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Imai K, Hotta K, Ito S, Kishida Y, Takada K, Suwa T, Ashizawa H, Minamide T, Yamamoto Y, Yoshida M, Maeda Y, Kawata N, Sato J, Ishiwatari H, Matsubayashi H, Oishi T, Sugino T, Mori K, Ono H. A novel low-power pure-cut hot snare polypectomy for 10-14 mm colorectal adenomas: An ex vivo and a clinical prospective feasibility study (SHARP trial). J Gastroenterol Hepatol 2024; 39:667-673. [PMID: 38149747 DOI: 10.1111/jgh.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/10/2023] [Accepted: 12/03/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIM Hot snare polypectomy using blend or coagulation current is widely used; however, it causes deeper tissue heat injury, leading to adverse events. We hypothesized that hot polypectomy using low-power pure cut current (PureCut, effect 1 10 W) could reduce deeper tissue heat injury. We conducted animal experiments to evaluate the deeper tissue heat injury and conducted a prospective clinical study to examine its cutting ability. METHODS In a porcine rectum, hot polypectomy using Blend current (EndoCut, effect 3 40 W) and low-power pure cut current was performed. The deepest part of heat destruction and thickness of the non-burned submucosal layer were evaluated histologically. Based on the results, we performed low-power pure cut current hot polypectomy for 10-14 mm adenoma. The primary endpoint was complete resection defined as one-piece resection with negative for adenoma in quadrant biopsies from the defect margin. RESULTS In experiments, all low-power pure-cut resections were limited within the submucosal layer whereas blend current resections coagulated the muscular layer in 13% (3/23). The remaining submucosal layer was thicker in low-power pure cut current than in blend current resections. In the clinical study, low-power pure-cut hot polypectomy removed all 100 enrolled polyps. For 98 pathologically neoplastic polyps, complete resection was achieved in 84 (85.7%, 95% confidence interval, 77-92%). The lower limit of the 95% confidence interval was not more than 15% below the pre-defined threshold of 86.6%. No severe adverse events occurred. CONCLUSIONS A novel low-power pure-cut hot polypectomy may be feasible for adenoma measuring 10-14 mm. (UMIN000037678).
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Kazunori Takada
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Tetsuya Suwa
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Hiroshi Ashizawa
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Tatsunori Minamide
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Yoichi Yamamoto
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Yuki Maeda
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | | | | | - Takuma Oishi
- Division of Pathology, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Takashi Sugino
- Division of Pathology, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
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Attree C, Ogra R, Yusoff IF, Moss AC, Jacques A, Brown G, Alexander S, Efthymiou M, Raftopoulos S. Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial. JGH Open 2024; 8:e13052. [PMID: 38533237 PMCID: PMC10964916 DOI: 10.1002/jgh3.13052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/28/2024]
Abstract
Background and Aim Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed. Methods Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months. Results From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition. Conclusion Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.
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Affiliation(s)
- Chloe Attree
- GastroenterologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Ravinder Ogra
- GastroenterologyMiddlemore HospitalAucklandNew Zealand
| | - Ian F Yusoff
- GastroenterologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
- GastroenterologyHollywood Private HospitalNedlandsWestern AustraliaAustralia
- Medical School, University of Western AustraliaNedlandsWestern AustraliaAustralia
| | - Alan C Moss
- GastroenterologyWestern HealthMelbourneVictoriaAustralia
| | - Angela Jacques
- GastroenterologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
- University of Notre DameFremantleWestern AustraliaAustralia
| | - Gregor Brown
- GastroenterologyAlfred HospitalRichmondVictoriaAustralia
| | - Sina Alexander
- GastroenterologySt John of God HospitalGeelongVictoriaAustralia
| | - Marios Efthymiou
- GastroenterologyAustin HealthHeidelbergVictoriaAustralia
- Medical School, University of MelbourneMelbourneVictoriaAustralia
| | - Spiro Raftopoulos
- GastroenterologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
- GastroenterologyHollywood Private HospitalNedlandsWestern AustraliaAustralia
- Medical School, University of Western AustraliaNedlandsWestern AustraliaAustralia
- Curtin Medical School, Curtin UniversityBentleyWestern AustraliaAustralia
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Tate DJ, Desomer L, Argenziano ME, Mahajan N, Sidhu M, Vosko S, Shahidi N, Lee E, Williams SJ, Burgess NG, Bourke MJ. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72:1875-1886. [PMID: 37414440 DOI: 10.1136/gutjnl-2023-330300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort. DESIGN Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two. RESULTS 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up. CONCLUSIONS RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases. TRIAL REGISTRATION NUMBERS NCT01368289 and NCT02000141.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Maria Eva Argenziano
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
| | - Neha Mahajan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Attard TM, Cohen S, Durno C. Polyps and Polyposis Syndromes in Children: Novel Endoscopic Considerations. Gastrointest Endosc Clin N Am 2023; 33:463-486. [PMID: 36948756 DOI: 10.1016/j.giec.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Polypectomy is the most common therapeutic endoscopic intervention in children. Management of sporadic juvenile polyps is limited to polypectomy to resolve symptoms, whereas polyposis syndromes pose a multidisciplinary challenge with broader ramifications. In preparation for polypectomy, there are key patient, polyp, endoscopy unit, and provider characteristics that factor into the likelihood of success. Younger age and multiple medical comorbidities increase the risk of adverse outcomes, classified as intraoperative, immediate postoperative, and delayed postoperative complications. Novel techniques, including cold snare polypectomy, can significantly decrease adverse events but a more structured training process for polypectomy in pediatric gastroenterology is needed.
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Affiliation(s)
- Thomas M Attard
- Division of Gastroenterology, Hepatology and Nutrition, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; The University of Missouri in Kansas City School of Medicine, Kansas City, MO, USA.
| | - Shlomi Cohen
- Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carol Durno
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; The Zane Cohen Centre for Digestive Diseases, 60 Murray Street, Toronto, Ontario M5T 3L9, Canada; Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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5
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Moon JY, Lee MR, Yim SK, Ha GW. Colo-colonic intussusception with post-polypectomy electrocoagulation syndrome: A case report. World J Clin Cases 2022; 10:8939-8944. [PMID: 36157670 PMCID: PMC9477040 DOI: 10.12998/wjcc.v10.i25.8939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 07/25/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Post-polypectomy electrocoagulation syndrome (PPES) can occur after colonoscopic polypectomy and is usually treated conservatively with a positive prognosis. Nevertheless, there can be cases with complications developing.
CASE SUMMARY A 58-year-old woman, who had no previous medical history, visited the Emergency Department of another hospital with symptoms of abdominal pain and fever, 1 d after multiple colonoscopic polypectomies. An abdominopelvic computed tomography (CT) scan demonstrated colo-colonic intussusception, and she was transferred to our hospital to consider an operation. CT showed colo-colonic intussusception with PPES and no evidence of obstruction. The physical examination showed localized mild tenderness on the right sided abdomen. The patient fasted and was admitted for treatment with intravenous antibiotics (piperacillin/tazobactam 4.5 g each 8 h, ornidazole 500 mg each 12 h). After admission, the symptoms got better and a follow-up CT scan demonstrated resolution of the PPES and intussusception. The patient was discharged on hospital day 9.
CONCLUSION Colo-colic intussusception can occur with PPES, and it can be properly treated conservatively.
