDENTES:Las lesiones de la pared del colon son los eventos adversos más temidos por los endoscopistas durante las resecciones endoscópicas. La implementación del cierre endoscópico ha ofrecido una forma confiable de tratar tales lesiones y, por lo tanto, disminuyendo su morbilidad y mortalidad general.OBJETIVOS:El objetivo de nuestro estudio es evaluar las características y resultados de las lesiones de la pared colónica posterior a la resección endoscópica, centrándose en su tratamiento endoscópico.DISEÑO:Es un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Se incluyeron pacientes tratados en la Unidad Central de Endoscopia del Centro Médico de Mannheim.PACIENTES:Se analizaron retrospectivamente todos los pacientes sometidos a resección endoscópica de la mucosa y polipectomía en asa en nuestro centro entre 2004 y 2019, seleccionando las lesiones de la pared colónica relacionadas a la resección. Estas se dividieron en tres grupos: Grupo A: lesiones tempranas de la pared colónica tratadas endoscópicamente; Grupo B: lesiones tempranas de la pared colónica no tratadas endoscópicamente; y Grupo C: perforaciones tardías.PRINCIPALES MEDIDAS DE VALORACION:Se analizaron y compararon los factores relacionados al procedimiento y los resultados del tratamiento entre los tres grupos.RESULTADOS:De 3782 resecciones endoscópicas identificamos 177 casos de lesiones de la pared colónica, de los cuales 148 fueron identificados y tratados endoscópicamente (Grupo A), 9 fueron identificados durante el procedimiento pero no pudieron ser tratados endoscópicamente (Grupo B) y 20 fueron perforaciones tardías. (Grupo C). El tratamiento endoscópico con el uso de clips tuvo una tasa de éxito técnico del 94,3%, mientras que la tasa de éxito clínico del cierre endoscópico técnicamente completo fue del 92,6%. El veintidós por ciento de todas las lesiones de la pared colónica requirieron tratamiento quirúrgico; el tipo y los resultados de la cirugía fueron los mismos en todos los grupos. La estancia hospitalaria global fue significativamente menor en el grupo A.LIMITACIONES:La principal limitación del estudio es su diseño retrospectivo.CONCLUSIONES:El cierre endoscópico con el uso de clips es un tratamiento seguro y factible para las lesiones de la pared colónica identificadas durante el procedimiento y se asocia con una disminución significativa de la necesidad de cirugía, morbilidad y de estancia hospitalaria. Consulte Video Resumen en http://links.lww.com/DCR/B755.

Polypectomy for Large Polyps with Endoscopic Mucosal Resection

Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.

Current endoscopic closure techniques for the management of gastrointestinal perforations

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes.

Outcomes of Deep Mural Injury After Endoscopic Resection: An International Cohort of 3717 Large Non-Pedunculated Colorectal Polyps

BACKGROUND & AIMS

Although perforation is the most feared adverse event associated with endoscopic mucosal resection (EMR), limited data exists concerning its management. Therefore, we sought to evaluate the short- and long-term outcomes of intra-procedural deep mural injury (DMI) in an international multi-center observational cohort of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs).

METHODS

Consecutive patients who underwent EMR for a LNPCP ≥20 mm were evaluated. Significant DMI (S-DMI) was defined as Sydney DMI Classification type III (muscularis propria injury, target sign) or type IV/V (perforation without or with contamination, respectively). The primary outcome was successful S-DMI defect closure. Secondary outcomes included technical success (removal of all visible polypoid tissue during index EMR), surgical referral and recurrence at first surveillance colonscopy (SC1).

RESULTS

Between July 2008 to May 2020, 3717 LNPCPs underwent EMR. Median lesion size was 35mm (interquartile range (IQR) 25 to 45mm). Significant DMI was identified in 101 cases (2.7%), with successful defect closure in 98 (97.0%) using a median of 4 through-the-scope clips (TTSCs; IQR 3 to 6 TTSCs). Three (3.0%) patients underwent S-DMI-related urgent surgery. Technical success was achieved in 94 (93.1%) patients, with 46 (45.5%) admitted to hospital (median duration 1 day; IQR 1 to 2 days). Comparing LNPCPs with and without S-DMI, no differences in technical success (94 (93.1%) vs 3316 (91.7%); P = .62) or SC1 recurrence (12 (20.0%) vs 363 (13.6%); P = .15) were identified.

