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Chaptini LA, Jalloul S, Karam K. Cold snare polypectomy: A closer look at the efficacy and limitations for polyps 10-20 mm in size. World J Gastrointest Endosc 2024; 16:445-450. [PMID: 39155992 PMCID: PMC11325874 DOI: 10.4253/wjge.v16.i8.445] [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: 05/26/2024] [Revised: 06/29/2024] [Accepted: 07/29/2024] [Indexed: 08/01/2024] Open
Abstract
Current guidelines recommend cold snare polypectomy for polyps less than 10 mm in size. Conversely, endoscopic mucosal resection is still the preferred technique for larger polyps. Concerns regarding cold snare polypectomy for larger polyps revolve around the difficulty in conducting en-bloc resection (resulting in piecemeal removal), and the potential for local residual polyp tissue and a high rate of recurrence. On the other hand, cold snare technique has the advantages of shortening procedure time, reducing delayed bleeding risks and lowering cost of treatment. Numerous ongoing and recent studies are focused on evaluating the risks and benefits of this technique for polyps larger than 10 mm, with the goal of providing clear guidelines in the near future. The aim of this editorial is to provide our readers with an overview regarding this subject and the latest developments surrounding it.
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Affiliation(s)
- Louis A Chaptini
- Department of Medicine, Digestive Diseases, Yale School of Medicine, New Haven, CT 06510, United States
- Department of Medicine, Gastroenterology, University of Balamand, Balamand 100, Lebanon
| | - Sarah Jalloul
- Department of Medicine, Gastroenterology, University of Balamand, Balamand 100, Lebanon
| | - Karam Karam
- Department of Medicine, Gastroenterology, University of Balamand, Balamand 100, Lebanon
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Niu C, Zhang J, Joshi U, Elkhapery A, Boppana HK, Okolo PI. Efficacy and Safety of Cold Versus Hot Snare Endoscopic Mucosal Resection in Colorectal Polyp Removal: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2024:00004836-990000000-00338. [PMID: 39145841 DOI: 10.1097/mcg.0000000000002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND Cold snare endoscopic mucosal resection (C-EMR) is hypothesized to offer a safety advantage over hot snare endoscopic mucosal resection (H-EMR). The primary objective of this meta-analysis is to evaluate the effectiveness and safety of C-EMR versus H-EMR for the management of colorectal lesions. METHODS A meta-analysis was performed to determine pooled odds ratios (ORs) for comparing outcomes between the C-EMR and H-EMR groups. RESULTS The pooled OR for complete resection rates were estimated at 0.70 (95% CI: 0.36-1.36, P =0.29) and en bloc rates were 0.24 (95% CI: 0.05-1.08, P=0.06) between C-EMR group and H-EMR group. The overall complete resection rate for C-EMR was 84%, and the en bloc resection rate was 57. Notably, C-EMR was associated with a significantly lower incidence of delayed bleeding. The recurrence rate of polyps was very low (2%) when treating sessile serrated polyp (SSP) lesions, but higher (23%) for non-SSP lesions. Subgroup analysis revealed minimal recurrence of polyps after using C-EMR for lesions between 10 to 20 mm and ≥20 mm. CONCLUSIONS This meta-analysis suggests that C-EMR could be a safer and equally effective alternative to H-EMR for resecting colorectal lesions. We recommend C-EMR as the preferred method for excising large colorectal lesions.
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Affiliation(s)
- Chengu Niu
- Internal Medicine Residency Program, Rochester General Hospital
| | - Jing Zhang
- Rainier Springs Behavioral Health Hospital, Vancouver, WA
| | - Utsav Joshi
- Internal Medicine Residency Program, Rochester General Hospital
| | - Ahmed Elkhapery
- Internal Medicine Residency Program, Rochester General Hospital
| | | | - Patrick I Okolo
- Division of Gastroenterology, Rochester General Hospital, Rochester, NY
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Ramai D, Clement B, Maida M, Previtera M, Brooks OW, Wang Y, Chandan S, Dhindsa B, Deliwala S, Facciorusso A, Khashab M, Ofosu A. Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:661-667. [PMID: 38227846 DOI: 10.1097/mcg.0000000000001958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND There is increasing evidence that cold endoscopic mucosal resection (c-EMR) can effectively treat large colorectal polyps. We aim to appraise the current literature and evaluate outcomes following c-EMR for nonpedunculated colonic polyps ≥20 mm. METHODS Major databases were searched. Primary outcomes included recurrence rate and adverse events. Meta-analysis was performed using a random-effects model. RESULTS Nine articles were included in the final analysis, which included 817 patients and 1077 colorectal polyps. Average polyp size was 28.8 (±5.1) mm. The pooled recurrence rate of polyps of any histology at 4 to 6 months was 21.0% (95% CI: 9.0%-32.0%, P <0.001, I2 =97.3, P <0.001). Subgroup analysis showed that recurrence was 10% for proximal lesions (95% CI: 0.0%-20.0%, P =0.054, I2 =93.7%, P =0.054) and 9% for distal lesions (95% CI: 2.0%-21.0%, P =0.114, I2 =95.8%, P =0.114). Furthermore, subgroup analysis showed that recurrence was 12% for adenoma (95% CI: 4.0%-19.0%, P =0.003, I2 =98.0%, P =0.003), and 3% for sessile serrated polyps (95% CI: 1.0%-5.0%, P =0.002, I2 =34.4%, P =0.002). Post-polypectomy bleeding occurred in 1% (n=8/817) of patients, whereas abdominal pain occurred in 0.2% (n=2/817) of patients. CONCLUSIONS C-EMR for nonpedunculated colorectal polyps ≥20 mm shows an excellent safety profile with a very low rate of delayed bleeding as well as significantly less recurrence for sessile serrated polyps than adenomas.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology and Endoscopy Unit, S. Elia Hospital, Caltanissetta, Italy
| | | | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta
| | - Melissa Previtera
- University of Cincinnati Libraries, Donald C. Harrison Health Sciences Library, Cincinnati, OH
| | - Olivia W Brooks
- Internal Medicine Residency, University of Connecticut, Farmington, CT
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, MA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, NE
| | - Smit Deliwala
- Gastroenterology & Hepatology, Emory University Hospital, Atlanta, GA, USA
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Andrew Ofosu
- Faculty of Medicine, "Kore" University of Enna, Enna, Italy
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O’Sullivan T, Bourke MJ. Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm. Visc Med 2024; 40:217-227. [PMID: 39157731 PMCID: PMC11326768 DOI: 10.1159/000539219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/03/2024] [Indexed: 08/20/2024] Open
Abstract
Background Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors. Summary A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection. Key Messages Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.
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Affiliation(s)
- Timothy O’Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
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O'Sullivan T, Cronin O, van Hattem WA, Mandarino FV, Gauci JL, Kerrison C, Whitfield A, Gupta S, Lee E, Williams SJ, Burgess N, Bourke MJ. Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial. Gut 2024:gutjnl-2024-332807. [PMID: 38964854 DOI: 10.1136/gutjnl-2024-332807] [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: 05/05/2024] [Accepted: 05/31/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND AND AIMS Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR. METHODS Flat, 15-50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success. RESULTS 177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034). CONCLUSION Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique. TRIAL REGISTRATION NUMBER NCT04138030.
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Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julia L Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Clarence Kerrison
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, 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, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Lv YC, Dong Q, Yao YH, Lei JJ. Cold sub-mucosal injection versus traditional cold snare polypectomy for diminutive and small colorectal polyps: A systematic review and meta-analysis. Indian J Gastroenterol 2024:10.1007/s12664-024-01600-7. [PMID: 38955995 DOI: 10.1007/s12664-024-01600-7] [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: 11/02/2023] [Accepted: 04/23/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The guidelines recommend conventional cold snare polypectomy (C-CSP) for diminutive and small colorectal polyps (≤ 10 mm). However, it remains unclear whether CSP with sub-mucosal injection (SI-CSP) achieves comparable efficacy to C-CSP for managing these lesions. This study compares SI-CSP with C-CSP for patients with diminutive and small colorectal polyps. METHODS An electronic literature search was conducted to retrieve articles comparing resection outcomes between SI-CSP and C-CSP in diminutive and small colorectal polyps (registration number INPLASY2023100096). Our primary outcomes of interest were the complete resection rate (CRR), complications (namely immediate bleeding, delayed bleeding and perforation) and polypectomy time. Mean differences with 95% confidence intervals (CI) were employed for continuous variables, while odds ratios (OR) with 95% CI were calculated for categorical variables. Data was analyzed using a random effects model and the I2 test was utilized to assess heterogeneity. RESULTS Eight studies involving 1470 patients with 2223 polyps were included in our analysis. The CRR was not significantly higher in the SI-CSP group, with an OR of 95% CI 0.50 (0.22, 1.15). The incidences of immediate bleeding (OR 95% CI 0.60 [0.26-1.40]) and delayed bleeding (OR 95% CI 0.88 [0.32-2.42]) did not differ significantly between the two groups. On average, the mean polypectomy time was 64.75 seconds shorter in the C-CSP group (95% CI, - 102.96 to - 26.53). Notably, no perforation events were reported in the included studies. CONCLUSIONS The use of SI-CSP was not superior to C-CSP in managing diminutive and small colorectal polyps and the procedure required significantly more time.