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Affiliation(s)
- Jae Young Moon
- Department of Surgery, Jeonbuk National University Hospital, Jeonju 561-180, Jeonbuk, South Korea
| | - Min-Ro Lee
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 561-180, Jeonbuk, South Korea
| | - Sung Kyun Yim
- Department of Internal Medicine, Biomedical Research Institute, Jeonbuk National University Hospital and Medical School, Jeonju 54907, Jeonbuk, South Korea
| | - Gi Won Ha
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 561-180, Jeonbuk, South Korea
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Mi B, Wang H, Liu C, Wang Q, Fu X, Wang Z, Liu F, Li W. Endoscopic follow-up of mucosal defect after hot versus cold snare polypectomy in animal model. J Gastroenterol Hepatol 2022; 37:1090-1095. [PMID: 35234317 DOI: 10.1111/jgh.15811] [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: 11/27/2021] [Revised: 01/11/2022] [Accepted: 02/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Cold snare polypectomy (CSP) has received increasing attention in recent years, but few studies have assessed defect repair after polypectomy. Therefore, we compared the repair of mucosal defect after CSP and hot snare polypectomy (HSP) in a rabbit model. METHODS Resection of normal colonic mucosa using both HSP and CSP were performed in 40 male New Zealand white rabbits by an experienced endoscopist. Follow-up colonoscopy was performed after 7 and 15 days by another endoscopist. We assessed mucosal defect repair, status of healing, scar formation, and intraoperative or delayed complications (including perforation and bleeding). RESULTS Eight animals died of intraoperative or delayed perforation; follow-up colonoscopy was performed in 32 animals. On follow-up colonoscopy at 7 days after operation, 78.1% cases in the CSP group showed healing of mucosal defect compared with none in the HSP group (P < 0.001); mucosal repair score in the CSP group was significantly higher than HSP group (P < 0.001). On follow-up colonoscopy at 15 days, mucosal defect after CSP had completely healed in all cases (100%) versus 96.9% after HSP (P = 0.313). Among these healed defects, scar formation was observed in 2 of 32 cases in the CSP group compared with 19 of 31 in the HSP group (P < 0.001). Intraoperative perforation rate was significantly higher in the HSP group (15% vs 2.5%; P = 0.048). CONCLUSIONS Mucosal defect repair after CSP is quicker compared with HSP and is more likely to result in scarless healing. HSP is more likely to cause perforation in the thin colon walls.
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Affiliation(s)
- Biantao Mi
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China.,Department of Gastroenterology and Hepatology, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Huimin Wang
- Department of Gastroenterology and Hepatology, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Chunliang Liu
- Department of Gastroenterology and Hepatology, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Qi Wang
- Department of Gastroenterology and Hepatology, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaohong Fu
- Department of Gastroenterology and Hepatology, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Zikai Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Fang Liu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Whitfield AM, Burgess NG, Bahin FF, Kabir S, Pellisé M, Sonson R, Subramanian V, Mahajan H, McLeod D, Byth K, Bourke MJ. Histopathological effects of electrosurgical interventions in an in vivo porcine model of colonic endoscopic mucosal resection. Gut 2022; 71:864-870. [PMID: 34172512 DOI: 10.1136/gutjnl-2021-324140] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR) in the colon has been widely adopted, but there is limited data on the histopathological effects of the differing electrosurgical currents (ESCs) used. We used an in vivo porcine model to compare the tissue effects of ESCs for snare resection and adjuvant margin ablation techniques. DESIGN Standardised EMR was performed by a single endoscopist in 12 pigs. Two intersecting 15 mm snare resections were performed. Resections were randomised 1:1 using either a microprocessor-controlled current (MCC) or low-power coagulating current (LPCC). The lateral margins of each defect were treated with either argon plasma coagulation (APC) or snare tip soft coagulation (STSC). Colons were surgically removed at 72 hours. Two specialist pathologists blinded to the intervention assessed the specimens. RESULTS 88 defects were analysed (median 7 per pig, median defect size 29×17 mm). For snare ESC effects, 156 tissue sections were assessed. LPCC was comparable to MCC for deep involvement of the colon wall. For margin ablation, 172 tissue sections were assessed. APC was comparable to STSC for deep involvement of the colon wall. Islands of preserved mucosa at the coagulated margin were more likely with APC compared with STSC (16% vs 5%, p=0.010). CONCLUSION For snare resection, MCC and LPCC did not produce significantly different tissue effects. The submucosal injectate may protect the underlying tissue, and technique may more strongly dictate the depth and extent of final injury. For margin ablation, APC was less uniform and complete compared with STSC.
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Affiliation(s)
- Anthony M Whitfield
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Farzan F Bahin
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Sharir Kabir
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - María Pellisé
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Vishnu Subramanian
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Hema Mahajan
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Duncan McLeod
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia.,WSLHD Research and Education Network, Westmead Hospital, Westmead, New South Wales, Australia
| | - Michael J Bourke
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia .,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
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8
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A Randomized Controlled Trial of Cold Snare Polypectomy Technique: Technique Matters More Than Snare Wire Diameter. Am J Gastroenterol 2022; 117:100. [PMID: 34817440 DOI: 10.14309/ajg.0000000000001554] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cold snare polypectomy (CSP) is safe and effective for the removal of small adenomas (≤10 mm); however, reported incomplete resection rates (IRRs) vary. The optimal CSP technique, where a wide margin of normal tissue is resected around the target lesion, and snare design have both been hypothesized to reduce the IRR after CSP. We sought to investigate the efficacy of a thin-wire versus thick-wire diameter snare on IRR, using the standardized CSP technique. METHODS This was an international multicenter parallel design randomized trial with 17 endoscopists of varying experience (NCT02581254). Patients were randomized in a 1:1 ratio to the use of a thin-wire (0.30 mm) or thick-wire (0.47 mm) snare for CSP of small (≤10 mm) colorectal polyps. The primary end point was the IRR as determined by the histologic assessment of the defect margin after polypectomy. RESULTS Over 52 months to January 2020, 1,393 patients were eligible. A total of 660 patients with polyps (57.4% male) were randomized to a thin-wire (n = 339) or thick-wire (n = 321) snare. The overall IRR of the cohort was 1.5%. There was no significant difference in the IRR between the thin- and thick-wire arms; relative risk-0.41, 95% CI (0.11-1.56), P = 0.21. No significant differences were observed in the rate of adverse events. DISCUSSION In this multicenter randomized trial, CSP is safe and effective with very low rates of incomplete resection independent of the diameter of the snare wire used. This suggests that the optimal operator technique is more important than the snare design alone in minimizing residual adenoma after CSP.
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Fukushima H, Sakamoto N, Shibuya T, Haga K, Nomura O, Murakami T, Ueyama H, Ishikawa D, Hojo M, Nagahara A. A Comparative Study of Early Mucosal Healing Following Hot Polypectomy and Cold Polypectomy. Med Sci Monit 2021; 27:e933043. [PMID: 34432770 PMCID: PMC8404476 DOI: 10.12659/msm.933043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Cold polypectomy (CP) and hot polypectomy (HP) are both accepted methods for polypectomy. In recent years, the use of CP has increased for reasons of safety. However, there have been few investigations of conditions at follow-up early after resection. This prospective study from a single center aimed to compare colonic mucosal healing at 1 week following HP vs CP of benign colonic polyps <10 mm in diameter. Material/Methods Six patients with a total of 52 lesions under 10 mm in size were randomized to either the HP group (n=25) or CP group (n=27) using information in opaque envelopes. One week after endoscopic treatment, the site of treatment was evaluated using colonoscopy. We assessed the mean tumor size, ulcer diameter, exposed blood vessels, residual lesion, and complications. Results Mean tumor size did not differ between the 2 groups (CP vs HP: 5.41 mm vs 5.68 mm). The CP group had a smaller ulcer base diameter (2.70 mm vs 4.84 mm; P<0.05) and fewer exposed blood vessels than the HP group (3.7% vs 36.0%; P<0.05). One residual lesion was found in the CP group. No patients experienced delayed perforation or post-polypectomy bleeding. Conclusions Our study findings showed that at 1-week follow-up, cold polypectomy resulted in improved colonic mucosal healing, with a smaller ulcer diameter and fewer blood vessels, when compared with hot polypectomy.
