ASGE review of adverse events in colonoscopy

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024

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.

Cold Vs Hot Snare Endoscopic Resection of Large Nonpedunculated Colorectal Polyps: Randomized Controlled German CHRONICLE Trial

BACKGROUND & AIMS

Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing.

METHODS

In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant.

RESULTS

Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and for high-grade dysplasia/cancer for residual adenoma (OR, 2.92).

CONCLUSIONS

Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170.

Screening for Colorectal Cancer

Colorectal cancer (CRC) is the second leading cause of cancer death. Screening has been proven to reduce both cancer incidence and cancer-related mortality. Various screening tests are available, each with their own advantages and disadvantages and varying levels of evidence to support their use. Clinicians should offer CRC screening to average-risk persons aged 50 to 75 years; starting screening at age 45 years remains controversial. Screening may be beneficial in select persons aged 76 to 85 years, based on their overall health and screening history. Offering a choice of screening tests or sequentially offering an alternate test for those who do not complete screening can significantly increase participation.

Deaths and cardiopulmonary events following colorectal cancer screening-A systematic review with meta-analyses

BACKGROUND

Colorectal cancer screening programmes (CRCSPs) are implemented worldwide despite recent evidence indicating more physical harm occurring during CRCSPs than previously thought. Therefore, we aimed to review the evidence on physical harms associated with endoscopic diagnostic procedures during CRCSPs and, when possible, to quantify the risk of the most serious types of physical harm during CRCSPs, i.e. deaths and cardiopulmonary events (CPEs).

METHODS

Systematic review with descriptive statistics and random-effects meta-analyses of studies investigating physical harms following CRCSPs. We conducted a systematic search in the literature and assessed the risk of bias and the certainty of the evidence.

RESULTS

We included 134 studies for review, reporting findings from 151 unique populations when accounting for multiple screening interventions per study. Physical harm can be categorized into 17 types of harm. The evidence was very heterogeneous with inadequate measurement and reporting of harms. The risk of bias was serious or critical in 95% of assessments of deaths and CPEs, and the certainty of the evidence was very low in all analyses. The risk of death was assessed for 57 populations with large variation across studies. Meta-analyses indicated that 3 to 23 deaths occur during CRCSPs per 100,000 people screened. Cardiopulmonary events were assessed for 55 populations. Despite our efforts to subcategorize CPEs into 17 distinct subtypes, 41% of CPE assessments were too poorly measured or reported to allow quantification. We found a tendency towards lower estimates of deaths and CPEs in studies with a critical risk of bias.

DISCUSSION

Deaths and CPEs during CRCSPs are rare, yet they do occur during CRCSPs. We believe that our findings are conservative due to the heterogeneity and low quality of the evidence. A standardized system for the measurement and reporting of the harms of screening is warranted.

TRIAL REGISTRATION

PROSPERO Registration number CRD42017058844.

An intraprocedural bowel cleansing system for difficult-to-prepare patients-A multicenter prospective feasibility study

BACKGROUND

Adequate bowel preparation is a prerequisite for colonoscopy. However, up to 20% of colonoscopies remain inadequately prepared. Risk factors for inadequate bowel preparation often overlap with those of failed cecal intubation. This study aimed to assess the feasibility of an intraprocedural bowel cleansing system (BCS) in patients with a history of inadequate bowel preparation.

METHODS

Patients (n = 44) with a history of inadequate bowel preparation in the past 2 years were included. After a limited preparation with 300 mL split-dose sodium picosulfate magnesium citrate, additional cleansing during colonoscopy was performed with the BCS. The primary outcome was adequate bowel preparation using the Boston Bowel Preparation Scale (BBPS). Secondary outcomes included cecal intubation rate, procedure times, usability, and safety.

RESULTS

Median BBPS increased from 1-2-2 (IQR 1-2) to 3-3-3 (IQR) (p < 0.0001), with 31.8% and 88.6% of patients adequately prepared before and after using the BCS, respectively (p < 0.0001). Cecal intubation rate was 88.6%. Reasons for incomplete colonoscopy were looping (n = 2), technical failure (n = 1), relative stricture (n = 1), and residual feces (n = 1). In patients with complete colonoscopy, the adequate cleansing rate was 97.5%. Median total procedure time was 26 min, of which 5.3 min were spent on cleaning. General ease of use was scored with a median of 4 out of 5, representing "as good as conventional colonoscopy". No serious adverse events occurred.