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Affiliation(s)
- Yong-Cai Lv
- Department of Gastroenterology, Huzhou Central Hospital, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, No.1558, Sanhuan North Road, Wuxing District, Huzhou, 313000, Zhejiang Province, China
- Department of Gastroenterology, Zhenning Buyi and Miao Autonomous County People's Hospital, Zhenning, 561200, Guizhou Province, China
| | - Quan Dong
- Department of Gastroenterology, Huzhou Central Hospital, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, No.1558, Sanhuan North Road, Wuxing District, Huzhou, 313000, Zhejiang Province, China.
| | - Yan-Hua Yao
- Department of Gastroenterology, Zhenning Buyi and Miao Autonomous County People's Hospital, Zhenning, 561200, Guizhou Province, China
| | - Jing-Jing Lei
- Department of Gastroenterology, The Affiliated Baiyun Hospital of Guizhou Medical University, Guiyang, 550014, Guizhou Province, China
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Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, Paspatis GA, Moss A, Libânio D, Lorenzo-Zúñiga V, Voiosu AM, Rutter MD, Pellisé M, Moons LMG, Probst A, Awadie H, Amato A, Takeuchi Y, Repici A, Rahmi G, Koecklin HU, Albéniz E, Rockenbauer LM, Waldmann E, Messmann H, Triantafyllou K, Jover R, Gralnek IM, Dekker E, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024; 56:516-545. [PMID: 38670139 DOI: 10.1055/a-2304-3219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
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Affiliation(s)
- Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Gastroenterology, Evangelical Hospital, Vienna, Austria
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Mauro Risio
- Department of Pathology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy
| | - Gregorios A Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Vincente Lorenzo-Zúñiga
- Endoscopy Unit, La Fe University and Polytechnic Hospital / IISLaFe, Valencia, Spain
- Department of Medicine, Catholic University of Valencia, Valencia, Spain
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthew D Rutter
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
- Department of Gastroenterology, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Leon M G Moons
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, Ospedale A. Manzoni, Lecco, Italy
| | - Yoji Takeuchi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Gabriel Rahmi
- Hepatogastroenterology and Endoscopy Department, Hôpital européen Georges Pompidou, Paris, France
- Laboratoire de Recherches Biochirurgicales, APHP-Centre Université de Paris, Paris, France
| | - Hugo U Koecklin
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Teknon Medical Center, Barcelona, Spain
| | - Eduardo Albéniz
- Gastroenterology Department, Hospital Universitario de Navarra (HUN); Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lisa-Maria Rockenbauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Helmut Messmann
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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8
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Arruda do Espirito Santo P, Meine GC, Baraldo S, Barbosa EC. Cold endoscopic mucosal resection versus cold snare polypectomy for colorectal lesions: a systematic review and meta-analysis of randomized controlled trials. Endoscopy 2024; 56:503-511. [PMID: 38503302 DOI: 10.1055/a-2275-5349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cold resection of colorectal lesions is widely performed because of its safety and effectiveness; however, it remains uncertain whether adding submucosal injection could improve the efficacy and safety. We aimed to compare cold endoscopic mucosal resection (C-EMR) versus cold snare polypectomy (CSP) for colorectal lesions. METHODS We performed a systematic review of randomized controlled trials (RCTs) identified from PubMed, Cochrane Library, and Embase. The primary outcome was complete resection. Secondary outcomes were procedure time, en bloc resection, and adverse events (AEs). Prespecified subgroup analyses based on the size and morphology of the polyps were performed. The random-effects model was used to calculate the pooled risk ratio (RR) and mean difference, with corresponding 95%CIs, for dichotomous and continuous variables, respectively. Heterogeneity was assessed using the Cochran Q test and I 2 statistics. RESULTS 7 RCTs were included, comprising 1556 patients, with 2287 polyps analyzed. C-EMR and CSP had similar risk ratios for complete resection (RR 1.02, 95%CI 0.98-1.07), en bloc resection (RR 1.08, 95%CI 0.82-1.41), and AEs (RR 0.74, 95%CI 0.41-1.32). C-EMR had a longer procedure time (mean difference 42.1 seconds, 95%CI 14.5-69.7 seconds). In stratified subgroup analyses, the risk was not statistically different between C-EMR and CSP for complete resection in polyps<10 mm or ≥10 mm, or for complete resection, en bloc resection, and AEs in the two groups among nonpedunculated polyps. CONCLUSIONS The findings of this meta-analysis suggest that C-EMR has similar efficacy and safety to CSP, but significantly increases the procedure time. PROSPERO CRD42023439605.
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Affiliation(s)
- Paula Arruda do Espirito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of São Carlos, São Carlos, Brazil
| | - Gilmara Coelho Meine
- Department of Internal Medicine (Division of Gastroenterology), FEEVALE University, Novo Hamburgo, Brazil
| | - Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, Barretos, Brazil
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9
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Kimoto Y, Sawada R, Banjoya S, Iida T, Kimura T, Furuta K, Nagae S, Ito Y, Yamazaki H, Takeuchi N, Takayanagi S, Kano Y, Sakuno T, Ono K, Negishi R, Sakai E, Minato Y, Chiba H, Ohata K. Comparison of cold snare polypectomy for sessile serrated lesions ≥10 mm between experienced and trainee endoscopists: A propensity score matching cohort study. DEN OPEN 2024; 4:e328. [PMID: 38188356 PMCID: PMC10771227 DOI: 10.1002/deo2.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/28/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
Objectives Previous studies of cold snare polypectomy (CSP) for sessile serrated lesions (SSLs) ≥10 mm were performed by experienced endoscopists, and therefore their skills might have significantly influenced results. In this study, we compared the efficacy and safety of CSP for SSLs ≥10 mm between experienced and trainee endoscopists. Methods In a 1:1 propensity score matched retrospective cohort study, we compared the complete resection rate, en-bloc resection rate, adverse event rate, and procedure time between experienced and trainee groups. Thirteen endoscopists performed CSP, and we defined the experienced group as endoscopists with board certification from the Japan Gastroenterological Endoscopy Society. Results We examined 616 lesions with SSLs ≥10 mm resected by CSP between February 2018 and May 2022. We excluded 61 lesions from the analysis because they had simultaneously undergone hot snare polypectomy (n = 57) or had been taken over by experienced endoscopists from trainees in the CSP procedure (n = 4). Finally, we identified 217 propensity score-matched pairs (n = 434). Between experienced and trainee groups, the results were complete resection rate (100 vs. 100%; p = 1.00), en-bloc resection rate (73.2 vs. 75.6%; p = 0.24), adverse event rate (3.2 vs. 2.8%; p = 0.77), or procedure time (6.2 vs. 5.9 min; p = 0.64). Conclusions We have demonstrated the safety and efficacy of CSP for SSLs ≥10 mm performed by experienced and trainee endoscopists.
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Affiliation(s)
- Yoshiaki Kimoto
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Rikimaru Sawada
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Susumu Banjoya
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Toshihumi Iida
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Tomoya Kimura
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Koichi Furuta
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Shinya Nagae
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Yohei Ito
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Hiroshi Yamazaki
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Nao Takeuchi
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Syunya Takayanagi
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Yuki Kano
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Takashi Sakuno
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Kohei Ono
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Ryoju Negishi
- Division of GastroenterologyItabashi Chuo Medical CenterTokyoJapan
| | - Eiji Sakai
- Division of GastroenterologyYokohama Sakae Kyosai HospitalKanagawaJapan
| | - Yohei Minato
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Hideyuki Chiba
- Department of GastroenterologyOmori Red Cross HospitalTokyoJapan
| | - Ken Ohata
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
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10
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Ding C, Yang JF, Wang X, Zhou YF, Khizar H, Jin Z, Zhang XF. Cold EMR vs. Hot EMR for the removal of sessile serrated polyps larger than 10 mm: a systematic review and meta-analysis. BMC Surg 2024; 24:93. [PMID: 38509508 PMCID: PMC10953062 DOI: 10.1186/s12893-024-02325-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/16/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) appears to be a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. To assess the effectiveness and safety of EMR for removing SSPs ≥ 10 mm, we conducted this systematic review and meta-analysis. METHODS We conducted a thorough search of Embase, PubMed, Cochrane, and Web of Science databases for relevant studies reporting on EMR of SSPs ≥ 10 mm, up until December 2023. Our primary endpoints of interest were rates of technical success, residual SSPs, and adverse events (AE). RESULTS Our search identified 426 articles, of which 14 studies with 2262 SSPs were included for analysis. The rates of technical success, AEs, and residual SSPs were 100%, 2.0%, and 3.1%, respectively. Subgroup analysis showed that the technical success rates were the same for polyps 10-19 and 20 mm, and en-bloc and piecemeal resection. Residual SSPs rates were similar in en-bloc and piecemeal resection, but much lower in cold EMR (1.0% vs. 4.2%, P = 0.034). AEs rates were reduced in cold EMR compared to hot EMR (0% vs. 2.9%, P = 0.168), in polyps 10-19 mm compared to 20 mm (0% vs. 4.1%, P = 0.255), and in piecemeal resection compared to en-bloc (0% vs. 0.7%, P = 0.169). CONCLUSIONS EMR is an effective and safe technique for removing SSPs ≥ 10 mm. The therapeutic effect of cold EMR is superior to that of hot EMR, with a lower incidence of adverse effects. PROSPERO REGISTRATION NUMBER CRD42023388959.
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Affiliation(s)
- Cong Ding
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Jian-Feng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Xia Wang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Yi-Feng Zhou
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Hayat Khizar
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Zheng Jin
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China.
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China.
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11
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Gupta S, Craciun A, Wang H, Whitfield A, Gauci J, O'Sullivan T, Cronin O, Abu Arisha M, Klein A, Lee EYT, Burgess NG, Bourke MJ. Hybrid resection versus conventional resection for laterally spreading lesions of the papilla. Gastrointest Endosc 2024; 99:428-436. [PMID: 37858758 DOI: 10.1016/j.gie.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 09/06/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS Although conventional hot snare resection (CR) of laterally spreading lesions of the major papilla (LSL-Ps) is effective, it can be associated with delayed bleeding in upward of 25% of cases. Given the excellent safety profile of cold snare polypectomy in the colorectum, we investigated the efficacy and safety of a novel hybrid resection (HR) technique for LSL-P management, consisting of hot snare papillectomy plus cold snare resection of the laterally spreading component. METHODS A prospective cohort of patients underwent HR in a tertiary referral center over 60 months until December 2022. This cohort was compared with a historical cohort of patients who underwent CR at the same institution over 120 months until August 2017. The primary outcomes were recurrence and bleeding. RESULTS Twenty patients underwent HR (14 female; mean age 65.2 ± 12.2 years). Median lesion size was 30 mm (interquartile range, 25.0-47.5 mm). Recurrent or residual adenoma (RRA) was greater with HR (58.8% [n = 10] vs 29.8% [n = 14]; P = .034). The odds ratio for recurrence was 3.6 times (95% CI, 1.2-11.0) higher with HR (P = .027). RRA was multifocal in 4 (40%) and had a composite RRA volume >10 mm in 7 (70%). The median number of procedures required to treat RRA was higher with HR (4 vs 1, P = .002). There was no difference between CR and HR for intraprocedural bleeding (41.1% [n = 23] vs 25% [n = 5]; P = .587) or delayed bleeding (25.0% vs 10.0%, P = .211). There were no perforations. CONCLUSIONS The novel HR technique for LSL-P management is associated with a high rate of RRA that is recalcitrant to treatment, without mitigating the risk of intraprocedural or delayed bleeding. Therefore, CR should remain the mainstay management option for treating patients with an LSL-P. (Clinical trial registration number: NCT02306603.).