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Affiliation(s)
- Hirofumi Fukushima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Keiichi Haga
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Osamu Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Mariko Hojo
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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10
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Keswani RN, Crockett SD, Calderwood AH. AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review. Gastroenterology 2021; 161:701-711. [PMID: 34334168 DOI: 10.1053/j.gastro.2021.05.041] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 12/23/2022]
Abstract
The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.
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Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Chandrasekhara V, Kumta NA, Abu Dayyeh BK, Bhutani MS, Jirapinyo P, Krishnan K, Maple JT, Melson J, Pannala R, Parsi MA, Sethi A, Trikudanathan G, Trindade AJ, Lichtenstein DR. Endoscopic polypectomy devices. VideoGIE 2021; 6:283-293. [PMID: 34278088 PMCID: PMC8267590 DOI: 10.1016/j.vgie.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Amrita Sethi
- Department of Digestive and Liver Diseases, Columbia University Medical Center/New York-Presbyterian, New York, New York
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Rutter MD, Jover R. Personalizing Polypectomy Techniques Based on Polyp Characteristics. Clin Gastroenterol Hepatol 2020; 18:2859-2867. [PMID: 31563558 DOI: 10.1016/j.cgh.2019.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/20/2019] [Indexed: 12/18/2022]
Abstract
Polypectomy is an essential skill for all endoscopists performing lower gastrointestinal endoscopy. Different polypectomy tools and techniques have evolved and it is important that endoscopists are familiar with these so they can select the most appropriate technique for each polyp. This narrative review updates the different concepts in tailoring polypectomy technique to the characteristics of polyps. Effective polypectomy requires different components, including the following: careful evaluation of the polyp; decision making about optimal polyp management; actual polypectomy, which includes careful positioning of the endoscope and polyp; and postpolypectomy evaluation of the results (for completeness of resection and prophylaxis of complications).
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Affiliation(s)
- Matthew D Rutter
- University Hospital of North Tees, Stockton on Tees, United Kingdom; Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Rodrigo Jover
- Servicio de Medina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain.
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13
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Rex DK. The Case for High-Quality Colonoscopy Remaining a Premier Colorectal Cancer Screening Strategy in the United States. Gastrointest Endosc Clin N Am 2020; 30:527-540. [PMID: 32439086 DOI: 10.1016/j.giec.2020.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Most colorectal cancer screening in the United States occurs in the opportunistic setting, where screening is initiated by a patient-provider interaction. Colonoscopy provides the longest-interval protection, and high-quality colonoscopy is ideally suited to the opportunistic setting. Both detection and colonoscopic resection have improved as a result of intense scientific investigation. Further improvements in detection are expected with the introduction of artificial intelligence programs into colonoscopy platforms. We may expect recommended intervals or colonoscopy after negative examinations performed by high-quality detectors to expand beyond 10 years. Thus, high-quality colonoscopy remains an excellent approach to colorectal cancer screening in the opportunistic setting.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA.
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14
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Willems P, Orkut S, Ditisheim S, Pohl H, Barkun A, Djinbachian R, Bouin M, von Renteln D. An international polypectomy practice survey. Scand J Gastroenterol 2020; 55:497-502. [PMID: 32267187 DOI: 10.1080/00365521.2020.1749297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and study aims: In recent years, cold snare polypectomy (CSP) has been recommended as the preferred approach for removal of small and diminutive colorectal polyps. We conducted an international survey among endoscopists to understand the uptake of CSP and changes in polypectomy practice during recent years.Patients and methods: Endoscopists were invited through gastroenterology, colorectal surgery and endoscopy societies to participate in an online survey. The primary outcome was to identify the predominant polypectomy approach used to remove 4‒10 mm colorectal polyps. Secondary outcomes included the uptake of CSP in the past 5 years, current polypectomy practice patterns for 1‒20 mm polyps, practice changes in recent years, and perceived benefits/concerns related to different polypectomy techniques.Results: The survey was distributed internationally by nine societies and completed by 808 endoscopists (response rate 3.7%). CSP was the predominant polypectomy technique for 4‒5 mm polyps (67.0%, 95% CI, 63.7-70.2%) and 6‒10 mm polyps (55.2%, 95% CI, 51.8-58.6%). For 1‒3 mm polyps, cold forceps remained the predominant technique (78.4%, 95% CI, 75.6-81.3%), whereas hot snare polypectomy (HSP) remained the predominant technique for 10‒20 mm polyps (92.5%, 95% CI, 90.7-94.3%). 87.5% (95% CI, 85.2-89.8%) of endoscopists reported an increase in CSP use during the past 5 years.Conclusions: This survey found a substantial increase in CSP use during recent years. CSP has become the predominant polypectomy approach for 4‒10 mm colorectal polyps, while HSP remained the predominant approach for larger (10‒20 mm) polyps. Clinical practice patterns are well aligned with recently issued guideline recommendations.
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Affiliation(s)
- Philippe Willems
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sinan Orkut
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Saskia Ditisheim
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Hartford, VT, USA.,Dartmouth, Geisel School of Medicine, Hanover, NH, USA
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Mickael Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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15
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:486-519. [PMID: 32067745 DOI: 10.1016/j.gie.2020.01.029] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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16
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Tate DJ, Desomer L, Heitman SJ, Forbes N, Burgess NG, Awadie H, Gralnek IM, Geldof J, De Looze D, Rex D, Anderson J, Bourke MJ. Clinical implications of decision making in colorectal polypectomy: an international survey of Western endoscopists suggests priorities for change. Endosc Int Open 2020; 8:E445-E455. [PMID: 32118117 PMCID: PMC7035139 DOI: 10.1055/a-1079-4298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction Colonoscopy prevents colorectal cancer via the detection and resection of premalignant polyps. This effect may be attenuated by variations in polypectomy, with multiple techniques available and a wide range of experience amongst endoscopists. We assessed current practice against the best available contemporary evidence. Methods An online survey was distributed to members of the gastroenterological and surgical societies of seven countries during July 2017. Images of colorectal polyps were presented and respondents requested to provide the polypectomy technique they would employ in their daily practice. Responses were compared to the evidence-based techniques in the 2017 ESGE Colorectal Polypectomy Guideline. Results In total, 707 endoscopists (627 physicians, 71 surgeons, 9 nurse endoscopists, median practice duration 18 years) completed the survey. Of these, 3.1 % selected hot biopsy forceps and 5.2 % hot snare polypectomy (without submucosal lifting) to remove a 3 mm ascending colon polyp. Only 43.3 % selected cold snare polypectomy (CSP) to remove an 8 mm ascending colon polyp. Surgical referral was selected by 16.7 % of respondents for a 45 mm transverse colon polyp without endoscopic evidence of submucosal invasive cancer (SMIC). Endoscopic resection was selected by 12.0 % for an 80 mm sigmoid polyp with imaging consistent with deep SMIC, and a further 26.4 % selected tertiary endoscopist referral, suggesting they had not appreciated that it was endoscopically unresectable. Conclusion CSP is underutilized for small polyp resection despite its favorable safety and efficacy. Benign polyps are commonly referred for surgery and overt SMIC is underappreciated using endoscopic imaging. Addressing these issues may reduce diathermy-related adverse events, surgery, and unnecessary colonoscopic procedures for patients and reduce rates of post-colonoscopy colorectal cancer.