CONCLUSIONS

Adequate bowel cleaning can be achieved with an intraprocedural BCS in patients with a history of inadequate bowel preparation, which may reduce repeat colonoscopies and clinical admissions for bowel preparation. However, since these patients more frequently have complicated anatomy (surgical scarring, diverticulosis, etc.), adequate patient selection is advised to avoid incomplete procedures.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS)

BACKGROUND

Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement.

METHODS

Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy.

RESULTS

From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings.

CONCLUSIONS

This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.

Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases

BACKGROUND

Current evidence on the surgical rate, indication, procedure, risk factors, mortality, and postoperative rebleeding for acute lower gastrointestinal bleeding (ALGIB) is limited.

METHODS

We constructed a retrospective cohort of 10,342 patients admitted for acute hematochezia at 49 hospitals (CODE BLUE J-Study) and evaluated clinical data on the surgeries performed.

RESULTS

Surgery was performed in 1.3% (136/10342) of the cohort with high rates of colonoscopy (87.7%) and endoscopic hemostasis (26.7%). Indications for surgery included colonic diverticular bleeding (24%), colorectal cancer (22%), and small bowel bleeding (16%). Sixty-four percent of surgeries were for hemostasis for severe refractory bleeding. Postoperative rebleeding rates were 22% in patients with presumptive or obscure preoperative identification of the bleeding source and 12% in those with definitive identification. Thirty-day mortality rates were 1.5% and 0.8% in patients with and without surgery, respectively. Multivariate analysis showed that surgery-related risk factors were transfusion need ≥ 6 units (P < 0.001), in-hospital rebleeding (P < 0.001), small bowel bleeding (P < 0.001), colorectal cancer (P < 0.001), and hemorrhoids (P < 0.001). Endoscopic hemostasis was negatively associated with surgery (P = 0.003). For small bowel bleeding, the surgery rate was significantly lower in patients with endoscopic hemostasis as 2% compared to 12% without endoscopic hemostasis.

CONCLUSIONS

Our cohort study elucidated the outcomes and risks of the surgery. Extensive exploration including the small bowel to identify the source of bleeding and endoscopic hemostasis may reduce unnecessary surgery and improve the management of ALGIB.

PSMA-Targeted PET Radiotracer [18F]DCFPyL as an Imaging Biomarker in Inflammatory Bowel Disease

Background

Prostate-specific membrane antigen (PSMA) is highly and specifically upregulated in active-inflamed mucosa of patients with inflammatory bowel disease (IBD). We hypothesized that this upregulation would be detectable using a PSMA-targeted positron emission tomography/computed tomography (PET/CT) imaging agent, [18F]DCFPyL, enabling non-invasive visualization of inflammation. A noninvasive means of detecting active inflammation would have high clinical value in localization and management of IBD.

Study

We performed [18F]DCFPyL imaging in three IBD patients with active disease. Abnormally increased gastrointestinal [18F]DCFPyL uptake was observed in areas with endoscopic, histologic, and immunohistochemical inflammation, demonstrating partial overlap of segments of bowel with abnormal [18F]DCFPyL uptake and active inflammation.

Conclusion

This study demonstrates that PSMA-targeted [18F]DCFPyL PET can effectively detect regions of inflamed mucosa in patients with IBD, suggesting its utility as a non-invasive imaging agent to assess location, extent, and disease activity in IBD.

Differential impact of test performance characteristics on burden-to-benefit tradeoffs for blood-based colorectal cancer screening: A microsimulation analysis

OBJECTIVES

To inform the development and evaluation of new blood-based colorectal cancer (CRC) screening tests satisfying minimum United States (US) coverage criteria, we estimated the impact of the different test performance characteristics on long-term testing benefits and burdens.

METHODS

A novel CRC-Microsimulation of Adenoma Progression and Screening (CRC-MAPS) model was developed, validated, then used to assess different screening tests for CRC. We compared multiple, hypothetical blood-based CRC screening tests satisfying minimum coverage criteria of 74% CRC sensitivity and 90% specificity, to measure how changes in a test's CRC sensitivity, specificity, and adenoma sensitivity (sizes 1-5 mm, 6-9 mm, ≥10 mm) affect total number of colonoscopies (COL), CRC incidence reduction (IR), CRC mortality reduction (MR), and burden-to-benefit ratios (incremental COLs per percentage-point increase in IR or MR).