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Ana Craciun
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Departamento de Gastrenterologia e Hepatologia, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Julia Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Muhammad Abu Arisha
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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12
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Copland AP, Kahi CJ, Ko CW, Ginsberg GG. AGA Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review. Clin Gastroenterol Hepatol 2024; 22:470-479.e5. [PMID: 38032585 DOI: 10.1016/j.cgh.2023.10.012] [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: 05/03/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
DESCRIPTION In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.
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Affiliation(s)
- Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Charles J Kahi
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Cynthia W Ko
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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O'Sullivan T, Sidhu M, Gupta S, Byth K, Elhindi J, Tate D, Cronin O, Whitfield A, Wang H, Lee E, Williams S, Burgess NG, Bourke MJ. A novel tool for case selection in endoscopic mucosal resection training. Endoscopy 2023; 55:1095-1102. [PMID: 37391184 DOI: 10.1055/a-2121-1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND As endoscopic mucosal resection (EMR) of large (≥ 20 mm) adenomatous nonpedunculated colonic polyps (LNPCPs) becomes widely practiced outside expert centers, appropriate training is necessary to avoid failed resection and inappropriate surgical referral. No EMR-specific tool guides case selection for endoscopists learning EMR. This study aimed to develop an EMR case selection score (EMR-CSS) to identify potentially challenging lesions for "EMR-naïve" endoscopists developing competency. METHODS Consecutive EMRs were recruited from a single center over 130 months. Lesion characteristics, intraprocedural data, and adverse events were recorded. Challenging lesions with intraprocedural bleeding (IPB), intraprocedural perforation (IPP), or unsuccessful resection were identified and predictive variables identified. Significant variables were used to form a numerical score and receiver operating characteristic curves were used to generate cutoff values. RESULTS Of 1993 LNPCPs, 286 (14.4 %) were in challenging locations (anorectal junction, ileocecal valve, or appendiceal orifice), 368 (18.5 %) procedures were complicated by IPB and 77 (3.9 %) by IPP; 110 (5.5 %) procedures were unsuccessful. The composite end point of IPB, IPP, or unsuccessful EMR was present in 526 cases (26.4 %). Lesion size, challenging location, and sessile morphology were predictive of the composite outcome. A six-point score was generated with a cutoff value of 2 demonstrating 81 % sensitivity across the training and validation cohorts. CONCLUSIONS The EMR-CSS is a novel case selection tool for conventional EMR training, which identifies a subset of adenomatous LNPCPs that can be successfully and safely attempted in early EMR training.
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Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- The NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - James Elhindi
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Ghent, Ghent, Belgium
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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14
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Abdallah M, Ahmed K, Abbas D, Mohamed MFH, Suryawanshi G, McDonald N, Wilson N, Umar S, Shaukat A, Bilal M. Cold snare endoscopic mucosal resection for colon polyps: a systematic review and meta-analysis. Endoscopy 2023; 55:1083-1094. [PMID: 37451284 DOI: 10.1055/a-2129-5752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Cold snare endoscopic mucosal resection (CS-EMR) can reduce the risks associated with electrocautery during colon polyp resection. Data on efficacy are variable. This systematic review and meta-analysis aimed to estimate the pooled efficacy and safety rates of CS-EMR. METHODS We conducted a comprehensive literature search of multiple databases, from inception to March 2023, for studies addressing outcomes of CS-EMR for colon polyps. The weighted pooled estimates with 95 %CIs were calculated using the random effects model. I2 statistics were used to evaluate heterogeneity. RESULTS 4137 articles were reviewed, and 16 studies, including 2592 polyps in 1922 patients (51.4 % female), were included. Overall, 54.4 % of polyps were adenomas, 45 % were sessile serrated lesions (SSLs), and 0.6 % were invasive carcinomas. Polyp recurrence after CS-EMR was 6.7 % (95 %CI 2.4 %-17.4 %, I2 = 94 %). The recurrence rate was 12.3 % (95 %CI 3.4 %-35.7 %, I2 = 94 %) for polyps ≥ 20 mm, 17.1 % (95 %CI 4.6 %-46.7 %, I2 = 93 %) for adenomas, and 5.7 % (95 %CI 3.2 %-9.9 %, I2 = 50 %) for SSLs. The pooled intraprocedural bleeding rate was 2.6 % (95 %CI 1.5 %-4.5 %, I2 = 51 %), the delayed bleeding rate was 1.5 % (95 %CI 0.8 %-2.7 %, I2 = 18 %), and no perforations or post-polypectomy syndromes were reported, with estimated rates of 0.6 % (95 %CI 0.3 %-1.3 %, I2 = 0 %) and 0.6 % (95 %CI 0.3 %-1.4 %, I2 = 0 %), respectively. CONCLUSION CS-EMR demonstrated an excellent safety profile for colon polyps, with variable recurrence rates based on polyp size and histology. Large prospective studies are needed to validate these findings.
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Affiliation(s)
- Mohamed Abdallah
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Khalid Ahmed
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, United States
| | - Daniyal Abbas
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, United States
| | - Mouhand F H Mohamed
- Brown University, Warren Alpert Medical School, Providence, Rhode Island, United States
| | - Gaurav Suryawanshi
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Nicholas McDonald
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Natalie Wilson
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Shifa Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine and Population Health, NYU Grossman School of Medicine, New York, New York, United States
| | - Mohammad Bilal
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
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15
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Malik TF, Mohan BP, Deliwala S, Kassab LL, Chandan S, Sharma NR, Adler DG. Cold Versus Hot Endoscopic Mucosal Resection for Sessile Serrated Colorectal Polyps ≥10 mm: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023:00004836-990000000-00239. [PMID: 38019045 DOI: 10.1097/mcg.0000000000001951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/02/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION We performed a systematic review and meta-analysis studying the efficacy and safety of cold versus hot endoscopic mucosal resection (EMR) for resection of sessile serrated polyps (SSPs) ≥10 mm. METHODS Multiple databases were searched until January 2023 for studies reporting outcomes of cold versus hot EMR for SSPs ≥10 mm. The primary outcome was the residual SSP rate. Secondary outcomes included technical success rate, R0 resection rate, and adverse events. We used standard meta-analysis methods using the random-effects model, and I2% was used to assess heterogeneity. RESULTS Thirteen studies were included in the final analysis. In all, 1896 SSPs were included with a mean polyp size of 23.7 mm (range, 15.9 to 33). A total of 1452 SSPs were followed up for a median follow-up duration of 15.3 months (range, 6 to 37). The pooled residual SSP rate for cold EMR was 4.5% (95% CI: 1.0-17.4), and 5.1% (95% CI: 2.4-10.4) for hot EMR (P=0.9). The pooled rates of technical success, R0 resection, immediate bleeding, and perforation were comparable. Hot EMR was significantly associated with lower piecemeal resection (59.2% vs. 99.3%, P<0.001), higher en-bloc resection (41.4% vs. 1.4%, P<0.001), and delayed bleeding rate (4% vs. 0.7%, P=0.05) compared to cold EMR. CONCLUSIONS Cold EMR has similar efficacy compared to hot EMR for resection of SSP ≥ 10 mm, despite limitations in piecemeal R0 resection rate reporting. Although hot EMR was associated with a higher rate of en-bloc resection, it also showed an increased risk of delayed bleeding compared to cold EMR.
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Affiliation(s)
- Talia F Malik
- Department of Internal Medicine, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Babu P Mohan
- Department of Gastroenterology & Hepatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Smit Deliwala
- Department of Gastroenterology & Hepatology, Emory University, Atlanta, GA
| | - Lena L Kassab
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Saurabh Chandan
- Department of Gastroenterology, CHI Creighton University Medical Center, Omaha, NE
| | - Neil R Sharma
- Department of Gastroenterology, Parkview Cancer Institute, Fort Wayne, IN
| | - Douglas G Adler
- Department of Gastroenterology, Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, CO
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16
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Liang Z, Wei Y, Zhang S, Li P. The efficacy and safety of cold snare polypectomy with submucosal injection for the removal of polyps less than 20 mm in size: a systematic review and meta-analysis. J Gastroenterol Hepatol 2023; 38:1892-1899. [PMID: 37608577 DOI: 10.1111/jgh.16308] [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: 03/10/2023] [Revised: 06/25/2023] [Accepted: 07/10/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND AIM Neoplastic polyp removal is important for colorectal cancer prevention. Endoscopists have proposed cold snare endoscopic mucosal resection (CS-EMR) as a solution to solve positive cutting edges and postoperative bleeding. However, many controversies regarding its specific performance in practice have been reported. The aim of this pooled analysis was to report the efficacy and safety of CS-EMR. METHODS PubMed/Medline, Embase, Google Scholar, and the Cochrane Library searched up to January 2022 to identify studies in which CS-EMR was performed for the removal of colorectal polyps measuring less than 20 mm. The primary outcome was the complete resection rate (CRR), and the secondary outcome was the rate of adverse events. RESULTS Eleven studies were included in the final analysis, which included 861 colorectal polyps. The overall CRR with CS-EMR was 96.3% (95% CI, 93.9-98.2%). The early and delayed bleeding rates of CS-EMR were 3.1% (95% CI, 1.2-5.5%) and 1.4% (95% CI, 0.6-2.4%), respectively. There were no statistical significances between CS-EMR and cold snare polypectomy (CSP) in terms of the CRR and adverse events, as well as CS-EMR and hot snare endoscopic mucosal resection (HS-EMR). CONCLUSIONS For resecting colorectal polyps measuring ≤20 mm, CS-EMR is an effective attempt. However, compared with CSP and HS-EMR, CS-EMR did not improve the efficiency and safety of polypectomy as expected. Multicenter randomized controlled trials are needed to compare CSP with CS-EMR in the resection of <10 mm polyps and HSP with CS-EMR in the resection of ≥10 mm polyps.