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Affiliation(s)
- David J. Tate
- Westmead Hospital, Sydney, New South Wales, Australia,University of Sydney, Sydney, New South Wales, Australia,University Hospital Gent, Gent, Belgium
| | | | | | | | | | | | | | | | | | - Douglas Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Michael J. Bourke
- Westmead Hospital, Sydney, New South Wales, Australia,University of Sydney, Sydney, New South Wales, Australia
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17
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Abstract
Colonoscopy with polypectomy is frequently performed in pediatric patients based on symptoms, with the majority of polyps identified being benign juvenile pedunculated polyps with a vascular stalk. This is in distinction to adults where polypectomy is often performed as part of a colon cancer screening and prevention strategy and a higher fraction of polyps are sessile and or dysplastic. In adults, polypectomy techniques emphasize a need for deeper resection to ensure complete resection of adenomas or potential carcinoma in situ. Adenomatous polyps can occur in the pediatric age group and may be associated with an underlying polyposis, hereditary or chronic inflammatory conditions. Polypectomy techniques include use of cold biopsy forceps for very small polyps, cold snare polypectomy for small sessile polyps and hot snare polypectomy for the majority of polyps in the pediatric age group. Adjuvant techniques include epinephrine volume reduction, saline-assisted polypectomy and hemostatic techniques including injection, clip application and loop application to prevent or treat post-polypectomy bleeding. Electrosurgical principles guide the settings and type of current utilized during hot snare polypectomy. Polypectomy utilizing thermal techniques is associated with a higher risk of complications compared with diagnostic colonoscopy.
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18
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Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:435-464. [PMID: 32058340 DOI: 10.14309/ajg.0000000000000555] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1095-1129. [PMID: 32122632 DOI: 10.1053/j.gastro.2019.12.018] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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20
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Rex DK. Best Practices for Resection of Diminutive and Small Polyps in the Colorectum. Gastrointest Endosc Clin N Am 2019; 29:603-612. [PMID: 31445685 DOI: 10.1016/j.giec.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diminutive colorectal lesions are polyps and flat lesions 1 to 5 mm in size, and small are 6 to 9 mm in size. The best resection method is the cold snare. Cold forceps are acceptable for 1- to 3-mm lesions, but should not be used to piecemeal polyps. Cold snaring has few complications and is more effective than cold forceps for 4- to 5-mm polyps and as effective and more efficient than hot snaring for 6- to 9-mm polyps.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA.
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21
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Safety and efficacy of hot avulsion as an adjunct to EMR (with videos). Gastrointest Endosc 2019; 89:999-1004. [PMID: 30529357 DOI: 10.1016/j.gie.2018.11.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Excision of all visible neoplastic tissue is the goal of EMR of colorectal laterally spreading tumors. Flat and fibrotic tissue can resist snaring. Ablation of visible polyps is associated with high recurrence rates. Avulsion is a technique to continue resection when snaring fails. METHODS We retrospectively analyzed colonic EMRs of 564 consecutive referred polyps between 2015 and 2017. Hot avulsion was used when snaring was unsuccessful. Polyps treated with and without avulsion were compared. RESULTS Hot avulsion was used in 20.9% (n = 112) of all resected lesions. The recurrence rates on follow-up colonoscopy were 17.52% in the avulsion group versus 16.02% in the non-avulsion group (P = .76). Hot avulsion was associated with a trend toward higher rates of delayed hemorrhage (5.35% vs 2.58%; P = .15) and post-coagulation syndrome (1.8% vs 0.47%; P = .15), but polyps treated with any avulsion were larger than those in which no avulsion was used (P < .001). There were an insufficient number of adverse events to perform a multivariable analysis to test the effects of avulsion, size, and location on the risk of overall adverse events. CONCLUSIONS Unlike previous reports of using argon plasma coagulation to treat visible polyps during EMR, hot avulsion of visible/fibrotic neoplasia was associated with similar EMR efficacy compared with cases that did not require hot avulsion. The safety profile of hot avulsion appears acceptable.
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22
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Jegadeesan R, Aziz M, Desai M, Sundararajan T, Gorrepati VS, Chandrasekar VT, Jayaraj M, Singh P, Saeed A, Rai T, Choudhary A, Repici A, Hassan C, Fuccio L, Sharma P. Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies. Endosc Int Open 2019; 7:E708-E716. [PMID: 31073538 PMCID: PMC6506415 DOI: 10.1055/a-0808-3680] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/03/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction In recent years, cold snare polypectomy (CSP) has increasingly been used over hot snare polypectomy (HSP) for the removal of colorectal polyps (4 - 10 mm in size). However, the optimal technique (CSP vs. HSP), in terms of complete polyp resection and complications, is uncertain. Our aim was to compare incomplete resection rate (IRR) of polyps and complications using CSP vs. HSP. Methods Randomized controlled studies (RCTs) comparing CSP and HSP for removal of 4 - 10 mm colorectal polyps were considered. Studies were included in the analysis if they obtained biopsy specimens from the resection margin to confirm the absence of residual tissue and reported complications. IRR and complication rate were the outcome measures. Pooled rates were reported as Odds Ratios (OR) or risk difference with 95 % Confidence Interval (CI). Results In total, three RCTs were included in the final analysis. A total of 1051 patients with 1485 polyps were randomized to either HSP group (n = 741 polyps) or CSP group (n = 744 polyps). The overall IRR did not differ between the two groups (HSP vs. CSP: 2.4 % vs. 4.7 %; OR 0.51, 95 %CI 0.13 - 1.99, P = 0.33, I 2 = 73 %). The HSP group had a lower rate of overall complications compared to the CSP group (3.7 % vs. 6.6 %; OR 0.53, 95 % CI 0.3 - 0.94, P = 0.03, I 2 = 0 %). Polyp retrieval rates were not different between the two groups (99 % vs. 98.1 %). Conclusion Our results suggest that HSP and CSP techniques can be effectively used for the complete removal of 4 - 10 mm colorectal polyps; however, HSP has a lower incidence of overall complications.
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Affiliation(s)
- Ramprasad Jegadeesan
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Muhammad Aziz
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Madhav Desai
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Tharani Sundararajan
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | | | - Viveksandeep Thogulva Chandrasekar
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Mahendran Jayaraj
- Division of Gastroenterology, University of Nevada, Las Vegas, NV, USA
| | - Pratiksha Singh
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Ahmed Saeed
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Tarun Rai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Abhishek Choudhary
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Alessandro Repici
- Division of Gastroenterology, Humanitas Research Hospital & Humanitas University, Milan, Italy
| | - Cesare Hassan
- Nuovo Regina Margherita Hospital, Digestive Endoscopy Unit, Rome, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
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23
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Corral JE, Keihanian T, Diaz LI, Morgan DR, Sussman DA. Management patterns of gastric polyps in the United States. Frontline Gastroenterol 2019; 10:16-23. [PMID: 30651953 PMCID: PMC6319157 DOI: 10.1136/flgastro-2017-100941] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 06/01/2018] [Accepted: 06/16/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Recent guidelines on endoscopic sampling recommend complete gastric polyp removal for solitary fundic polyps >10 mm, hyperplastic polyps >5 mm and all adenomatous polyps. We aim to describe endoscopic approach to polyps in the time period prior to the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and to identify opportunities for clinical practice improvements. DESIGN Retrospective review of the Clinical Outcome Research Initiative (CORI) database, including all oesophagogastroduodenoscopies (OGDs). Reviewers grouped interventions during procedures based on instruments used for polyp sampling by forceps or snare polypectomy. Logistic regression estimated the effect of variables of interest on method of polypectomy. RESULTS Of 783 037 OGDs reported in the CORI database, 25 670 (3.3%) described gastric polyps and met the inclusion criteria. Mean gastric polyp size was 6.5±4.9 mm, and 46.2% and 14.5% were located in the corpus and antrum, respectively. Polyps in the forceps group were smaller than polyps in the snare group (5.7±4.0 mm vs 9.3±6.4 mm, respectively, p<0.001). We identified 1056 polyps (41.3%) >10 mm that only underwent forceps biopsy. Forceps were used more frequently in the gastric fundus. CONCLUSIONS Snare polypectomy was underused in gastric polyps, per current ASGE guidelines. Anatomical location and endoscopic features of polyps were important predictors of the approach to gastric polypectomy.