CONCLUSIONS

Significant DMI is readily managed endoscopically and does not appear to affect technical success or recurrence.

Endoscopic mucosal resection of colorectal polyps: results, adverse events and two-year outcome

Background and study aims

Endoscopic mucosal resection (EMR) is the first-line treatment for large sessile and flat colorectal polyps in Western centres, however recurrence after EMR continues to be a challenge. The aim of this study is to assess efficacy, safety and recurrence rate of EMR in a tertiary centre and to identify risk factors for recurrence at first surveillance endoscopy (SE1).

Patients and methods

We performed a retrospective study of 165 sessile and flat colorectal lesions ≥15 mm, treated by EMR between 2017-2019. We used multivariate logistic regression to identify independent risk factors for recurrence at SE1.

Results

EMR was performed for 165 colorectal polyps in 142 patients with technical success in 158 cases (95,2%). SE1 data for 117 of 135 eligible cases (86,7%) showed recurrent adenoma in 19 cases (16,2%) after a median time of 6,2 months (IQR 5-9,9). This was primarily treated endoscopically (78,9%). Independent risk factors for recurrence at SE1 were lesion size ≥40 mm (OR 4,03; p=0,018) and presence of high-grade dysplasia (HGD) (OR 3,89; p=0,034). Early adverse event occurred in 4 patients (2,4%), with 3 bleeding complications and one perforation. Twelve patients (7,2%) presented with delayed bleeding of which 3 required transfusion, with radiological intervention in one case. All other complications were managed either conservatively (n=8) or endoscopically (n=5).

Conclusions

EMR is a safe and effective treatment for large sessile and flat colorectal lesions with low recurrence rates. Lesion size ≥40 mm and presence of HGD were identified as risk factors for early recurrence, highlighting the importance of compliance to follow-up in these cases.

Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video)

BACKGROUND AND AIMS

The endoscopic management of large nonpedunculated colorectal polyps involving the ileocecal valve (ICV-LNPCPs) remains challenging because of its unique anatomic features, with long-term outcomes inferior to LNPCPs not involving the ICV. We sought to evaluate the impact of technical innovations and advances in the EMR of ICV-LNPCPs.

METHODS

The performance of EMR for ICV-LNPCPs was retrospectively evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by clinical success (removal of all polypoid tissue during index EMR and avoidance of surgery) and recurrence at first surveillance colonoscopy. Accounting for the adoption of technical innovations, comparisons were made between an historical cohort (September 2008 to April 2016) and contemporary cohort (May 2016 to October 2020). Safety was evaluated by documenting the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury, and delayed perforation.

RESULTS

Between September 2008 to October 2020, 142 ICV-LNPCPs were referred for EMR. Median ICV-LNPCP size was 35 mm (interquartile range, 25-50 mm). When comparing the contemporary (n = 66) and historical cohorts (n = 76) of ICV-LNPCPs, there were significant differences in clinical success (93.9% vs 77.6%, P = .006) and recurrence (4.6% vs 21.0%, P = .019).

CONCLUSIONS

With technical advances, ICV-LNPCPs can be effectively and safely managed by EMR, independent of lesion complexity. Most patients experience excellent outcomes and avoid surgery.

Prophylactic clipping after endoscopic mucosal resection of large nonpedunculated colorectal lesions: A meta-analysis

BACKGROUND AND AIM

It is not clear whether prophylactic clipping after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions (LNPCLs) prevents delayed bleeding (DB). We aimed to conduct a meta-analysis to clarify the efficacy of prophylactic clipping in prevention of DB following EMR of LNPCLs.

METHODS

We searched PubMed, EMBASE, Web of Science, ScienceDirect, Cochrane Library databases, and ClinicalTrials.gov for studies that compared clipping versus (vs) nonclipping in prevention of DB following EMR of LNPCLs. Pooled odds ratio (OR) was determined using a random effects model. The pooled ORs of DB, perforation, and post-polypectomy syndrome in the clipping group compared with the nonclipping group comprised the outcomes. Subgroup analyses based on study design, polyp location, and completeness of wound closure were performed.