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Affiliation(s)
- Zheng Liang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China
| | - Yongqiu Wei
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China
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von Renteln D, Djinbachian R, Benard F, Barkun AN, Bouin M, Bouchard S, Deslandres É, Panzini B, Sidani S, Leduc R, Jobse BC, Pohl H. Incomplete resection of colorectal polyps of 4-20 mm in size when using a cold snare, and its associated factors. Endoscopy 2023; 55:929-937. [PMID: 36377124 DOI: 10.1055/a-1978-3277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND : Cold snare polypectomy (CSP) is increasingly used for polypectomy and is recommended as the first-line modality for small (< 10 mm) polyps. This study aimed to evaluate incomplete resection rates (IRRs) when using CSP for colorectal polyps of 4-20 mm. METHODS : Adults (45-80 years) undergoing screening, surveillance, or diagnostic colonoscopy and CSP by one of nine endoscopists were included. The primary outcome was the IRR for colorectal polyps of 4-20 mm, defined as the presence of polyp tissue in marginal biopsies after resection of serrated polyps or adenomas. Secondary outcomes included the IRR for serrated polyps, ease of resection, and complications. RESULTS: 413 patients were included (mean age 63; 48 % women) and 182 polyps sized 4-20 mm were detected and removed by CSP. CSP required conversion to hot snare resection in < 1 % of polyps of < 10 mm and 44 % of polyps sized 10-20 mm. The IRRs for polyps < 10 mm and ≥ 10 mm were 18 % and 21 %. The IRR was higher for serrated polyps (26 %) compared with adenomas (16 %). The IRR was higher for flat (IIa) polyps (odds ratio [OR] 2.9, 95 %CI 1.1-7.4); and when resection was judged as difficult (OR 4.2, 95 %CI 1.5-12.1), piecemeal resection was performed (OR 6.6, 95 %CI 2.0-22.0), or visible residual polyp was present after the initial resection (OR 5.4, 95 %CI 2.0-14.9). Polyp location, use of a dedicated cold snare, and submucosal injection were not associated with incomplete resection. Intraprocedural bleeding requiring endoscopic intervention occurred in 4.7 %. CONCLUSIONS : CSP for polyps of 4-9 mm is safe and feasible; however, for lesions ≥ 10 mm, CSP failure occurs frequently, and the IRR remains high even after technical success. Incomplete resection was associated with flat polyps, visual residual polyp, piecemeal resection, and difficult polypectomies.
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Affiliation(s)
- Daniel von Renteln
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Roupen Djinbachian
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Florence Benard
- Division of General Surgery, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Mickael Bouin
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Simon Bouchard
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Érik Deslandres
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Benoit Panzini
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Sacha Sidani
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Raymond Leduc
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Bruce C Jobse
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
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18
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Capogreco A, Alfarone L, Massimi D, Repici A. Cold resection for colorectal polyps: where we are and where we are going? Expert Rev Gastroenterol Hepatol 2023; 17:719-730. [PMID: 37318101 DOI: 10.1080/17474124.2023.2223976] [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: 04/03/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Endoscopic resection of colonic precancerous lesions has been demonstrated to significantly decrease colorectal cancer (CRC) incidence and mortality. Among resection techniques, cold snare polypectomy (CSP) has been shown as a highly feasible, effective and safe option and is widely used in clinical practice, being regarded as the first-line technique for removal of small and diminutive colorectal polyps. On the other hand, conventional hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR), namely the gold standard treatments for larger polyps, may be occasionally associated to complications due to electrocautery injury. AREAS COVERED To overcome these shortcomings of electrocautery-based resection techniques, in the last few years CSP has been increasingly assessed as a treatment option for additional indications, with a focus on nonpedunculated colorectal polyps ≥10 mm. EXPERT OPINION This review aims to present current and widened indications of CSP discussing the latest findings from the most remarkable studies, with an insight into technical issues, novelties and potential advances in the near future.
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Affiliation(s)
- Antonio Capogreco
- Department of Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Ludovico Alfarone
- Department of Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of biomedical scienses, Humanitas University, Milan, Italy
| | - Davide Massimi
- Department of Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Alessandro Repici
- Department of biomedical scienses, Humanitas University, Milan, Italy
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19
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Tate DJ, Argenziano ME, Anderson J, Bhandari P, Boškoski I, Bugajski M, Desomer L, Heitman SJ, Kashida H, Kriazhov V, Lee RRT, Lyutakov I, Pimentel-Nunes P, Rivero-Sánchez L, Thomas-Gibson S, Thorlacius H, Bourke MJ, Tham TC, Bisschops R. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023. [PMID: 37285908 DOI: 10.1055/a-2077-0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
- Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
| | - John Anderson
- Cheltenham General Hospital, Gloucestershire Hospitals Foundation Trust, Cheltenham, UK
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marek Bugajski
- Department of Gastroenterology, Luxmed Oncology, Warsaw, Poland
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Vladimir Kriazhov
- Endoscopy Department, Nizhny Novgorod Regional Clinical Oncology Center, Nizhny Novgorod, Russia Federation
| | - Ralph R T Lee
- The Ottawa Hospital - Civic Campus, University of Ottawa, Ottawa, Canada
| | - Ivan Lyutakov
- University Hospital Tsaritsa Yoanna-ISUL, Medical University Sofia, Sofia, Bulgaria
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
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Jiang Q, Yan X, Wang D, Zhang S, Zhang Y, Feng Y, Yang A, Wu D. Endoscopic mucosal resection using cold snare versus hot snare in treatment for 10-19 mm non-pedunculated colorectal polyps: protocol of a non-inferiority randomised controlled study. BMJ Open 2023; 13:e070321. [PMID: 37217262 DOI: 10.1136/bmjopen-2022-070321] [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] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Cold polypectomy has the advantages of simple operation, less time-consuming and fewer complications. Guidelines have recommended cold snare polypectomy (CSP) to resect small polyps sized ≤5 mm and sessile polyps sized 6-9 mm. However, evidence is scarce regarding cold resection for non-pedunculated polyps sized ≥10 mm. Cold snare endoscopic mucosal resection (CS-EMR) combining CSP and submucosal injection was designed to improve the complete resection rate and reduce adverse events. We hypothesise that CS-EMR is non-inferior to conventional hot snare endoscopic mucosal resection (HS-EMR) in the resection of 10-19 mm non-pedunculated colorectal polyps. METHODS AND ANALYSIS This study is a prospective, randomised, open-label, non-inferiority, single-centre trial. Outpatients scheduled to undergo a colonoscopy and present eligible polyps will be randomised to receive either CS-EMR or HS-EMR. The primary endpoint is the complete resection. Considering that HS-EMR of 10-19 mm colorectal polyps will yield a complete resection rate of at least 92% and a non-inferiority margin of -10%, a total of 232 polyps will be included (one-sided α, 2.5%; β, 20%). The analyses are intended to evaluate first non-inferiority (lower limit 95% CI greater than -10% for group difference) and then superiority (lower limit 95% CI>0%) if non-inferiority is achieved. Secondary endpoints include en-bloc resection, the occurrence of adverse events, the use of endoscopic clips, resection time and cost. ETHICS AND DISSEMINATION The study has been approved by the institutional review board of the Peking Union Medical College Hospital (No. K2203). All participants in the trial will provide written informed consent. The results of this trial will be published in an open-access way. TRIAL REGISTRATION NUMBER NCT05545787.
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Affiliation(s)
- Qingwei Jiang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaxiao Yan
- Eight-year Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Duan Wang
- Eight-year Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengyu Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunlu Feng
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Katagiri A, Suzuki N, Nakatani S, Kikuchi K, Fujiwara T, Gocho T, Konda K, Inoki K, Yamamura F, Yoshida H. Submucosal Injection Using Epinephrine-Added Saline in Cold Snare Polypectomy for Colorectal Polyps Shortens Time Required for Resection: A Randomized Controlled Study. Cureus 2023; 15:e39164. [PMID: 37332405 PMCID: PMC10276175 DOI: 10.7759/cureus.39164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
AIMS Immediate bleeding after cold snare polypectomy (CSP) for colorectal polyps might interfere with confirmation of residuals and prolong the time required for resection. We investigated whether submucosal epinephrine-added saline injection reduces the time required for the CSP procedure. METHODS We conducted a single-center, prospective, randomized controlled trial (clinical trial registration number: UMIN000046770). Patients with colorectal polyps ≤ 10 mm were randomly allocated to either CSP with epinephrine-added submucosal injection (CEMR group) or conventional CSP (CSP group). The primary outcome was the time required for resection defined as the time from the initiation of resection (the first insertion of the snare in the CSP group or the injection needle in the CEMR group) to the end of resection (confirming complete resection endoscopically after recognizing the cessation of immediate bleeding) in each lesion, and the secondary outcome was the time to spontaneous cessation of immediate bleeding after resection defined as the time from ensnaring the lesion to confirming the spontaneous cessation of immediate bleeding. RESULTS A total of 126 patients were randomly assigned. Finally, 261 lesions in 118 patients (CEMR group, n = 59; CSP group, n = 59) were analyzed. The time required for resection calculated using the least-square mean was significantly shorter in the CEMR group (106.3 s, 95% CI 97.5 to 115.4 s) than in the CSP group (130.9 s, 95% CI 121.2 to 140.7 s) (P < 0.001). The time to spontaneous cessation of immediate bleeding was also significantly shorter in the CEMR group (20.4 s, 95% CI 14.3 to 26.5 s) than in the CSP group (74.2 s, 95% CI 67.6 to 80.7 s) (P < 0.001). Neither group had cases requiring hemostasis, perforation, or delayed bleeding. CONCLUSIONS CEMR shortened the time for resection by shortening the time to cessation of immediate bleeding compared with conventional CSP in colorectal polyps ≤ 10 mm.