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Affiliation(s)
- Juan E Corral
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Tara Keihanian
- Department of Internal Medicine, University of Miami Miller School of Medicine—Jackson Memorial Hospital, Miami, Florida, USA
| | - Liege I Diaz
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Douglas R Morgan
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University, Nashville, Tennessee, USA
| | - Daniel A Sussman
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Abstract
BACKGROUND Delayed postpolypectomy bleeding occurs more frequently after hot resection than after cold resection. OBJECTIVE To elucidate the underlying mechanism, we performed a histological comparison of tissue after cold and hot snare resections. DESIGN This is a prospective study, registered in the University Hospital Medical Information Network (UMIN000020104). SETTING This study was conducted at Aizu Medical Center, Fukushima Medical University, Japan. PATIENTS Fifteen patients scheduled to undergo resection of colorectal cancer were enrolled. INTERVENTION On the day before surgery, 2 mucosal resections (hot and cold) of normal mucosa were performed on each patient using the same snare without saline injection. The difference was only the application of electrocautery or not. Resection sites were placed close to the cancer to be included in the surgical specimen. MAIN OUTCOME MEASURES The primary outcome measure was the depth of destruction. Secondary outcome measures included the width of destruction, depth of the remaining submucosa, and number of vessels remaining at the resection sites. The number and diameter of vessels in undamaged submucosa were also evaluated. RESULTS All cold resections were limited to the shallow submucosa, whereas 60% of hot resections advanced to the deep submucosa and 20% to the muscularis propria (p < 0.001). There was no significant difference in the width of destruction. The number of remaining large vessels after hot resections trended toward fewer (p = 0.15) with a decreased depth of remaining submucosa (p = 0.007). In the deep submucosa, the vessel diameter was larger (p < 0.001) and the number of large vessels was greater (p = 0.018). LIMITATIONS Histological assessment was not blinded to the 2 reviewers. Normal mucosa was used instead of adenomatous tissue. CONCLUSIONS Hot resection caused damage to deeper layers involving more large vessels. This may explain the mechanism for the reduced incidence of hemorrhage after cold snare polypectomy. See Video Abstract at http://links.lww.com/DCR/A631.
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Ma MX, Bourke MJ. Sessile Serrated Adenomas: How to Detect, Characterize and Resect. Gut Liver 2018; 11:747-760. [PMID: 28494577 PMCID: PMC5669590 DOI: 10.5009/gnl16523] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/06/2016] [Indexed: 12/13/2022] Open
Abstract
Serrated polyps are important contributors to the burden of colorectal cancers (CRC). These lesions were once considered to have no malignant potential, but currently up to 30% of all CRC are recognized to arise from the serrated neoplasia pathway. The primary premalignant lesions are sessile serrated adenomas/polyps (SSA/Ps), although traditional serrated adenomas are relatively uncommon. Compared to conventional adenomas, SSA/Ps are morphologically subtle with indistinct borders, may be difficult to detect endoscopically, are more prevalent than previously thought, are associated with synchronous and metachronous advanced neoplasia, and have a higher risk of incomplete resection. Although many lesions remain “dormant,” progressive disease is associated with the development of dysplasia and more rapid progression to CRC. As a result, SSA/Ps are strongly implicated in the development of interval cancers. These factors represent unique challenges that require a meticulous approach to their management. In this review, we summarize the contemporary literature on the characterization, detection and resection of SSA/Ps.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
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26
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Dekker E, Rex DK. Advances in CRC Prevention: Screening and Surveillance. Gastroenterology 2018; 154:1970-1984. [PMID: 29454795 DOI: 10.1053/j.gastro.2018.01.069] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
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Panteris V, Vezakis A, Triantafillidis JK. Should hot biopsy forceps be abandoned for polypectomy of diminutive colorectal polyps? World J Gastroenterol 2018; 24:1579-1582. [PMID: 29662295 PMCID: PMC5897861 DOI: 10.3748/wjg.v24.i14.1579] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/19/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023] Open
Abstract
Standardized approach to polypectomy of diminutive colorectal polyps (DCPs) is lacking since cold biopsy forceps have been associated with high levels of recurrence, hot biopsy forceps are considered inadequate and risky and cold snaring is currently under investigation for its efficacy and safety. This has led to confusion and a gap in clinical practice. This article discusses the usefulness and contemporary practical applicability of hot biopsy forceps and provides well-intentioned criticism of the new European guidelines for the treatment of DCPs. Diminutive colorectal polyps are a source of frustration for the endoscopist since their small size is accompanied by a considerable risk of premalignant neoplasia and a small but non-negligible risk of advanced neoplasia and even cancer. Since the proportion of diminutive colorectal polyps is substantial and exceeds that of larger polyps, their effective removal poses a considerable workload and a therapeutic challenge. During the last decade, the introduction of cold snaring to routine endoscopy practice has attempted to overcome the use of prior techniques, such as hot biopsy forceps. It is important to recognize that with the exception of endoscopic methods that are obviously unsafe and inadequate to serve their purpose, all other interventional endoscopic methods are operator-dependent in the sense that specific expertise and training are obligatory for the success of any therapeutic intervention. Since relevant publications on hot biopsy forceps are still in favor of its careful use, as it has not yet demonstrated inferiority compared with newer techniques, it would be prudent for any medical practitioner to evaluate the available tools and judge any new proposed technique based on the evidence before it is adopted.
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Affiliation(s)
- Vasileios Panteris
- Department of Gastroenterology, Sismanogleio-A.Fleming General Hospital, Attiki, Athens 15126, Greece
| | - Antonios Vezakis
- Department of Surgery, Aretaieio Hospital, Attiki, Athens 11528, Greece
| | - JK Triantafillidis
- Department of Gastroenterology, Iaso General Hospital, Attiki, Athens 15562, Greece
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Dwyer JP, Tan JYC, Urquhart P, Secomb R, Bunn C, Reynolds J, La Nauze R, Kemp W, Roberts S, Brown G. A prospective comparison of cold snare polypectomy using traditional or dedicated cold snares for the resection of small sessile colorectal polyps. Endosc Int Open 2017; 5:E1062-E1068. [PMID: 29250580 PMCID: PMC5659868 DOI: 10.1055/s-0043-113564] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 05/22/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The evidence for efficacy and safety of cold snare polypectomy is limited. The aim of this study was to assess the completeness of resection and safety of cold snare polypectomy, using either traditional or dedicated cold snares. PATIENTS AND METHODS This was a prospective, non-randomized study performed at a single tertiary hospital. Adult patients with at least one colorectal polyp (size ≤ 10 mm) removed by cold snare were included. In the first phase, all patients had polyps removed by traditional snare without diathermy. In the second phase, all patients had polyps removed by dedicated cold snare. Complete endoscopic resection was determined from histological examination of quadrantic polypectomy margin biopsies. Immediate or delayed bleeding within 2 weeks was recorded. RESULTS In total, 181 patients with 299 eligible polyps (n = 93 (173 polyps) traditional snare group, n = 88 (126 polyps) dedicated cold snare group) were included. Patient demographics and procedure indications were similar between groups. Mean polyp size was 6 mm in both groups ( P = 0.25). Complete polyp resection was 165 /173 (95.4 %; 95 %CI 90.5 - 97.6 %) in the traditional snare group and 124/126 (98.4 %; 95 %CI 93.7 - 99.6 %) in the dedicated cold snare group ( P = 0.16). Serrated polyps, compared with adenomatous polyps, had a higher rate of incomplete resection (7 % vs. 2 %, P = 0.03). There was no statistically significant difference in the rate of immediate bleeding (3 % vs. 1 %, P = 0.41) and there were no delayed hemorrhages or perforations. CONCLUSIONS Cold snare polypectomy is effective and safe for the complete endoscopic resection of small (≤ 10 mm) colorectal polyps with either traditional or dedicated cold snares.