RESULTS

Five studies with a total of 3112 LNPCLs were extracted. Prophylactic clipping reduced the risk of DB compared with nonclipping (3.3% vs 6.2%, OR: 0.494, P = 0.002) following EMR of LNPCLs. In subgroup analysis, prophylactic clipping reduced DB of LNPCLs at proximal location (3.8% vs 9.8%, P = 0.029), but not of them at distal location (P = 0.830). Complete wound closure showed superior efficacy to prevent DB compared with partial closure (2.0% vs 5.4%, P = 0.004). No benefit of clipping for preventing perforation or post-polypectomy syndrome was observed (P = 0.301 and 0.988, respectively).

CONCLUSIONS

Prophylactic clipping can reduce DB following EMR of LNPCLs at proximal location. Besides, complete wound closure showed superior efficacy to prevent DB compared with partial closure. Further cost analyses should be conducted to implement the most cost-effective strategies.

Underwater Endoscopic Mucosal Resection for 10 mm or Larger Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis

Background/Aims

Recent studies have reported the favorable outcomes of underwater endoscopic mucosal resection (UEMR) for colorectal polyps. We performed a systematic review and meta-analysis evaluating the efficacy and safety of UEMR for nonpedunculated polyps ≥10 mm.

Methods

We performed a comprehensive search of multiple databases (through May 2020) to identify studies reporting the outcomes of UEMR for ≥10 mm nonpedunculated colorectal polyps. The assessed outcomes were recurrence rate on the first follow-up, en bloc resection, incomplete resection, and adverse events after UEMR.

Results

A total of 1276 polyps from 16 articles were included in our study. The recurrence rate was 7.3% (95% confidence interval [CI], 4.3–12) and 5.9% (95% CI, 3.6–9.4) for nonpedunculated polyps ≥10 and ≥20 mm, respectively. For nonpedunculated polyps ≥10 mm, the en bloc resection, R0 resection, and incomplete resection rates were 57.7% (95% CI, 42.4–71.6), 58.9% (95% CI, 42.4–73.6), and 1.5% (95% CI, 0.8–2.6), respectively. The rates of pooled adverse events, intraprocedural bleeding, and delayed bleeding were 7.0%, 5.4%, and 2.9%, respectively. The rate of perforation and postpolypectomy syndrome was 0.8%.

Conclusions

Our systematic review and meta-analysis demonstrates that UEMR for nonpedunculated colorectal polyps ≥10 mm is safe and effective with a low rate of recurrence.

Endoscopic polypectomy devices

Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.

Cold or Hot Snare with Endoscopic Mucosal Resection for 6-9 mm Colorectal Polyps: A Propensity Score Matching Analysis

Objective: To investigate the efficacy and safety of cold snare endoscopic mucosal resection (CS-EMR) and hot snare endoscopic mucosal resection (HS-EMR) for colorectal polyps with diameters of 6-9 mm. Methods: Retrospective analysis was performed on the clinical data of 485 patients with colorectal polyps (6-9 mm in size) who were treated with CS-EMR or HS-EMR in the endoscopy center of Hangzhou Third People's Hospital from January 2017 to December 2019. Colorectal polyps were lifted by submucosal injection of normal saline. The CS-EMR group used a cold snare to remove the lifting polyps, while the HS-EMR group used a hot snare. Propensity score matching analysis with 1:1 matching and the nearest neighbor matching method were performed to ensure well-balanced characteristics of the CS-EMR and HS-EMR groups. Matching factors included age, gender, body mass index, blood routine, coagulation indicators, polyp site, size, number, and morphology. This resulted in a balanced cohort of 128 patients per group. Polyp recovery, complications, clipping for disclosure, and length of hospital stay were compared after matching. t-Tests, χ² tests, McNemar's tests, and Fisher's exact test were used for comparison between the two groups before and after matching. Results: There were no differences between the two groups of intraoperative and postoperative bleeding (P > .05), but the CS-EMR clipping rate was lower than the HS-EMR group (P < .01). There was a higher incidence of post-polypectomy syndrome (PPS) (P = .03) and longer hospital stays (P < .01) in the HS-EMR group than the CS-EMR group. Conclusions: Compared with HS-EMR, CS-EMR is more convenient to operate, with a low incidence of PPS, clipping rates, and short hospital stays. It is a safe and effective removal method for 6-9 mm colorectal polyps.

Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD)

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation.

AREAS COVERED

This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing.

EXPERT OPINION

As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video)

BACKGROUND AND AIMS

Conventional EMR using a hot snare is the standard of care for resection of large (≥20 mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly because of electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). This study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized ≥20 mm.

METHODS

All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps ≥20 mm over a 2-year period, from January 2016 to December 2017, were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records.

RESULTS

CSP-EMR was performed on 204 polyps sized ≥20 mm in 186 patients (men, 33.8%; median age, 68 years). SC1 for 164 polyps (80.4%) at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% confidence interval, 3%-11%). SC2 for 113 polyps (72.9%) at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% confidence interval, .9%-8.5%) after a normal SC1. Intraprocedural bleeding was successfully treated in 4 patients (2.2%), whereas 7 patients (3.8%) experienced self-limited clinically significant post-EMR bleeding and 1 patient (.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events.

CONCLUSIONS

CSP-EMR of sessile colonic polyps ≥20 mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR and to further determine the polyp morphologies that are best suited for CSP-EMR.

First case of paralytic ileus after endoscopic mucosal resection of caecal polyp

Endoscopic mucosal resection (EMR) is a technique developed for the removal of sessile or flat neoplastic lesions confined to the superficial layers (mucosa and submucosa) of the gastrointestinal tract. Bleeding and perforation are well-known complications of EMR. Here we report the first case of paralytic ileus after EMR of a caecal polyp. A 66-year-old man was scheduled for elective EMR of a 3.5-cm caecal polyp under general anaesthesia after a screening colonoscopy. The procedure was performed by an expert endoscopist, and air was insufflated during the procedure because of the unavailability of CO₂. The polyp was successfully removed; the procedure duration was 81 min. After the procedure, the patient complained of abdominal pain and dyspnoea. He developed tachypnoea and tachycardia as well as oxygen desaturation with SpO₂ 84%. He was administered oxygen therapy via a non-rebreather mask, following which his oxygenation improved. His abdominal X-ray findings were consistent with ileus. Therefore, a nasogastric tube was placed, and the patient was admitted to our hospital. He was managed conservatively and underwent serial abdominal X-rays that showed improvement of the ileus. On the fourth day of admission, he was started on an oral diet; on the sixth day of admission, he was discharged with resolving ileus. Computed tomography enterography performed 1 week after discharge showed complete resolution of the ileus. Factors that may have contributed to the occurrence of ileus in our patient include the use of air during the procedure, location of the polyp (caecal), duration of the procedure, effect of electrocautery, use of general anaesthesia and possibility of aspiration pneumonitis. This case report will make endoscopists aware of the abovementioned factors while performing EMR as this procedure can lead to the complication of paralytic ileus with significant patient morbidity. Conservative treatment should be attempted first before any other intervention.

Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction

OBJECTIVE

The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs.

DESIGN

EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC).

RESULTS

Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027).

CONCLUSION

EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.

Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract

Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.

The Use of the Overstitch to Close Endoscopic Resection Defects

Endoscopic resection of luminal gastrointestinal neoplasia offers a minimally invasive, lower risk alternative that can be successful in the appropriate setting. Bleeding and perforation can occur with endoscopic mucosal resection and endoscopic submucosal dissection. Defect closure with conventional endoclips or modified technique using endoloops can decrease the risk of adverse events. The Overstitch (Apollo Endosurgery, Austin, TX) endoscopic suturing device is designed for tissue apposition and thus can effectively close a large resection defect. Herein we describe our technique. Our and other groups' initial experience with suturing for closure of the resection defect demonstrates high procedural success rates and safety.