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Affiliation(s)
- Atsushi Katagiri
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Norihiro Suzuki
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Shinya Nakatani
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Kazuo Kikuchi
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Takahisa Fujiwara
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Toshihiko Gocho
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Kenichi Konda
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Kazuya Inoki
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Fuyuhiko Yamamura
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
| | - Hitoshi Yoshida
- Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, JPN
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Motchum L, Djinbachian R, Rahme E, Taghiakbari M, Bouchard S, Bouin M, Sidani S, Deslandres É, Takla M, Frija-Gruman NM, Barkun A, von Renteln D. Incomplete resection rates of 4- to 20-mm non-pedunculated colorectal polyps when using wide-field cold snare resection with routine submucosal injection. Endosc Int Open 2023; 11:E480-E489. [PMID: 37206693 PMCID: PMC10191736 DOI: 10.1055/a-2029-2392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/31/2023] [Indexed: 05/21/2023] Open
Abstract
Background and study aims Incomplete resection of 4- to 20-mm colorectal polyps occur frequently (> 10 %), putting patients at risk for post-colonoscopy colorectal cancer. We hypothesized that routine use of wide-field cold snare resection with submucosal injection (CSP-SI) might reduce incomplete resection rates (IRRs). Patients and methods Patients aged 45 to 80 years undergoing elective colonoscopies were enrolled in a prospective clinical study. All 4- to 20-mm non-pedunculated polyps were resected using CSP-SI. Post-polypectomy margin biopsies were obtained to determine IRRs through histopathology assessment. The primary outcome was IRR, defined as remnant polyp tissue found on margin biopsies. Secondary outcomes included technical success and complication rates. Results A total of 429 patients (median age 65 years, 47.1 % female, adenoma detection rate 40 %) with 204 non-pedunculated colorectal polyps 4 to 20 mm removed using CSP-SI were included in the final analysis. CSP-SI was technical successful in 97.5 % (199/204) of cases (5 conversion to hot snare polypectomy). IRR for CSP-SI was 3.8 % (7/183) (95 % confidence interval [CI] 2.7 %-5.5 %). IRR was 1.6 % (2/129), 16 % (4/25), and 3.4 % (1/29) for adenomas, serrated lesions, and hyperplastic polyps respectively. IRR was 2.3 % (2/87), 6.3 % (4/64), 4.0 % (6/151), and 3.1 % (1/32) for polyps 4 to 5 mm, 6 to 9 mm, < 10 mm, and 10 to 20 mm, respectively. There were no CSP-SI-related serious adverse events. Conclusions Use of CSP-SI results in lower IRRs compared to what has previously been reported in the literature for hot or cold snare polypectomy when not using wide-field cold snare resection with submucosal injection. CSP-SI showed an excellent safety and efficacy profile, however comparative studies to CSP without SI are required to confirm these results.
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Affiliation(s)
- Leslie Motchum
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Faculty of Medicine of Montreal University, Montreal, Canada
| | - Roupen Djinbachian
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Elham Rahme
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Mahsa Taghiakbari
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Faculty of Medicine of Montreal University, Montreal, Canada
| | - Simon Bouchard
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Mickaël Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sacha Sidani
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Érik Deslandres
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Mark Takla
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Faculty of Medicine of Montreal University, Montreal, Canada
| | | | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
- Division of Clinical Epidemiology, McGill University Health Center, McGill University, 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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23
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Ishibashi F, Suzuki S, Nagai M, Mochida K, Morishita T. Colorectal cold snare polypectomy: Current standard technique and future perspectives. Dig Endosc 2023; 35:278-286. [PMID: 35962754 DOI: 10.1111/den.14420] [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: 06/22/2022] [Accepted: 08/12/2022] [Indexed: 02/08/2023]
Abstract
It has been shown that resection of adenomatous colorectal polyps can reduce mortality due to colorectal cancer. In daily clinical practice, simpler and safer methods of colorectal polypectomy have been sought to enable endoscopists to resect all detected lesions. Among these, cold snare polypectomy (CSP) is widely used in clinical practice because of its advantages in shortening procedure time, reducing delayed bleeding risk, and lowering treatment costs, while maintaining a similar complete resection rate for lesions smaller than 10 mm when compared to conventional hot snare polypectomy. This review introduces the findings of previous studies that investigated the efficacy and safety of the CSP procedure for nonpedunculated polyps smaller than 10 mm, and describes technical points to remember when practicing CSP based on the latest evidence, including using a thin wire snare specifically designed for CSP, and observing the surrounding mucosa of the resection site with chromoendoscopy or image-enhanced endoscopy to ensure that there is no residual lesion. This review also describes the potential of expanding the indication of CSP as a treatment for lesions larger than 10 mm, those with pedunculated morphology, those located near the appendiceal orifice, and for patients under continuous antithrombotic agent therapy. Finally, the perspective on optimal treatments for recurrent lesions after CSP is also discussed, despite the limited related evidence and data.
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Affiliation(s)
- Fumiaki Ishibashi
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Sho Suzuki
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Mizuki Nagai
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Kentaro Mochida
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Tetsuo Morishita
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in flexible sigmoidoscopy. Frontline Gastroenterol 2023; 14:181-200. [PMID: 37056324 PMCID: PMC10086722 DOI: 10.1136/flgastro-2022-102259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionJoint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).MethodsA modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.ResultsIn total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Vathsan Ravindran
- Department of Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Ian L P Beales
- University of East Anglia, Norwich, UK
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Elizabeth Ratcliffe
- Department of Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
- Division of Diabetes, Endocrinology and Gastroenterology Faculty of Biology, Medicine and Health School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Catherine Regan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, UK
| | - Eleanor Wood
- Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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25
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in colonoscopy. Frontline Gastroenterol 2023; 14:201-221. [PMID: 37056319 PMCID: PMC10086724 DOI: 10.1136/flgastro-2022-102260] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionIn the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.MethodsUnder the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.ResultsIn total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate–severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, Greater London, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, UK
| | - John Anderson
- Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Vathsan Ravindran
- Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Ian L P Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
- University of East Anglia, Norwich, Norfolk, UK
| | | | - Nicholas I Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Edinburgh, UK
| | - Elizabeth Ratcliffe
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, Manchester, UK
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, Wigan, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Catherine Regan
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, Tyne and Wear, UK
| | - Eleanor Wood
- Department of Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, Gloucestershire, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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26
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Kim MJ, Na SY, Kim JS, Choi HH, Kim DB, Ji JS, Kim BW, Choi H. Cold snare polypectomy versus cold endoscopic mucosal resection for small colorectal polyps: a multicenter randomized controlled trial. Surg Endosc 2023; 37:3789-3795. [PMID: 36690892 DOI: 10.1007/s00464-023-09875-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is recommended for the resection of small colorectal polyps. However, few studies have investigated the efficacy of cold endoscopic mucosal resection (cold EMR) for small polyps. Thus, the aim of this study was to investigate the efficacy and safety of cold EMR compared with CSP for small colorectal polyps. METHODS This was a multicenter, randomized trial conducted in three tertiary centers from January 2018 to February 2021. Patients with polyps sized 6-10 mm were randomized to CSP or cold EMR group. After polypectomy, two additional biopsies were performed to assess the completeness of resection. The primary outcome was complete polyp resection rate. Secondary outcomes were total procedure time and rate of adverse events such as immediate bleeding, delayed bleeding, and perforation. RESULTS A total of 444 polyps in 327 patients were assessed and randomly assigned to each group. Of those, 425 polyps were finally analyzed based on pathology results. The complete resection rate was not significantly different between cold EMR and CSP groups (91.9% vs 89.8%, p = 0.24). However, the total procedure time was significantly increased in cold EMR (87.6 s vs. 45.8 s, p < 0.001). The rate of polypectomy adverse events was not significantly different between the two groups. No patient had massive bleeding or perforation. CONCLUSIONS There was no difference in complete resection rate or adverse events between CSP and cold EMR. However, CSP reduced the total procedure time.
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Affiliation(s)
- Min Ji Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo Young Na
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Hyun Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dae Bum Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong-Seon Ji
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwang Choi
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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27
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Rex DK, Pohl H. Selective Use of Endoscopic Submucosal Dissection Appropriate for Large Nonpedunculated Colorectal Neoplasms. Gastroenterology 2022; 164:1341-1342. [PMID: 36379248 DOI: 10.1053/j.gastro.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heiko Pohl
- Veterans Affairs Medical Center, White River Junction, Vermont, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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28
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Li DF, Van Overbeke L, Ohata K, Wang LS, Yao J. Efficacy and safety of cold snare polypectomy for sessile serrated polyps ≥ 10 mm: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1486-1493. [PMID: 35168877 DOI: 10.1016/j.dld.2022.01.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. However, the efficacy and safety of this technique remain undetermined. AIMS We aimed to comprehensively evaluate the efficacy and safety of CSP for SSPs ≥ 10 mm. METHODS PubMed, EMBASE, Web of Science and Cochrane Library were searched up to January 2021. RESULTS A total of 10 studies consisting of 1727 SSPs (range, 10-40 mm) from 1021 patients were included. The overall rates of technical success, adverse events (AEs) and residual SSPs were 100%, 0.7% and 2.9%, respectively. Subgroup analysis showed that the rates of technical success and AEs were comparable between CSP and cold endoscopic mucosal resection (EMR) (99.9% vs. 100% and 1.3% vs. 0.5%, respectively), between the proximal and distal colon (100% vs. 99.9% and 0.3% vs. 0, respectively), and between polyps of 10-19 mm and ≥20 mm (99.8% vs. 100% and 0.9% vs. 0, respectively). However, subgroup analysis showed that the rate of residual SSPs was slightly lower in CSP compared with cold EMR (1.3% vs. 3.9%), as well as in polyps of 10-19 mm compared with those ≥20 mm (3.1% vs. 4.7%). CONCLUSION CSP was an effective and safe technique for removing SSPs ≥ 10 mm.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China
| | | | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China.
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China.
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29
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Pedersen IB, Rawa-Golebiewska A, Calderwood AH, Brix LD, Grode LB, Botteri E, Bugajski M, Kaminski MF, Januszewicz W, Ødegaard H, Kleist B, Kalager M, Løberg M, Bretthauer M, Hoff G, Medhus A, Holme Ø. Complete polyp resection with cold snare versus hot snare polypectomy for polyps of 4-9 mm: a randomized controlled trial. Endoscopy 2022; 54:961-969. [PMID: 35008112 DOI: 10.1055/a-1734-7952] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic screening with polypectomy reduces the incidence of colorectal cancer (CRC). Incomplete polyp removal may attenuate the effect of screening. This randomized trial compared cold snare polypectomy (CSP) with hot snare polypectomy (HSP) in terms of complete polyp resection. METHODS We included patients ≥ 40 years of age at eight hospitals in four countries who had at least one non-pedunculated polyp of 4-9 mm detected at colonoscopy. Patients were randomized 1:1 to CSP or HSP. Biopsies from the resection margins were obtained systematically after polypectomy in both groups. We hypothesized that CSP would be non-inferior to HSP, with a non-inferiority margin of 5 %. Logistic regression models were fitted to identify the factors explaining incomplete resection. RESULTS 425 patients, with 601 polyps, randomized to either CSP or HSP were included in the analysis. Of 318 polyps removed by CSP and 283 polyps removed by HSP, 34 (10.7 %) and 21 (7.4 %) were incompletely resected, respectively, with an adjusted risk difference of 3.2 % (95 %CI -1.4 % to 7.8 %). There was no difference between the groups in terms of post-polypectomy bleeding, perforation, or abdominal pain. Independent risk factors for incomplete removal were serrated histology (odds ratio [OR] 3.96; 95 %CI 1.63 to 9.66) and hyperplastic histology (OR 2.52; 95 %CI 1.30 to 4.86) in adjusted analyses. CONCLUSION In this randomized trial, non-inferiority for CSP could not be demonstrated. Polyps with serrated histology are more prone to incomplete resection compared with adenomas. CSP can be used safely for small polyps in routine colonoscopy practice.