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Affiliation(s)
- Jeremy P. Dwyer
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Jonathan Y. C. Tan
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Paul Urquhart
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Robyn Secomb
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Catherine Bunn
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - John Reynolds
- Biostatistics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia 3004
| | - Richard La Nauze
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Stuart Roberts
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Gregor Brown
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004,Corresponding author Associate Professor Gregor Brown Head of EndoscopyAlfred Hospital55 Commercial RdMelbourneVIC 3004Australia+61-3-90762757
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Von Renteln D, Bouin M, Barkun AN. Current standards and new developments of colorectal polyp management and resection techniques. Expert Rev Gastroenterol Hepatol 2017; 11:835-842. [PMID: 28319429 DOI: 10.1080/17474124.2017.1309279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colonoscopy and endoscopic removal of precancerous polyps play an important role in colorectal cancer (CRC) prevention. Improved endoscopes and quality standards have led to an increasing polyp and adenoma detection rate. Optimal polyp resection techniques and management strategies are key for an effective colonoscopy practice. Areas covered: Strategies for how to improve diminutive polyp (polyps up to 5 mm in size) management are discussed because of their high prevalence. Systematic removal of diminutive polyps leads to increasing costs of colonoscopy practice, while the effect on colorectal cancer prevention might be negligible. Furthermore, polypectomy recommendations for mid-size and large polyps are provided. For all larger polyps larger, complete and safe resection is mandatory to avoid post colonoscopy cancers. The focus for managing such larger polyps is to use new techniques (i.e. cold snares) and to attempt complete removal and to reduce post-polypectomy complications. Expert commentary: The resect-and-discard strategy is a promising management strategy for diminutive polyps. However, modification of this approach might be required in order to make widespread adoption feasible. Cold snare polypectomy is a promising new approach for small polyp resection. For resection of large polyps adequate treatment recommendations with regard to endoscopic mucosal resection and complication prevention are provided.
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Affiliation(s)
- Daniel Von Renteln
- a Department of Medicine, Division of Gastroenterology , Montreal University Hospital (CHUM) , Montreal , Canada
| | - Mickael Bouin
- a Department of Medicine, Division of Gastroenterology , Montreal University Hospital (CHUM) , Montreal , Canada
| | - Alan N Barkun
- b Division of Gastroenterology , McGill University Health Center, McGill University , Montreal , Quebec , Canada
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Lorenzo-Zúñiga V, Boix J, Moreno de Vega V, Bon I, Marín I, Bartolí R. Endoscopic shielding technique with a newly developed hydrogel to prevent thermal injury in two experimental models. Dig Endosc 2017; 29:702-711. [PMID: 28294423 DOI: 10.1111/den.12864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM A newly developed hydrogel, applied through the endoscope as an endoscopic shielding technique (EndoSTech), is aimed to prevent deep thermal injury and to accelerate the healing process of colonic induced ulcers after therapeutic endoscopy. METHODS Lesions were performed in rats (n = 24) and pigs (n = 8). Rats were randomized to receive EndoSTech (eight rats each) with: saline (control), hyaluronic acid and product. In pigs, three ulcer sites were produced in each pig: endoscopic mucosal resection (EMR)-ulcer with prior saline injection (A; EMR-saline), EMR-saline plus EndoSTech with product (B; EMR-saline-P), and EMR with prior injection of product plus EndoSTech-P (C; EMR-P-P). At the end of the 14-day study, the same lesions were performed again in healthy mucosa to assess acute injury. Animals were sacrificed after 7 (rats) and 14 (pigs) days. Ulcers were macroscopically and histopathologically evaluated. Thermal injury (necrosis) was assessed with a 1-4 scale. RESULTS In rats, treatment with product improved mucosal healing comparing with saline and hyaluronic acid (70% vs 30.3% and 47.2%; P = 0.003), avoiding mortality (0% vs 50% and 25%; P = 0.038), and perforation (0% vs 100% and 33.3%; P = 0.02); respectively. In pigs, submucosal injection of product induced a marked trend towards a less deep thermal injury (C = 2.25-0.46 vs A and B = 2.75-0.46; P = 0.127). Mucosal healing rate was higher with product (B = 90.2-3.9%, C = 91.3-5.5% vs A = 73.1-12.6%; P = 0.002). CONCLUSIONS This new hydrogel demonstrates strong healing properties in preclinical models. In addition, submucosal injection of this product is able to avoid high thermal load of the gastrointestinal wall.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jaume Boix
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Vicente Moreno de Vega
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Ignacio Bon
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain.,Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
| | - Ingrid Marín
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Ramón Bartolí
- Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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Moss A, Nalankilli K. Standardisation of polypectomy technique. Best Pract Res Clin Gastroenterol 2017; 31:447-453. [PMID: 28842055 DOI: 10.1016/j.bpg.2017.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/28/2017] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Alan Moss
- Gastroenterology Department, Western Health, Melbourne, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia.
| | - Kumanan Nalankilli
- Gastroenterology Department, Western Health, Melbourne, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia
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32
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Klein A, Bourke MJ. Management of colonic polyps: an advancing discipline. ANZ J Surg 2017; 87:327-330. [PMID: 28470707 DOI: 10.1111/ans.13612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/20/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Amir Klein
- 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
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Komeda Y, Kashida H, Sakurai T, Tribonias G, Okamoto K, Kono M, Yamada M, Adachi T, Mine H, Nagai T, Asakuma Y, Hagiwara S, Matsui S, Watanabe T, Kitano M, Chikugo T, Chiba Y, Kudo M. Removal of diminutive colorectal polyps: A prospective randomized clinical trial between cold snare polypectomy and hot forceps biopsy. World J Gastroenterol 2017; 23:328-335. [PMID: 28127206 PMCID: PMC5236512 DOI: 10.3748/wjg.v23.i2.328] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the efficacy and safety of cold snare polypectomy (CSP) and hot forceps biopsy (HFB) for diminutive colorectal polyps.
METHODS This prospective, randomized single-center clinical trial included consecutive patients ≥ 20 years of age with diminutive colorectal polyps 3-5 mm from December 2014 to October 2015. The primary outcome measures were en-bloc resection (endoscopic evaluation) and complete resection rates (pathological evaluation). The secondary outcome measures were the immediate bleeding or immediate perforation rate after polypectomy, delayed bleeding or delayed perforation rate after polypectomy, use of clipping for bleeding or perforation, and polyp retrieval rate. Prophylactic clipping after polyp removal wasn’t routinely performed.
RESULTS Two hundred eight patients were randomized into the CSP (102), HFB (106) and 283 polyps were evaluated (CSP: 148, HFB: 135). The en-bloc resection rate was significantly higher with CSP than with HFB [99.3% (147/148) vs 80.0% (108/135), P < 0.0001]. The complete resection rate was significantly higher with CSP than with HFB [80.4% (119/148) vs 47.4% (64/135), P < 0.0001]. The immediate bleeding rate was similar between the groups [8.6% (13/148) vs 8.1% (11/135), P = 1.000], and endoscopic hemostasis with hemoclips was successful in all cases. No cases of perforation or delayed bleeding occurred. The rate of severe tissue injury to the pathological specimen was higher HFB than CSP [52.6% (71/135) vs 1.3% (2/148), P < 0.0001]. Polyp retrieval failure was encountered CSP (7), HFB (2).
CONCLUSION CSP is more effective than HFB for resecting diminutive polyps. Further long-term follow-up study is required.