Sealing the hole: endoscopic management of acute gastrointestinal perforations

Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal (GI) endoscopy. The incidence rate varies according to the type of procedure and the anatomical location within the GI tract. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the reduction of the burden of surgery. Various devices are available now such as through-the-scope clips, over-the-scope clips, endoscopic suturing devices, stents, bands and omental patch. All have been tested in studies done on humans or animal models, with a reasonable overall technical and clinical success rate, proving efficiency and feasibility of endoscopic closure. The choice of which device to use depends on the site and the size of the perforation. It also depends on availability of thee device and the endoscopist's experience. A number of factors that could predict success of endoscopic closure or favour surgical treatment have been suggested in different studies. After successful endoscopic closure, patients are usually kept nil by mouth and receive antibiotics for a duration that varied between different studies.

ASGE review of adverse events in colonoscopy

Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.

Lesion Retrieval, Specimen Handling, and Endoscopic Marking in Colonoscopy

Retrieval of lesions after endoscopic polypectomy enables histopathologic analysis and guides future surgical management and endoscopic surveillance intervals. Various techniques and devices have been described with distinct advantages and disadvantages to accomplish retrieval. Appropriate histopathologic analysis depends on lesion handling and preparation. How lesions are handled further depends on size, endoscopic appearance, and removal technique. Endoscopic marking or tattooing is a well-described process that uses dye mediums to leave longstanding marks in the colon. Techniques, dye mediums, and locations within the colon influence tattoo approach.

Closure of Defects and Management of Complications

Large and complex colon polyps are frequently referred to surgery for fear of perforation that may need emergency surgery. During the last 15 years, advances in clip and suturing devices allowed us to close perforations and avoid surgery. In addition, we have made substantial progress in our understanding of the lesions at risk for either immediate or delayed perforation. This article focuses on the colonoscopic closure of resection defects and perforations and the prevention and treatment of colon perforations after endoscopic resection.

Management of colonoscopic perforation: a systematic review and treatment algorithm

BACKGROUND

The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm.

METHODS

Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review.

RESULTS

A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair.

CONCLUSION

Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.

Complications of cold versus hot snare polypectomy of 10-20 mm polyps: A retrospective cohort study

Background and Aim

Cold snare polypectomy is safe and efficacious for removing polyps <10 mm with reduced rates of delayed postpolypectomy bleeding and postpolypectomy syndrome. This technique can also be used for sessile polyps ≥10 mm; however, further evidence is required to establish its safety. The aim of this study was to compare intraprocedure and postprocedure adverse events in patients who underwent cold (CSP) versus hot snare polypectomy (HSP) of 10-20 mm sessile colonic polyps.

Methods

Electronic medical records and endoscopy reports of all patients who underwent polypectomy for Paris 0-IIa, Is, or 0-IIa + Is 10-20 mm colonic polyps between January 2015 and June 2017 at three tertiary academic hospitals and one private hospital were retrospectively reviewed. Data on patient demographics, polyp characteristics, method of polypectomy, and intraprocedural and postpolypectomy adverse events were collected.

Results

A total of 408 patients (median age 67, 50% male) had 604 polyps, 10-20 mm in size, removed. Of these, 258 polyps were removed by HSP, with a median size of 15 mm (interquartile range [IQR] 12-20), compared to 346 polyps that were removed by CSP, with median size of 12 mm (IQR 10-15), P < 0.001. In the HSP group, 15 patients presented with postprocedure complications, including 11 with clinically significant bleeding, 2 with postpolypectomy syndrome, and 2 with abdominal pain. This compares with no postpolypectomy complications in the CSP group, P < 0.001.

Conclusion

In this study, CSP was not associated with any postpolypectomy adverse events. CSP appears to be safer than HSP for removing 10-20 mm-sized sessile polyps. A prospective multicenter study has been commenced to verify these findings and to assess the efficacy of CSP for the complete resection of polyps of this size.

Endoscopic Management of Iatrogenic Colon Perforation

Colon perforations are difficult to resolve because they occur unexpectedly and infrequently. If the clinician is unprepared or lacks training in dealing with perforations, the clinical prognosis will be affected, which can lead to legal issues. We describe here the proper approach to the management of perforations, including deciding on endoscopic or surgical treatment, selection of endoscopic devices, endoscopic closure procedures, and general management of perforations that occur during diagnostic or therapeutic colonoscopy.