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Affiliation(s)
- Ina B Pedersen
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway.,Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
| | - Anna Rawa-Golebiewska
- Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Audrey H Calderwood
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Lone D Brix
- Department of Anesthesiology, Surgery and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | - Louise B Grode
- Department of Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway.,Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Marek Bugajski
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Michal F Kaminski
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Wladyslaw Januszewicz
- Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | | | - Britta Kleist
- Department of Pathology, Sørlandet hospital, Kristiansand, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway.,Department of Medicine, Telemark Hospital Skien, Skien, Norway
| | - Asle Medhus
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Øyvind Holme
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway.,Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
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30
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Rotermund C, Djinbachian R, Taghiakbari M, Enderle MD, Eickhoff A, von Renteln D. Recurrence rates after endoscopic resection of large colorectal polyps: A systematic review and meta-analysis. World J Gastroenterol 2022; 28:4007-4018. [PMID: 36157546 PMCID: PMC9367239 DOI: 10.3748/wjg.v28.i29.4007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/11/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Complete polyp resection is the main goal of endoscopic removal of large colonic polyps. Resection techniques have evolved in recent years and endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) with margin ablation, cold snare polypectomy (CSP), cold EMR, and underwater EMR have been introduced. Yet, efficacy of these techniques with regard to local recurrence rates (LRRs) vs traditional hot snare polypectomy and standard EMR remains unclear.
AIM To analyze LRR of large colonic polyps in a systematic review and meta-analysis.
METHODS MEDLINE, EMBASE, EBM Reviews, and CINAHL were searched for prospective studies reporting LRR or incomplete resection rate (IRR) after colonic polypectomy of polyps ≥ 10 mm, published between January 2011 and July 2021. Primary outcome was LRR for polyps ≥ 10 mm.
RESULTS Six thousand nine hundred and twenty-eight publications were identified, of which 34 prospective studies were included. LRR for polyps ≥ 10 mm at up to 12 mo’ follow-up was 11.0% (95%CI, 7.1%-14.8%; 15 studies; 4904 polyps). ESD (1.7%; 95%CI, 0%-3.4%; 3 studies, 221 polyps) and endoscopic mucosal resection with margin ablation (3.3%; 95%CI, 2.2%-4.5%; 2 studies, 947 polyps) significantly reduced LRR vs standard EMR without (15.2%; 95%CI, 12.5%-18.0%; 4 studies, 650 polyps) or with unsystematic margin ablation (16.5%; 95%CI, 15.2%-17.8%; 6 studies, 3031 polyps).
CONCLUSION LRR is significantly lower after ESD or EMR with routine margin ablation; thus, these techniques should be considered standard for endoscopic removal of large colorectal polyps. Other techniques, such as CSP, cold EMR, and underwater EMR require further evaluation in prospective studies before their routine implementation in clinical practice can be recommended.
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Affiliation(s)
- Carola Rotermund
- Research and Basic Technologies, ERBE Elektromedizin GmbH, Tuebingen 72072, Germany
| | - Roupen Djinbachian
- Division of Internal Medicine, Montreal University Hospital Center, Montreal QC H2X 3E4, Canada
| | - Mahsa Taghiakbari
- Montreal University Hospital Research Center, Montreal University Hospital Center, Montreal QC H2X 3E4, Canada
| | - Markus D Enderle
- Research and Basic Technologies, ERBE Elektromedizin GmbH, Tuebingen 72072, Germany
| | - Axel Eickhoff
- Department of Internal Medicine II, Klinikum Hanau, Hanau 63450, Germany
| | - Daniel von Renteln
- Montreal University Hospital Research Center, Montreal University Hospital Center, Montreal QC H2X 3E4, Canada
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31
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Clip Closure Does Not Reduce Risk of Bleeding After Resection of Large Serrated Polyps: Results From a Randomized Trial. Clin Gastroenterol Hepatol 2022; 20:1757-1765.e4. [PMID: 34971811 DOI: 10.1016/j.cgh.2021.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Serrated polyps are important colorectal cancer precursors and are most commonly located in the proximal colon, where post-polypectomy bleeding rates are higher. There is limited clinical trial evidence to guide best practices for resection of large serrated polyps (LSPs). METHODS In a multicenter trial, patients with large (≥20 mm) non-pedunculated polyps undergoing endoscopic mucosal resection (EMR) were randomized to clipping of the resection base or no clipping. This analysis is stratified by histologic subtype of study polyp(s), categorized as serrated [sessile serrated lesions (SSLs) or hyperplastic polyps (HPs)] or adenomatous, comparing clip vs control groups. The primary outcome was severe post-procedure bleeding within 30 days of colonoscopy. RESULTS A total of 179 participants with 199 LSPs (191 SSLs and 8 HPs) and 730 participants with 771 adenomatous polyps were included in the study. Overall, 5 patients with LSPs (2.8%) experienced post-procedure bleeding compared with 42 (5.8%) of those with adenomas. There was no difference in post-procedure bleeding rates between patients in the clip vs control group among those with LSPs (2.3% vs 3.3%, respectively, difference 1.0%; P = NS). However, among those with adenomatous polyps, clipping was associated with a lower risk of post-procedure bleeding (3.9% vs 7.6%, difference 3.7%; P = .03) and overall serious adverse events (5.5% vs 10.6%, difference 5.1%; P = .01). CONCLUSION The post-procedure bleeding risk for LSPs removed via EMR is low, and there is no discernable benefit of prophylactic clipping of the resection base in this group. This study indicates that the benefit of endoscopic clipping following EMR may be specific for >2 cm adenomatous polyps located in the proximal colon. CLINICALTRIALS gov, Number: NCT01936948.
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Repeat Cold Snare Polypectomy Can Be Performed for Recurrent Benign Lesions After Cold Snare Polypectomy. Dig Dis Sci 2022; 67:3192-3199. [PMID: 34731360 DOI: 10.1007/s10620-021-07292-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Recurrence after cold snare polypectomy (CSP) sometimes occurs. We assessed the feasibility of repeat CSP for recurrence after CSP. METHODS We retrospectively reviewed recurrent lesions after CSP which were resected by repeat CSP from 2016 to 2021 in our institution and analyzed clinical outcomes of repeat CSP, comparing those of non-recurrent 454 lesions receiving standard CSP in 2016 and follow-up colonoscopy. We also analyzed the recurrent rate among cases receiving follow-up in both groups. Indication of repeat CSP was lesions diagnosed as benign tumors of ≤ 10 mm. RESULTS We analyzed 80 lesions receiving repeat CSP. The polyp size (mean ± standard deviation: SD) was 4.1 ± 2.3 mm (range 2-10 mm). The right-sided colon and non-polypoid morphology rates were 66.3% and 43.8%, respectively. Histopathological diagnosis was 66 adenomas, 12 sessile serrated lesions (SSLs), 1 SSL with dysplasia, and 1 high-grade dysplasia. The procedure time (min, mean ± SD) of repeat CSP was 0.9 ± 0.8. Regarding the comparison of repeat CSP/ standard CSP group, the en bloc resection and histopathological complete resection rates were 78.8%/ 98.0% (p < 0.001) and 43.8%/59.6% (p = 0.007) and the rates of perioperative hemorrhage requiring endoscopic clipping were 1.3%/ 1.0% (p = 0.646). There were no postoperative hemorrhage and perforation in both groups (p = 1.0). Among lesions receiving follow-up colonoscopy, the mean recurrence rates (number, median follow-up period: interquartile) of repeat CSP and standard CSP group were 2.0% (1/50, 12 months: 12-24) versus 0.7% (3/454, 12 months: 12-24) (p = 0.862). CONCLUSIONS Repeat CSP for benign recurrent lesions after CSP was safe and feasible.
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Yen AW, Leung JW, Koo M, Leung FW. Safety and effectiveness of underwater cold snare resection without submucosal injection of large non-pedunculated colorectal lesions. Endosc Int Open 2022; 10:E791-E800. [PMID: 35692912 PMCID: PMC9187401 DOI: 10.1055/a-1784-4523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022] Open
Abstract
Background and study aims Adverse events are uncommon with cold snaring, but cold techniques are generally reserved for lesions ≤ 9 mm out of concern for incomplete resection or inability to mechanically resect larger lesions. In a non-distended, water-filled lumen, colorectal lesions are not stretched, enabling capture and en bloc resection of large lesions. We assessed the effectiveness and safety of underwater cold snare resection (UCSR) without submucosal injection (SI) of ≥ 10 mm non-pedunculated, non-bulky (≤ 5 mm elevation) lesions with small, thin wire snares. Patients and methods Retrospective analysis of an observational cohort of lesions removed by UCSR during colonoscopy. A single endoscopist performed procedures using a small thin wire (9-mm diameter) cold or (10-mm diameter) hybrid snare. Results Fifty-three lesions (mean 15.8 mm [SD 6.9]; range 10-35 mm) were removed by UCSR from 44 patients. Compared to a historical cohort, significantly more lesions were resected en bloc by UCSR (84.9 % [45/53]; P = 0.04) compared to conventional endoscopic mucosal resection (EMR) (64.0 % [32/50]). Results were driven by high en bloc resection rates for 10- to 19-mm lesions (97.3 % [36/37]; P = 0.01). Multiple logistic regression analysis adjusted for potential confounders showed en bloc resection was significantly associated with UCSR compared to conventional EMR (OR 3.47, P = 0.027). Omission of SI and forgoing prophylactic clipping of post-resection sites did not result in adverse outcomes. Conclusions UCSR of ≥ 10 mm non-pedunculated, non-bulky colorectal lesions is feasible with high en bloc resection rates without adverse outcomes. Omission of SI and prophylactic clipping decreased resource utilization with economic benefits. UCSR deserves further evaluation in a prospective comparative study.