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34
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Holmes I, Kim HG, Yang DH, Friedland S. Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos). Gastrointest Endosc 2016; 84:822-829. [PMID: 27080417 DOI: 10.1016/j.gie.2016.03.1512] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/30/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS EMR is used widely for treatment of nonpedunculated colorectal adenomas ≥ 2 cm. Recurrence at the resection site occurs in 10% to 30% of cases. METHODS Records of consecutive patients referred for endoscopic resection over a 4-year period were reviewed retrospectively. In the first part of the study period, our routine practice was to use argon plasma coagulation (APC) to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. In the second part of the study period, we changed our practice to use avulsion to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. We analyzed the effect of this change in practice on recurrence rates after EMR. RESULTS Two hundred twenty-three resected lesions were analyzed. Fifty-nine (26%) were treated with en-bloc EMR, 55 (25%) by piecemeal EMR with complete snare removal of all visible neoplasia, 63 (28%) by piecemeal EMR with APC of visible residual neoplasia, and 46 (21%) by piecemeal EMR with avulsion of visible residual neoplasia. There was no significant difference in adverse event rates among the 4 groups. The recurrence rates on follow-up colonoscopy were 4.2%, 3.0%, 59.3%, and 10.3%, respectively. The recurrence rate for patients treated with avulsion was significantly lower than for those treated with APC (odds ratio, .079; P < .001). Multivariate analysis demonstrated that use of avulsion instead of APC was a significant predictor of no recurrence. CONCLUSIONS After exhaustive attempts at snare resection during EMR, avulsion is superior to APC for treatment of residual visible neoplasia. Compared with APC, avulsion significantly decreases the recurrence rate without significantly increasing the risk of the procedure.
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Affiliation(s)
- Ian Holmes
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Hyun Gun Kim
- Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Shai Friedland
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
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35
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Abstract
Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques now exist for the resection of polyps, and the endoscopist must decide on the appropriate resection approach for individual patients and lesions. This decision should maximize efficacy, safety and cost-effectiveness and provide optimal oncological outcomes while minimizing unnecessary surgical treatment. Advances in endoscopic imaging technology are improving the accuracy of endoscopic diagnosis and allowing more precise risk assessment of colonic lesions. Resection technique can be tailored to the endoscopic findings. Diminutive (≤5 mm) and small polyps (≤9 mm) are best resected primarily by snare techniques. Cold snare polypectomy has proven safety, but efficacy and technique require further study. There is variation in techniques used for polyps 6-20 mm in size and incomplete resection rates for conventional polypectomy may be considerable. Endoscopic mucosal resection (EMR) is well established, safe and effective for lesions without submucosal invasion (SMI); however, recurrence is a key limitation. Endoscopic submucosal dissection (ESD) is well established in the East; however, it is resource intensive and its role in lesions with a low risk of SMI is questionable. ESD in the West remains incompletely defined and is associated with high adverse event rates, but it is becoming increasingly available and successful as experience grows. Emerging full-thickness resection technologies are still in their infancy and remain experimental as a result of the absence of reliable closure devices and techniques. Patient-focused outcomes should guide technique selection.
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Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
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36
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Abstract
Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.
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Affiliation(s)
- Crispin J Corte
- Department of Gastroenterology, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Rupert W Leong
- Department of Gastroenterology, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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37
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Abstract
PURPOSE OF REVIEW Diminutive polyps, measuring between 1 and 5 mm, represent the vast majority of colorectal polyps encountered during screening colonoscopy. Although the chance of harboring advanced adenoma or neoplastic cells is low, ensuring a complete polyp resection with clear margins is crucial to reduce the risk of interval colorectal cancer. The purpose of this review was to evaluate the different methods applied for polypectomy of diminutive polyps and clarify whether a diminutive polyp should be retrieved or left in place. RECENT FINDINGS Cold biopsy polypectomy is indicated for resection of polyps measuring 1-3 mm and removal of 4-5 mm polyps should be ensured by cold snare polypectomy. Over the last decade, hot biopsy polypectomy has been gradually abandoned because of an increased risk of diathermic injury. The resect and discard strategy and the diagnose and disregard strategy should be performed only by expert endoscopists, who should use validated scales and document the polyp features by storing several endoscopic images. SUMMARY Nowadays, complete resection of diminutive polyps, following the most appropriate technique, is recommended in clinical practice. The resect and discard strategy and the diagnose and disregard strategy should be reserved to expert endoscopists.
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38
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Jehangir A, Bennett KM, Rettew AC, Fadahunsi O, Shaikh B, Donato A. Post-polypectomy electrocoagulation syndrome: a rare cause of acute abdominal pain. J Community Hosp Intern Med Perspect 2015; 5:29147. [PMID: 26486121 PMCID: PMC4612487 DOI: 10.3402/jchimp.v5.29147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 01/01/2023] Open
Abstract
While generally safe, the most feared complication of colonoscopy is perforation of the colon, occurring in nearly 1 in 1,000 procedures, and is more common when polypectomy is performed and electrocautery is used. Less commonly known is the post-polypectomy electrocoagulation syndrome, a transmural burn of the colon which mimics the signs and symptoms of perforation as well as the time course, but follows a benign course and can be treated conservatively.
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Affiliation(s)
- Asad Jehangir
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA;
| | - Kyle M Bennett
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Andrew C Rettew
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Opeyemi Fadahunsi
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Bilal Shaikh
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Anthony Donato
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
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Complete resection of colorectal adenomas: what are the important factors in fellow training? Dig Dis Sci 2015; 60:1579-88. [PMID: 25540087 DOI: 10.1007/s10620-014-3500-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/18/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND The complete removal of adenomatous polyps is important for reducing interval cancer after colonoscopy. AIMS To identify factors affecting the completeness of colonoscopic polypectomies and to evaluate the experience level of fellows who achieve competence compared with that of experts. METHODS Medical records of 1,860 patients who underwent at least one polypectomy for an adenomatous polyp at Seoul National University Hospital between March 2011 and February 2013 were retrospectively reviewed. A total of 3,469 adenomatous polyps were included. The lateral and deep margins of the resected polyps were evaluated to check the resection completeness. RESULTS Of the 3,469 adenomatous polyps, 1,389 (40.0 %) were removed by two experts and 2,080 (60.0 %) were removed by seven fellows. In the expert-treated group, larger size [odds ratio (OR) 2.81 for ≥20 mm, 95 % confidence interval (CI) 1.64-4.84, P < 0.001] and right-sided location (OR 1.31, 95 % CI 1.05-1.63, P = 0.019) were associated with incomplete resection. In the fellow-treated group, not only polyp characteristics [right-sided location (OR 1.41, 95 % CI 1.18-1.69, P < 0.001)], but also the cumulative number of procedures was also related to resection completeness. After 300 polypectomies, the complete resection rate of the fellows was comparable to that of the experts. CONCLUSIONS In the fellow-treated group, the level of procedure experience was closely associated with the polypectomy outcomes. Meticulous attention is critical to ensure the completeness of polypectomies performed by trainee endoscopists during the training program.
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Burgess NG, Bahin FF, Bourke MJ. Colonic polypectomy (with videos). Gastrointest Endosc 2015; 81:813-35. [PMID: 25805461 DOI: 10.1016/j.gie.2014.12.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/04/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Paggi S, Radaelli F, Repici A, Hassan C. Advances in the removal of diminutive colorectal polyps. Expert Rev Gastroenterol Hepatol 2015; 9:237-44. [PMID: 25155348 DOI: 10.1586/17474124.2014.950955] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diminutive polyps (<5 mm in diameter) represent the majority of polyps found during colonoscopy; about a half of them are adenomatous, with low risk of advanced neoplasia. Recent studies have demonstrated that cold polypectomy should be considered the recommended approach for resecting diminutive polyps and that cold snaring may be superior to cold forceps biopsy, at least for polyps of 4-5 mm. Recently, electronic chromoendoscopy has been applied to characterization of diminutive polyps to discriminate adenomatous from nonadenomatous lesions. Optical diagnosis of polyp histology could potentially exert huge cost savings by the 'resect and discard' strategy for diminutive polyps and 'leaving-in' for diminutive hyperplastic polyps in the recto-sigmoid colon. These policies represent the mainstay for adopting endoscopy-directed post-polypectomy surveillance strategies, endorsed by both American and European Endoscopy Societies. Accuracy of both histology and surveillance intervals predictions from academic centers have been encouraging, although the same performance has not been replicated in community practices.