RESULTS

A blood test meeting minimum US coverage criteria for performance characteristics resulted in 1576 lifetime COLs per 1000 individuals, 46.7% IR and 59.2% MR compared to no screening. Tests with increased CRC sensitivity of 99% ( + 25%) vs. increased ≥10 mm adenoma sensitivity of 13.6% ( + 3.6%) both yielded the same MR, 62.7%. Test benefits improved the most with increases in all-size adenoma sensitivity, then size-specific adenoma sensitivities, then specificity and CRC sensitivity, while increases in specificity or ≥10 mm adenoma sensitivity resulted in the most favorable burden-to-benefit tradeoffs (ratios <11.5).

CONCLUSIONS

Burden-to-benefit ratios for blood-based CRC screening tests differ by performance characteristic, with the most favorable tradeoffs resulting from improvements in specificity and ≥10 mm adenoma sensitivity.

Optimization of colonoscopy quality: Comprehensive review of the literature and future perspectives

Colonoscopy is crucial in preventing colorectal cancer (CRC) and reducing associated mortality. This comprehensive review examines the importance of high-quality colonoscopy and associated quality indicators, including bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate (ADR), complete resection, specimen retrieval, complication rates, and patient satisfaction, while also discussing other ADR-related metrics. Additionally, the review draws attention to often overlooked quality aspects, such as nonpolypoid lesion detection, as well as insertion and withdrawal skills. Moreover, it explores the potential of artificial intelligence in enhancing colonoscopy quality and highlights specific considerations for organized screening programs. The review also emphasizes the implications of organized screening programs and the need for continuous quality improvement. A high-quality colonoscopy is crucial for preventing postcolonoscopy CRC- and CRC-related deaths. Health-care professionals must develop a thorough understanding of colonoscopy quality components, including technical quality, patient safety, and patient experience. By prioritizing ongoing evaluation and refinement of these quality indicators, health-care providers can contribute to improved patient outcomes and develop more effective CRC screening programs.

Implementation of a Bleeding Risk Screening Tool and Hematology Referral Process Prior to Pediatric Endoscopy

OBJECTIVES

Gastrointestinal (GI) endoscopic procedures are considered low risk with an overall bleeding risk for upper and lower endoscopies of 0.11%. However, a certain population of patients may have a higher risk for bleeding, and there is not a standardized process for screening patients to determine who these patients are.

METHODS

At Children's Wisconsin, our gastroenterology and hematology divisions adapted an abbreviated version of a validated, history-based bleeding risk screening tool and implemented a hematology referral process to identify those at risk for bleeding prior to their first endoscopy. Provider compliance with the bleeding screen, referral to hematology, time to be seen in hematology clinic, new diagnoses of bleeding disorders, and bleeding complications were assessed from 2019 to 2021 across 3 phases.

RESULTS

Provider compliance with the bleeding screen improved throughout our study from 48% (120/251) to 75% (189/253). For those who screened positive, compliance with referral to hematology ranged from 38% to 74% across our phases. The overall time to be seen by hematology decreased from 30 days to 7.5 days. Eighteen patients ultimately screened positive and were seen in hematology clinic, of whom 22% (4/18) were diagnosed with a new bleeding disorder. No bleeding complications were seen in our study population.

CONCLUSIONS

Our quality improvement project provided a standardized screening tool to assess preoperative bleeding risk and reinforced the value of a history-based screening tool. This modified screening tool identified those with an undiagnosed bleeding disorder and preventative measures were undertaken to prevent procedural bleeding complications.

Risk of Postcolonoscopy Thromboembolic Events: A Real-World Cohort Study

BACKGROUND& AIMS

Although antithrombotic agents could increase the risk of postpolypectomy bleeding, interruption of these agents also increases the risk of thromboembolism (TE). We assessed the risks of postcolonoscopy TE events and their association with the interruption of antithrombotic agents.

METHODS

This was a retrospective cohort study including consecutive patients undergoing colonoscopy between January 2016 and March 2021. We determined the rates of postcolonoscopy TE events in patients taking various antithrombotic agents (with or without interruption), and in different patient groups according to indications for colonoscopy, underlying TE, and bleeding risks.