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Affiliation(s)
- Andrew W. Yen
- Sacramento Veterans Affairs Medical Center, VANCHCS, Division of Gastroenterology, Mather, California, United States,University of California Davis School of Medicine, Sacramento, California, United States
| | - Joseph W. Leung
- Sacramento Veterans Affairs Medical Center, VANCHCS, Division of Gastroenterology, Mather, California, United States,University of California Davis School of Medicine, Sacramento, California, United States
| | - Malcom Koo
- Graduate Institution of Long-term Care, Tzu Chi University of Science and Technology, Hualien City, Hualien, Taiwan,Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Felix W. Leung
- Sepulveda Ambulatory Care Center, VAGLAHS, Division of Gastroenterology, North Hills, California, United States,David Geffen School of Medicine at UCLA, Los Angeles, California, United States
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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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Abstract
Colorectal cancer (CRC) continues to be the third leading cause of cancer-related deaths in the US. Colonoscopy remains the best preventative tool against the development of CRC. As a result, high-quality colonoscopy is becoming increasingly important. Specifically, recent guidelines have highlighted pre-procedural, peri-procedural, and post-procedural practices, which promise to improve patient outcomes and reduce the mortality and interval cancer rates in patients undergoing colonoscopies. Despite the guidelines and advances in modern endoscopy, the procedure remains provider-dependent, which results in differences in outcomes. As a result, incorporating high-quality colonoscopy approaches early in training is key to improving patient outcomes. Additionally, ensuring that high-quality colonoscopy is practiced widely by endoscopists can lead to the most cost-effective care.
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Mehta D, Loutfy AH, Kushnir VM, Faulx AL, Smith ZL. Cold versus hot endoscopic mucosal resection for large sessile colon polyps: a cost-effectiveness analysis. Endoscopy 2022; 54:367-375. [PMID: 33782926 DOI: 10.1055/a-1469-2644] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND : For large sessile colorectal polyps (LSCPs), endoscopic mucosal resection without diathermy ("cold endoscopic mucosal resection [EMR]") is gaining popularity because of its safety advantages over conventional EMR ("hot EMR"). Polyp recurrence rates have been reported to be higher with cold EMR. Considering these differences, we performed a cost-effectiveness analysis of these two techniques. METHODS : A decision analysis model was constructed for EMR of an LSCP. The decision tree incorporated the EMR method, clip use, procedural mortality, adverse events and their management, and polyp recurrence. Outcomes included days of lost productivity and marginal cost difference. Adverse event and recurrence rates were extracted from the existing literature, giving emphasis to recent systematic reviews and randomized controlled trials. RESULTS : Through 30 months of follow-up, the average cost of removing an LSCP by cold EMR was US$5213, as compared to $6168 by hot EMR, yielding a $955 cost difference (95 % confidence interval $903-$1006). Average days of lost productivity were 6.2 days for cold EMR and 6.3 days for hot EMR. This cost advantage remained over several analyses accounting for variations in recurrence rates and clip closure strategies. Clip cost and LSCP recurrence rate had the greatest and the least impacts on the marginal cost difference, respectively. CONCLUSION : Cold EMR is the dominant strategy over hot EMR, with lower cost and fewer days of lost productivity. In theory, a complete transition to cold EMR for LSCPs in the USA could result in an annual cost saving approaching US$7 million to Medicare beneficiaries.
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Affiliation(s)
- Dhairya Mehta
- Department of Medicine, University Hospitals, Cleveland, Ohio, USA.,Division of Gastroenterology and Liver Disease, University Hospitals, Cleveland Medical Center, Cleveland, Ohio, USA.,Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Adam H Loutfy
- Department of Medicine, University Hospitals, Cleveland, Ohio, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ashley L Faulx
- Department of Medicine, University Hospitals, Cleveland, Ohio, USA.,Division of Gastroenterology and Liver Disease, University Hospitals, Cleveland Medical Center, Cleveland, Ohio, USA
| | - Zachary L Smith
- Department of Medicine, University Hospitals, Cleveland, Ohio, USA.,Division of Gastroenterology and Liver Disease, University Hospitals, Cleveland Medical Center, Cleveland, Ohio, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Kwok K, Tran T, Lew D. Polypectomy for Large Polyps with Endoscopic Mucosal Resection. Gastrointest Endosc Clin N Am 2022; 32:259-276. [PMID: 35361335 DOI: 10.1016/j.giec.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.
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Affiliation(s)
- Karl Kwok
- Interventional Endoscopy, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, 1526 North Edgemont Street, 7th Floor, Los Angeles, CA 90027, USA.
| | - Tri Tran
- Department of Medicine, Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Daniel Lew
- Division of Gastroenterology, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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Winter K, Włodarczyk M, Włodarczyk J, Dąbrowski I, Małecka-Wojciesko E, Dziki A, Spychalski M. Risk Stratification of Endoscopic Submucosal Dissection in Colon Tumors. J Clin Med 2022; 11:jcm11061560. [PMID: 35329886 PMCID: PMC8949025 DOI: 10.3390/jcm11061560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/27/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Endoscopic submucosal dissection (ESD) is a technique proven effective in the treatment of early neoplastic lesions in the gastrointestinal tract. However, in the case of colon lesions, many doubts remain. The purpose of our study is to stratify the success rates of the ESD procedure in the colon. Materials and Methods: A retrospective analysis of 601 patients who underwent ESD procedure for colorectal neoplasm from 2016 to 2019 in Center of Bowel Treatment, Brzeziny, Poland. Excluding 335 rectal neoplasms, we selected 266 patients with lesions located in the colon. Results: Lesions located in the left colon were characterized by the statistically higher en bloc resection and success rate, compared with the right colon—87.76% vs. 73.95% (p = 0.004) and 83.67% vs. 69.75% (p = 0.007), respectively. The success rate was significantly lower in lesions with submucosal cancer, compared to low- and high-grade dysplasia (p < 0.001). Polyps located in the right colon were characterized by a slightly higher complication rate compared to the left colon, without statistical significance—13.45% vs. 9.52% (p = 0.315). Conclusions: Our results show that colonic ESD has a high success rate, especially in the left colon, with a low risk of complications, slightly higher than in the right colon.
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Affiliation(s)
- Katarzyna Winter
- Center of Bowel Treatment, 95-060 Brzeziny, Poland; (I.D.); (M.S.)
- Clinical Department of General and Oncological Gastroenterology, University Clinical Hospital No. 1, Medical University of Lodz, 90-153 Lodz, Poland
- Correspondence: ; Tel.: +48-426-776-664; Fax: +48-678-6480
| | - Marcin Włodarczyk
- Department of General and Oncological Surgery, Medical University of Lodz, 90-153 Lodz, Poland; (M.W.); (J.W.)
| | - Jakub Włodarczyk
- Department of General and Oncological Surgery, Medical University of Lodz, 90-153 Lodz, Poland; (M.W.); (J.W.)
| | - Igor Dąbrowski
- Center of Bowel Treatment, 95-060 Brzeziny, Poland; (I.D.); (M.S.)
| | - Ewa Małecka-Wojciesko
- Department of Digestive Tract Diseases, Medical University of Lodz, 90-153 Lodz, Poland;
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Haller Square 1, 90-419 Lodz, Poland;
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Rashid MU, Alomari M, Afraz S, Erim T. EMR and ESD: Indications, techniques and results. Surg Oncol 2022; 43:101742. [DOI: 10.1016/j.suronc.2022.101742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/21/2022] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
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S. Al Ghamdi S, Leeds I, Fang S, Ngamruengphong S. Minimally Invasive Endoscopic and Surgical Management of Rectal Neoplasia. Cancers (Basel) 2022; 14:cancers14040948. [PMID: 35205695 PMCID: PMC8869910 DOI: 10.3390/cancers14040948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 12/10/2022] Open
Abstract
Rectal cancer demonstrates a characteristic natural history in which benign rectal neoplasia precedes malignancy. The worldwide burden of rectal cancer is significant, with rectal cancer accounting for one-third of colorectal cancer cases annually. The importance of early detection and successful management is essential in decreasing its clinical burden. Minimally invasive treatment of rectal neoplasia has evolved over the past several decades, which has led to reduced local recurrence rates and improved survival outcomes. The approach to diagnosis, staging, and selection of appropriate treatment modalities is a multidisciplinary effort combining interventional endoscopy, surgery, and radiology tools. This review examines the currently available minimally invasive endoscopic and surgical management options of rectal neoplasia.
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Affiliation(s)
- Sarah S. Al Ghamdi
- Division of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Ira Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Sandy Fang
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21224, USA;
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD 21224, USA
- Correspondence:
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Kimoto Y, Sakai E, Inamoto R, Kurebayashi M, Takayanagi S, Hirata T, Suzuki Y, Ishii R, Konishi T, Kanda K, Negishi R, Takita M, Ono K, Minato Y, Muramoto T, Ohata K. Safety and Efficacy of Cold Snare Polypectomy Without Submucosal Injection for Large Sessile Serrated Lesions: A Prospective Study. Clin Gastroenterol Hepatol 2022; 20:e132-e138. [PMID: 33152541 DOI: 10.1016/j.cgh.2020.10.053] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cold snare polypectomy (CSP) has become the standard resection method for small colorectal polyps (<10 mm). Sessile serrated lesions (SSL) have low prevalence of advanced histology irrespective of size, and thus could be amenable to CSP. In this study, we evaluated the safety and efficacy of CSP for SSLs ≥10 mm. METHODS Between November 2018 and January 2020, we prospectively enrolled 300 consecutive patients who underwent CSP for 474 SSLs ≥10 mm. To delineate SSL borders, indigo carmine chromoendoscopy and/or image-enhanced endoscopy was conducted. Piecemeal CSP (pCSP) was performed in cases where en-bloc resection was difficult. Biopsy specimens were obtained from the margins of the post-polypectomy defect to confirm complete resection. Surveillance colonoscopy was performed to screen for local recurrence. RESULTS All lesions were successfully resected using CSP without submucosal injection. The median diameter of the resected lesions was 14 mm, and pCSP was used to resect 106 (22%) lesions. Post-polypectomy biopsies revealed residual serrated tissue in only one case (0.2%). Adverse events included immediate bleeding in 8 (3%) patients; no delayed bleeding events occurred, irrespective of the use of antithrombotic drugs. During a 7-month median follow-up period, surveillance colonoscopies were performed for 384 lesions (81%), and no local recurrences were detected. CONCLUSIONS CSP without submucosal injection is a safe and effective treatment for SSLs ≥10 mm. UMIN Clinical Trials, Number: UMIN000034763.