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Affiliation(s)
- Silvia Paggi
- Gastroenterology Unit, Valduce Hospital, Via Dante, 11 - 22100 - Como, Italy
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Affiliation(s)
- James E. East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom,Corresponding author James E. East, MD (Res) FRCP Translational Gastroenterology UnitExperimental Medicine DivisionNuffield Department of Clinical MedicineUniversity of OxfordJohn Radcliffe HospitalHeadley Way, HeadingtonOxford, OX3 9DUUnited Kingdom+44 01865 228763
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Rogart JN. Foregut and colonic perforations: practical measures to prevent and assess them. Gastrointest Endosc Clin N Am 2015; 25:9-27. [PMID: 25442955 DOI: 10.1016/j.giec.2014.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute endoscopic perforations of the foregut and colon are rare but can have devastating consequences. There are several principles and practices that can lower the risk of perforation and guide the endoscopist in early assessment when they do occur. Mastery of these principles will lead to overall improved patient outcomes.
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Affiliation(s)
- Jason N Rogart
- Capital Health Center for Digestive Health, Two Capital Way, Suite 380, Pennington, NJ 08534, USA.
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44
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Yasar B, Kayadibi H, Abut E, Benek D, Kochan K, Gonen C. The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps. Dig Dis Sci 2015; 60:217-25. [PMID: 25112723 DOI: 10.1007/s10620-014-3320-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/01/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Polypectomy with jumbo forceps (JF) and polypectomy with hot biopsy forceps (HBF) are still widely used techniques for removal of diminutive colorectal polyps (DCPs). JF may be more effective for the removal of DCPs because of their larger size. AIM To evaluate the histological quality and adequacy of DCPs resected using JF compared with HBF. METHODS One hundred and seventy-nine patients with 237 DCPs were included in this study. DCPs were removed using either JP or HBF. RESULTS The tissue architecture was good in 29.9 % of the HBF group, in comparison with 90 % of the JF group (p < 0.001). No cautery damage or crash artifact was observed in 93.3 % of JF group and in 8.5 % of HBF group (p < 0.001). Moreover, there were statistically significant differences between the groups with regard to the high level of cautery damage or crush artifact (p < 0.001). The overall diagnostic quality of the specimens removed using JF was significantly better than that of the specimens removed by HBF (96 vs. 80 %, respectively, p < 0.001). There were statistically significant inverse associations between cautery damage or crush artifact and overall diagnostic quality of HBF and JF (r = -0.373, p < 0.001; r = -0.382, p < 0.001, respectively). Surgical margins were determined as negative in 87.5 % of the JF group and in 76.1 % of the HBF group (p = 0.022). A total of 80.8 % of the JF specimens and 30.8 % of the HBF specimens were well evaluated for two lateral and deep surgical margins (p < 0.001). CONCLUSION JF was superior to HBF for histopathological interpretation and eradication of DCPs.
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Affiliation(s)
- Bulent Yasar
- Department of Gastroenterohepatology, Camlica Erdem Hospital, Alemdag Yanyol Street, 34696, Üsküdar, Istanbul, Turkey,
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Abstract
Small (<10 mm) and diminutive (<6 mm) polyps harbour high-grade dysplasia or cancer in 0.3-5% of cases. The potential to grow and develop advanced histology is low. Traditional guidelines still recommend the removal of all polyps. Visual characterisation with modern endoscopic technology could enable us to leave diminutive hyperplastic polyps in situ and remove but discard small polyps. In expert hands, high-definition white-light endoscopy and virtual chromoendoscopy can reach an accuracy of more than 90% in distinguishing between hyperplastic and adenomatous pathology. For less experienced endoscopists the values are lower and therefore the concept is not yet fit for routine use. Polyps can be removed completely with snares but not with forceps. The cold snaring technique in particular has proved safe and effective for small polyps. With more experience in the future a 'cut and discard' strategy for small polyps and a 'do not resect' strategy for diminutive polyps will save money and time to deal with more advanced lesions.
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Affiliation(s)
- Rainer Schoefl
- Department of Gastroenterology, Hepatology, Metabolism, Nutrition and Endocrinology, Krankenhaus der Elisabethinen Linz, Linz, Austria
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Tutticci N, Bourke MJ. Advances in colonoscopy. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:119-139. [PMID: 24615389 DOI: 10.1007/s11938-014-0009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Colonoscopy with polypectomy has been established as the major prevention and detection strategy for colorectal cancer for over a decade. Over this period advances in colonoscopic imaging, polyp detection, prediction of histopathology and polypectomy techniques have all been seen; however, the true magnitude of the limitations of colonoscopy has only recently been widely recognized. The rate and location of missed or interval cancers after complete colonoscopy appears to be influenced by the operator-dependency of colonoscopy and failure of conventional practices to detect and treat adenomatous, and possibly more importantly, non-adenomatous colorectal cancer precursors. Consequently, studies that expand our understanding of these factors and advances that aim to improve colonoscopy, polypectomy, and cancer protection are of critical importance.
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Affiliation(s)
- Nicholas Tutticci
- Department of Gastroenterology and Hepatology, Westmead Hospital, 106A/151 Hawkesbury Road, Westmead, NSW, 2145, Australia,
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Uraoka T, Ramberan H, Matsuda T, Fujii T, Yahagi N. Cold polypectomy techniques for diminutive polyps in the colorectum. Dig Endosc 2014; 26 Suppl 2:98-103. [PMID: 24750157 DOI: 10.1111/den.12252] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 01/10/2014] [Indexed: 12/17/2022]
Abstract
Adequate colonoscopic polypectomy is a very important intervention for the prevention of colorectal cancer progression during screening and surveillance colonoscopy. Whereas various techniques are used for the removal of diminutive polyps, including cold biopsy forceps, hot biopsy forceps, hot snare, and cold snare, hot polypectomy techniques with electrocautery have been associated with an increased risk of electrocautery-related complications, including immediate and/or delayed bleeding or perforation. In contrast, recent studies have found a polypectomy technique without electrocautery, so-called cold polypectomy, to be a safer and more efficacious technique. The present article discusses the use of cold polypectomy techniques and describes how cold biopsy forceps polypectomy using jumbo biopsy forceps designed with a greater capacity for removing larger tissue samples, and cold snare polypectomy, are adequate for removing diminutive polyps completely and safely and shorten withdrawal time of the colonoscopy procedure.
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Affiliation(s)
- Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
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Abstract
Colonoscopic polypectomy is fundamental to effective colonoscopy. Through its impact on the polyp-cancer sequence, colonoscopic polypectomy reduces colorectal cancer incidence and mortality. Because it eliminates electrosurgical risk, cold snaring has emerged as the preferred technique for most small and all diminutive polyps. Few clinical trial data are available on the effectiveness and safety of specific techniques. Polypectomy technique seems highly variable between endoscopists, with some techniques more effective than others are. Further research is needed to investigate operator variation in polypectomy outcomes and establish an evidence base for best practice.
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Affiliation(s)
- David G Hewett
- School of Medicine, The University of Queensland, Mayne Medical Building, Herston Road, Herston, Brisbane, Queensland 4006, Australia.
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