A systematic description of the post-EMR defect to identify risk factors for clinically significant post-EMR bleeding in the colon

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.).

The importance of early recognition in management of ERCP-related perforations

BACKGROUND

Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare events, carrying with it a mortality of up to 8%. Given the rarity of this adverse event, there remains limited data and continued uncertainties when choosing therapeutic strategies. Our aims were to evaluate the management of ERCP-related perforations and compare outcomes based on timing of recognition.

METHODS

The endoscopic databases of two tertiary care centers were interrogated to identify consecutive adult patients who sustained ERCP-related perforation over a 10-year period from 2006 to 2016. Electronic medical records were reviewed to extract demographic data, perforation type, management strategies, clinical data, and patient outcomes.

RESULTS

14,045 ERCP's were performed during our 10-year study period. Sixty-three patients (average age 62.3 ± 2.38 years, 76% female) with ERCP-related perforations were included. Stapfer I perforations were found in 14 (22.2%) patients, Stapfer II in 24 (38.1%), and Stapfer III and IV perforations were identified in 16 (25.4%) and 9 (14.28%), respectively. Forty-seven (74.6%) perforations were recognized immediately during the ERCP, whereas 16 (25.4%) were recognized late. Endoscopic therapy was attempted in 35 patients in whom perforations were identified immediately, and was technically successful in 33 (94.3%). In all, 4 (1 immediate/ 3 delayed) patients required percutaneous drainage and 9 (5 immediate/ 4 delayed) surgery. Length of hospital stay, ICU admission were significantly shorter and incidence of SIRS was significantly lower when perforation was recognized immediately.

CONCLUSIONS

Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.

Advances in CRC Prevention: Screening and Surveillance

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

Colorectal endoscopic mucosal resection (EMR)

Colonoscopy has the benefit of detecting and treating precancerous adenomatous polyps and thus reduces mortality associated with CRC. Screening colonoscopy is the keystone for prevention of colorectal cancer. Over the last 20 years there has been increased in the management of large colorectal polyps from surgery to endoscopic removal techniques which is less invasive. Traditionally surgical resection was the treatment of choice for many years for larger polyps but colectomy poses significant morbidity of 14-46% and mortality of up to 7%. There are several advantages of endoscopic resection technique over surgery; it is less invasive, less expensive, has rapid recovery, and preserves the normal gut functions. In addition patient satisfaction and efficacy of EMR is higher with minor complications. Thus, this has facilitated the development of advanced resection technique for the treatment of large colorectal polyps called as endoscopic mucosal resection (EMR).

Standardisation of polypectomy technique

There are several approaches to polypectomy for sessile polyps <20 mm and for pedunculated polyps. Recent evidence is leading towards standardisation of polypectomy technique. Key recent polypectomy developments include: 1. Use of cold snare polypectomy (CSP) for sessile polyps <10 mm; 2. Use of hot snare polypectomy (HSP) following submucosal injection for sessile polyps sized 10-19 mm; 3. Piecemeal cold snare polypectomy (PCSP), with or without prior submucosal injection, for select sessile polyps sized 10-19 mm, where the potential risk for an adverse event is increased (e.g. polyps in the caecum or ascending colon, or patients with increased risk of post-polypectomy bleeding), and where the risk of submucosal invasion is low; 4. Avoidance of hot biopsy forceps (HBF); 5. Limiting the use of cold biopsy forceps (CBF) to the smallest of diminutive polyps, where CSP is not feasible; 6. Mechanical haemostasis prior to polypectomy for large pedunculated polyps with head ≥20 mm or stalk ≥10 mm.

Optimizing Resection of Large Colorectal Polyps

OPINION STATEMENT

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

Extended endoscopic mucosal resection does not reduce recurrence compared with standard endoscopic mucosal resection of large laterally spreading colorectal lesions

BACKGROUND AND AIMS

Effective interventions to prevent residual and/or recurrent adenoma (RRA) after EMR of large sessile and laterally spreading colorectal lesions (LSL) are yet to be determined. RRA may occur due to inconspicuous adenoma at the EMR margin. We aimed to determine the efficacy and safety of extended EMR (X-EMR) compared with standard EMR (S-EMR).