RESULTS

Of the 6220 patients, 1755 (28.2%) were on antithrombotics. Overall, 20 patients (0.32%) developed TE events, and 25 (0.80%) of 3134 patients with polypectomy experienced major episodes of bleeding. Among all patients on antithrombotic agents, the highest rates of TE events were observed in patients on dual-antiplatelet therapy (4.65%; adjusted odds ratio [aOR], 28.0; 95% CI, 3.77-142.1) and clopidogrel (2.78%; aOR, 12.2; 95% CI, 2.10-57.0), compared with 0.11% among those not on antithrombotics. In patients interrupting anti-thrombotic agents, the risk of TE was increased compared to those on no agent as follows: stopping 2 or more antithrombotic agents (4.55%; aOR, 22.5; 95% CI, 1.09-158.0), monotherapy with clopidogrel (3.06%; aOR, 15.5; 95% CI, 2.86-69.6), warfarin (1.33%; aOR, 6.96; 95% CI, 1.14-33.5), or direct-acting oral anticoagulants (0.87%; aOR, 6.23; 95% CI, 1.22-26.8). Having an underlying high TE risk (aOR, 16.8; 95% CI, 6.33-46.6) was associated with higher postcolonoscopy TE events.

CONCLUSIONS

The risk of post-colonoscopy thromboembolic events is low. However, the temporary interruption of antithrombotic agents, particularly stopping 2 or more agents, clopidogrel, warfarin, or direct-acting oral anticoagulants was associated with higher postcolonoscopy TE events, particularly in high-risk patients.

Tip-in Versus Conventional Endoscopic Mucosal Resection for Colorectal Neoplasia: A Systematic Review and Meta-analysis

BACKGROUND

Early-stage gastrointestinal neoplasms are frequently treated with conventional endoscopic mucosal resection (C-EMR). However, C-EMR frequently leads to incomplete resection of large colorectal lesions. Tip-in endoscopic mucosal resection (EMR), which was recently introduced for en bloc resection of colorectal neoplasms, minimizes slippage during the procedure.

METHODS

We conducted a systematic review and meta-analysis of published studies that compared Tip-in EMR with conventional EMR. We searched several electronic databases and included studies that reported on the primary outcomes of en bloc resection rate and complete resection rate, as well as secondary outcomes such as procedure time and procedure-related complications (including perforation and delayed bleeding rate). We used a random effects model to calculate odds ratios (ORs) with 95% CIs for dichotomous data and weighted mean differences with 95% CIs for continuous data. We also conducted several sensitivity analyses to assess the robustness of our findings.

RESULTS

A total of 11 studies involving 1244 lesions (684 in the Tip-in EMR group and 560 in C-EMR group) were included in the meta-analysis. Our meta-analysis showed that compared with conventional EMR, Tip-in EMR significantly increased the en bloc resection rate in patients with colorectal neoplasia (OR=3.61; 95% CI, 2.09-6.23; P <0.00001; I2 =0%) and had a higher complete resection rate (OR=2.49; 95% CI, 1.65-3.76; P <0.0001; I2 =0%). However, the procedure time and rates of procedure-related complications did not differ significantly between the 2 groups.

CONCLUSIONS

Tip-in EMR outperformed C-EMR for both the en bloc and complete resection of colorectal lesions with similar rates of procedural complications.

Describing and Predicting Preprocedural Anxiety in Patients Scheduled for Advanced Gastrointestinal Endoscopy During the COVID-19 Pandemic

Advanced gastrointestinal endoscopy includes a group of specialized procedures and interventions that are being performed more frequently, with little attention given to a patient's preprocedural anxiety issues. Compounding this concern, in 2020 the COVID-19 pandemic resulted in the delay of many endoscopy cases. It is unknown how this affected the anxiety of patients preparing for advanced endoscopy procedures. Patients with higher anxiety require higher doses of anesthetic medications, and experience increased pain and decreased satisfaction. The purpose of this study was to describe the biological, psychological, and social attributes of patients and identify whether social support, COVID-19-related anxiety, delay of procedure, patient's physical status, and procedural indication category were predictors of state anxiety levels in patients undergoing advanced gastrointestinal endoscopy during the COVID-19 pandemic. The research study was a cross-sectional descriptive design with 90 patients. Patients were classified into low state and high state anxiety groups. Fifty-eight percent of patients had high state anxiety scores. Using logistic regression, social support was identified as a predictor of preprocedural anxiety (odds ratio [OR] = 0.318 [95% confidence interval, CI = 0.170, 0.597, p < .001]) as less social support was associated with higher anxiety. It is imperative that strategies to maximize social support are reinforced.