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Affiliation(s)
- Yoshiaki Kimoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Eiji Sakai
- Division of Gastroenterology, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Rin Inamoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Marie Kurebayashi
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Syunya Takayanagi
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Tomoya Hirata
- Department of Gastroenterology, University of Miyazaki Hospital, Miyazaki, Japan
| | - Yuichiro Suzuki
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Rindo Ishii
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takafumi Konishi
- Department of Gastroenterology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Keisuke Kanda
- Department of Internal Medicine, Kameda Family Clinic, Tateyama, Japan
| | - Ryoju Negishi
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Maiko Takita
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Kohei Ono
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yohei Minato
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takashi Muramoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Tribonias G, Theodoropoulou A, Stylianou K, Giotis I, Mpitouli A, Moschovis D, Komeda Y, Manola ME, Paspatis G, Tzouvala M. Irrigating Acetic Acid Solution During Colonoscopy for the Detection of Sessile Serrated Neoplasia: A Randomized Controlled Trial. Dig Dis Sci 2022; 67:282-292. [PMID: 33515378 DOI: 10.1007/s10620-021-06858-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 01/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Misdiagnosed sessile serrated lesions (SSLs) are important precursors for interval colorectal cancers. AIMS We investigated the usage of acetic acid (AA) solution for improving the detection of SSLs in the right colon in a randomized controlled trial. METHODS A tandem observation of the right colon was performed in 412 consecutive patients. A first inspection was performed under white light high-definition endoscopy. In the AA group, a low concentration vinegar solution (AA: 0.005%) irrigated by a water pump in the right colon was compared with a plain solution of normal saline (NS) in the diagnostic yield of SSLs during the second inspection. Secondary outcomes in overall polyp detection were measured. RESULTS Qualitative comparisons showed significant differences in the detection rates of all polyps except adenomas, with remarkable improvement in the demonstration of advanced (> 20 mm), SSLs, and hyperplastic polyps during the second inspection of the right colon using the AA solution. Significant improvement was also noted in the AA group, as far as the mean number of polyps/patient detected, not only in SSLs (AA group: 0.14 vs. NS group: 0.01, P < 0.001), but also in all histological types and all size-categories in the right colon. Small (≤ 9 mm) polyps were detected at a higher rate in the sigmoid colon expanding the effect of the method in the rest of the colon. CONCLUSION AA-assisted colonoscopy led to a significant increase in SSLs detection rate in the right colon in a safe, quick, and effective manner.
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Affiliation(s)
- George Tribonias
- Gastroenterology Department, General Hospital of Nikaia-Piraeus "Agios Panteleimon", Mantouvalou D. 3, 18454, Athens, Greece.
| | - Angeliki Theodoropoulou
- Gastroenterology Department, General Hospital of Heraklion "Venizeleio - Pananeio", Crete, Greece
| | | | - Ioannis Giotis
- Gastroenterology Department, General Hospital of Nikaia-Piraeus "Agios Panteleimon", Mantouvalou D. 3, 18454, Athens, Greece
| | - Afroditi Mpitouli
- Gastroenterology Department, General Hospital of Heraklion "Venizeleio - Pananeio", Crete, Greece
| | - Dimitrios Moschovis
- Gastroenterology Department, General Hospital of Nikaia-Piraeus "Agios Panteleimon", Mantouvalou D. 3, 18454, Athens, Greece
| | - Yoriaki Komeda
- Gastroenterology Department, Kindai University Hospital, Osaka, Japan
| | - Margarita-Eleni Manola
- Gastroenterology Department, General Hospital of Nikaia-Piraeus "Agios Panteleimon", Mantouvalou D. 3, 18454, Athens, Greece
| | - Gregorios Paspatis
- Gastroenterology Department, General Hospital of Heraklion "Venizeleio - Pananeio", Crete, Greece
| | - Maria Tzouvala
- Gastroenterology Department, General Hospital of Nikaia-Piraeus "Agios Panteleimon", Mantouvalou D. 3, 18454, Athens, Greece
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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: 22] [Impact Index Per Article: 11.0] [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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45
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Takeuchi Y, Shichijo S, Uedo N, Kawakami Y, Okubo Y, Tani Y, Sakurai H, Nakamura T, Miyake M, Matsueda K, Ishihara R. Safety and efficacy of cold versus hot snare polypectomy including colorectal polyps ≥1 cm in size. Dig Endosc 2022; 34:274-283. [PMID: 34324730 DOI: 10.1111/den.14096] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/23/2022]
Abstract
Cold snare polypectomy (CSP; polypectomy without electrocautery) has spread rapidly worldwide during the past decade in what has been called "Cold Revolution". We performed a PubMed literature search for studies investigating CSP outcomes for colorectal polyps. Five randomized controlled trials (RCTs) assessed the complete resection rates (CRRs). The CRRs were similar regardless of the presence or absence of electrocautery, and the efficacy of submucosal injection for better CRRs is still controversial. Eight RCTs assessed the adverse events. The incidence of intraprocedural bleeding with cold procedures was comparable to or higher than that of hot procedures. The incidences of delayed bleeding were comparable to or lower with cold procedures, especially in patients taking anticoagulants. Fifteen studies have been reported on CSP for large (≥1 cm) colorectal polyps (10 retrospective studies, four prospective single-arm studies, and one prospective RCT). These studies reported that the safe cold procedures (a low intra- and post-procedural bleeding rate without perforation) could be implemented for lesions ≥1 cm. However, considering the incision depth of CSP and the local recurrence rate based on the current evidence, only large sessile serrated lesions (SSLs) can be candidates for cold procedures, and large adenomas should not be candidates for this procedure. Based on the current evidence, CSP seems to be the appropriate standard procedure for sub-centimeter colorectal low-grade adenomas due to its safety and simplicity. Thus, large SSLs can be candidates for cold procedures; however, careful inspection and further prospective studies are warranted to confirm the procedure's clinical relevance.
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Affiliation(s)
- Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yushi Kawakami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yuki Okubo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuhiro Tani
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hirohisa Sakurai
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takahiko Nakamura
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Muneaki Miyake
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Katsunori Matsueda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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46
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Markarian E, Fung BM, Girotra M, Tabibian JH. Large polyps: Pearls for the referring and receiving endoscopist. World J Gastrointest Endosc 2021; 13:638-648. [PMID: 35070025 PMCID: PMC8716985 DOI: 10.4253/wjge.v13.i12.638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/04/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Polyps are precursors to colorectal cancer, the third most common cancer in the United States. Large polyps, i.e.,, those with a size ≥ 20 mm, are more likely to harbor cancer. Colonic polyps can be removed through various techniques, with the goal to completely resect and prevent colorectal cancer; however, the management of large polyps can be relatively complex and challenging. Such polyps are generally more difficult to remove en bloc with conventional methods, and depending on level of expertise, may consequently be resected piecemeal, leading to an increased rate of incomplete removal and thus polyp recurrence. To effectively manage large polyps, endoscopists should be able to: (1) Evaluate the polyp for characteristics which predict high difficulty of resection or incomplete removal; (2) Determine the optimal resection technique (e.g., snare polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, etc.); and (3) Recognize when to refer to colleagues with greater expertise. This review covers important considerations in this regard for referring and receiving endoscopists and methods to best manage large colonic polyps.
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Affiliation(s)
- Eric Markarian
- Academy of Science and Medicine, Crescenta Valley High School, Los Angeles, CA 91214, United States
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ 85006, United States
- Division of Gastroenterology, Banner - University Medical Center Phoenix, Phoenix, AZ 85006, United States
| | - Mohit Girotra
- Section of Gastroenterology and Therapeutic Endoscopy, Digestive Health Institute, Swedish Medical Center, Seattle, WA 98104, United States
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
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47
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Lao W, Prasoon P, Cao G, Tan LT, Dai S, Devadasar GH, Huang X. Risk factors for incomplete polyp resection during colonoscopy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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48
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Tziatzios G, Gkolfakis P, Papadopoulos V, Papanikolaou IS, Fuccio L, Facciorusso A, Ebigbo A, Gölder SK, Probst A, Messmann H, Triantafyllou K. Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions. Ann Gastroenterol 2021; 34:757-769. [PMID: 34815641 PMCID: PMC8596214 DOI: 10.20524/aog.2021.0647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/24/2021] [Indexed: 11/13/2022] Open
Abstract
Endoscopic mucosal resection (EMR) is a technique allowing efficacious and minimally invasive resection of precancerous lesions across the entire gastrointestinal tract. However, conventional EMR, involving injection of fluid into the submucosal space, is imperfect, given the high rate of recurrence of post-endoscopic resection adenoma, especially after piecemeal resection. In light of these observations, modifications of the technique have been proposed to overcome the weakness of conventional EMR. Some of them were designed to maximize the chance of en bloc resection—cap-assisted EMR, underwater EMR, tip-in EMR, precutting, assisted by ligation device—while others were designed to minimize the complications (cold EMR). In this review, we present their modes of action and summarize the evidence regarding their efficacy and safety.
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Affiliation(s)
- Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece (Georgios Tziatzios, Ioannis S. Papanikolaou, Konstantinos Triantafyllou)
| | - Paraskevas Gkolfakis
- Department of Gastroenterology Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (Paraskevas Gkolfakis)
| | - Vasilios Papadopoulos
- Department of Gastroenterology, Koutlimbaneio & Triantafylleio General Hospital, Larissa, Greece (Vasilios Papadopoulos)
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece (Georgios Tziatzios, Ioannis S. Papanikolaou, Konstantinos Triantafyllou)
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy (Lorenzo Fuccio)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Italy (Antonio Facciorusso)
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Stefan Karl Gölder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece (Georgios Tziatzios, Ioannis S. Papanikolaou, Konstantinos Triantafyllou)
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49
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Toward safer and more efficacious colonoscopy polypectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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50
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van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, Bar-Yishay I, Schoeman S, Tate DJ, Byth K, Hewett DG, Pellisé M, Hourigan LF, Moss A, Tutticci N, Bourke MJ. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70:1691-1697. [PMID: 33172927 DOI: 10.1136/gutjnl-2020-321753] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known. DESIGN Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods. RESULTS A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively. CONCLUSIONS In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.
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Affiliation(s)
- W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kaushali Britto
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David James Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
| | - Karen Byth
- Biostatistics, Sydney University, Sydney, New South Wales, Australia
| | - David G Hewett
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - María Pellisé
- Gastroenterology, 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
| | - Luke F Hourigan
- Department of gastroenterology and hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,Department of gastroenterology and hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Tutticci
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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