METHODS

A single-center post hoc analysis of LSL ≥20 mm referred for treatment was performed. S-EMR was the standard sequential inject and resect method including a 1-mm to 2-mm margin of normal mucosa around the lesion. With X-EMR, at least a 5-mm margin of normal mucosa was excised. Patient and lesion characteristics and procedural outcomes were recorded. The primary endpoint was RRA at first surveillance colonoscopy at 4 months.

RESULTS

Between January 2009 and May 2011, 471 lesions (mean size, 37.9 mm) in 424 patients were resected by S-EMR, and between January 2012 and December 2013, 448 lesions (mean size, 39.1 mm) in 396 patients were resected by X-EMR. Resection was successful in 92.3% and 92.6% of referred lesions in the S-EMR and X-EMR groups, respectively (P = .978). X-EMR was independently associated with a higher risk of intraprocedural bleeding (IPB) (odds ratio, 3.1; 95% confidence interval [CI], 2.0-5.0; P < .001) but not other adverse events. RRA was present in 39 of 333 patients (11.7%) and 30 of 296 patients (10.1%) in the S-EMR and X-EMR groups, respectively (P = .15). X-EMR was not related to recurrence (hazard ratio, 0.8; 95% CI, 0.5-1.3; P = .399).

CONCLUSIONS

X-EMR does not reduce RRA and increases the risk of IPB compared with S-EMR. Alternative methods for the prevention of RRA are required.

Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon

Endoscopic resection (ER), including endoscopic polypectomy (EP), endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are used to remove superficial neoplasms from the colon. Snare resection is used for EP and EMR, whereas endoscopic knives are used to perform dissection in the submucosal space in ESD. 80-90% colonic polyps are <10 millimetres (mm) and are effectively managed by conventional EP. Increasingly cold snare polypectomy is preferred. Large laterally spreading lesions (LSLs) and sessile polyps ≥20 mm are primarily removed by EMR. ESD may be used when superficial invasive disease is suspected and for some LSLs, particularly non-granular subtypes. Resection of colonic lesions by ER is associated with a small but definite incidence of significant complications, most commonly bleeding and perforation. This review discusses complications of ER with a particular focus on their prevention, early recognition and management. In many cases, complications from all three procedures share similar mechanisms and management principles and these are described at the start of each section, followed by a description of specific aspects for individual procedures.

Endoscopic management of colonic perforations: clips versus suturing closure (with videos)

BACKGROUND AND AIMS

Perforation during colonoscopy remains the most worrisome adverse event and usually requires urgent surgical rescue. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic closure of full-thickness colonic perforations.

METHODS

We performed a retrospective analysis of all consecutive patients with endoscopically closed colonic perforations over the past 6 years (2009-2014). Colonic perforations were closed by using endoscopic clips or an endoscopic suturing device. Most patients were admitted for treatment with intravenous antibiotics and kept on bowel rest. If their clinical condition deteriorated, urgent surgery was performed. If patients remained stable, oral feeding was resumed, and patients were discharged with subsequent clinical and endoscopic follow-up.

RESULTS

Twenty-one patients had iatrogenic colonic perforations closed with an endoscopic suturing device or endoscopic clips during the study period. Primary closure of a colonic perforation was performed with endoscopic clips in 5 patients and sutured with an endoscopic suturing device in 16 patients. All 5 patients after clip closure had worsening of abdominal pain and required laparoscopy (4 patients) or rescue colonoscopy with endoscopic suturing closure (1 patient). Two patients had abdominal pain after endoscopic suturing closure, but diagnostic laparoscopy confirmed complete and adequate endoscopic closure of the perforations. The other 15 patients did not require any rescue surgery or laparoscopy after endoscopic suturing. The main limitation of our study is its retrospective, single-center design and relatively small number of patients.

CONCLUSION

Endoscopic suturing closure of colonic perforations is technically feasible, eliminates the need for rescue surgery, and appears more effective than closure with hemostatic endoscopic clips.