Additional information obtained from mucosal biopsies is limited after pan-enteric capsule endoscopy in patients with suspected Crohn's disease

Background and study aims Pan-enteric capsule endoscopy (CE) is an emerging alternative to ileo-colonoscopy for diagnosing Crohn's disease (CD). However, CE does not offer the opportunity to take biopsies to support the diagnosis. This study examined the additional information obtained with mucosal biopsies and the feasibility of CE as a single diagnostic procedure. Patients and methods This retrospective study was based on a prospective, blind multicenter trial in which patients with suspected CD were examined with ileo-colonoscopy plus segmental biopsies and CE. Histopathological findings were compared to the result of CE. Results A total of 107 patients with a complete CE were included in the analysis. CE was consistent with CD in 44 patients (41.1%) and ulcerative colitis in 10 patients (9.3%). Histopathology confirmed the result of CE in 39.3% of patients and added new diagnostic information in 6.5% of patients. A CE consistent with CD was histologically confirmed in 20.5% of patients. Biopsies most often showed non-specific inflammation (61.4%). Only one patient with a normal CE had a specific histological diagnosis (microscopic colitis). Biopsies altered the diagnosis of ulcerative colitis to CD in two patients, and in two patients with a normal CE, biopsies showed CD or ulcerative colitis. In one patient with lymphoma in the terminal ileum and cecum, CE was misinterpreted as CD. Conclusions In patients with suspected CD and an evident result of CE, the additional information obtained from biopsies is limited, and CE as a single diagnostic procedure might be feasible in selected patients. Biopsies are warranted, however, in patients with an atypical endoscopic appearance or suspected malignancy.

Noninvasive Colorectal Cancer Prevention Options in Older Adults

Colorectal cancer (CRC) is a leading cause of morbidity and mortality worldwide and its incidence increases with age. The proportion of older adults in the United States continues to rise, making CRC prevention a key health priority for our aging population. CRC is a largely preventable disease through screening and polyp surveillance, and noninvasive modalities represent an important option for older adults in whom the burdens and risks of invasive testing are higher compared with younger adults. This review highlights the evidence, risks, and benefits of noninvasive CRC screening and surveillance options in older adults and discusses the challenges of CRC prevention in this cohort.

Safety and efficacy of a novel suturing device for closure of large defects after endoscopic submucosal dissection (with video)

BACKGROUND AND AIMS

Endoscopic suturing enables full closure of large defects after endoscopic submucosal dissection (ESD). However, its use is limited by the need for a double-channel endoscope. A novel closure system, the OverStitch Sx (Apollo Endosurgery, Austin, Tex, USA), compatible with any single-channel endoscope, was introduced to address these shortcomings. The aim of this study was to assess the safety and feasibility of OverStitch Sx for the closure of large defects after ESD.

METHODS

This is a prospective single-center feasibility study of patients who underwent closure of large defects after ESD using the OverStitch Sx system. Main outcomes of the study are technical and clinical success, same-day discharge rate, and adverse event rate.

RESULTS

Thirty-three patients were enrolled. The mean diameter of included lesions was 5.38 ± 2.52 cm. The defect occupied ≥50% of the lumen circumference in 70% of the cases. En-bloc resection, R0 resection, and curative resection were achieved in 97%, 87.5%, and 78.8% of patients, respectively. Technical success and clinical success were seen in 93.9% and 90.9% of the cases, respectively. Same-day hospital discharge was achieved in 77.4% of patients. Total adverse event rate was 35.7%, including delayed bleeding in 1 patient after rectal ESD that was managed conservatively, self-resolving rectal pain in 7 patients, rectal stricture requiring dilation in 1 patient, and temporary dysphagia in 1 patient. No immediate or delayed perforation was reported.

CONCLUSIONS

OverStitch Sx enabled safe and effective closure of large defects after ESD. Future trials are needed to determine its superiority over OverStitch for the closure of defects in challenging locations. (Clinical trial registration number: NCT04361227.).

Multi-level Factors Influencing Decisions About Stopping Surveillance Colonoscopy in Older Adults: a Qualitative Study

BACKGROUND

Little is known about patient or provider experience and perceptions of stopping surveillance among older adults with a history of colon polyps. While guidelines recommend ceasing routine colorectal cancer screening in adults  > 75 years and those with limited life expectancy, guidance for ceasing surveillance colonoscopy in those with prior colon polyps suggests individualizing recommendations.

OBJECTIVE

Identify processes, experiences, and gaps around individualizing decisions to stop or continue surveillance colonoscopy for older adults and areas for improvement.

DESIGN

Phenomenological qualitative study design using recorded semi-structured interviews from May 2020 through March 2021.

PARTICIPANTS

15 patients aged  ≥ 65 in polyp surveillance, 12 primary care providers (PCPs), and 13 gastroenterologists (GIs).

APPROACH

Data were analyzed using a mixed deductive (directed content analysis) and inductive (grounded theory) approach to identify themes related to stopping or continuing surveillance colonoscopies.

KEY RESULTS

Analysis resulted in 24 themes and were clustered into three main categories: health and clinical considerations; communication and roles; and system-level processes or structures. Overall, the study found support for discussions around age 75-80 on stopping surveillance colonoscopy with considerations for health and life expectancy and that PCPs should take a primary role. However, systems and processes for scheduling surveillance colonoscopies largely bypass PCPs which reduces opportunities to both individualize recommendations and facilitate patients' decision-making.

CONCLUSIONS

This study identified gaps in processes to implement current guidelines for individualizing surveillance colonoscopy as adults grow older, including opportunities to discuss stopping. Increasing the role of PCPs in polyp surveillance as patients grow older provides more opportunities for individualized recommendations, so patients can consider their own preferences, ask questions, and make a more informed choice for themselves. Changing existing systems and processes and creating supportive tools for shared decision-making specific to older adults with polyps would improve how surveillance colonoscopy is individualized in this population.

Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial

Importance

The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy.

Objective

To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors.

Design, Setting, and Participants

This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022.

Exposure

Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals.

Main Outcomes and Measures

Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year.

Results

A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25).

Conclusions and Relevance

In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

Colorectal Cancer Screening and Surveillance in the Geriatric Population

PURPOSE OF THE REVIEW

Our national guidelines regarding screening and surveillance for colorectal cancer recommend individualized discussions with patients 75-85 years of age. This review explores the complex decision-making that surrounds these discussions.

RECENT FINDINGS

Despite updated guidelines for colorectal cancer screening and surveillance, the guidance for patients 75 years of age or older remains unchanged. Studies exploring the risks to colonoscopy in this population, patient preferences, life expectancy calculators and additional studies in the subpopulation of inflammatory bowel disease patients provide points of consideration to aid in individualized discussions. The benefit-risk discussion for colorectal cancer screening in patients over 75 years old warrants further guidance to develop best practice. To craft more comprehensive recommendations, additional research with inclusion of such patients is needed.

[Structural, procedural, and personnel requirements for cross-sectoral provision of endoscopic gastroenterological procedures]

Gastroenterology has made crucial advances in diagnostic and interventional endoscopic procedures, opening up improvements in the treatment of many patients. Thus, organ-preserving treatments are increasingly being made possible, replacing more invasive organ resecting surgical procedures. At the same time, the degree of complexity and risks varies widely between different endoscopic procedures. In many cases, simpler endoscopic procedures are now offered on an outpatient basis. Further potential for cross-sectoral performance of endoscopic procedures exists in the case of complex endoscopic procedures, which, however, require special structural, procedural and personnel requirements in order to provide quality-assured treatment, enable post-interventional monitoring and, if necessary, take measures to ensure the success of the treatment. We summarize the essential prerequisites and limitations for cross-sector performance of endoscopic procedures in gastroenterology.

Identification and Reporting of Anal Pathology during Routine Colonoscopies

The gold-standard procedure for anal canal examination is anoscopy. Nonetheless, patients are referred for a colonoscopy for many reasons, and a routine exam might provide an opportunity to diagnose anal pathologies, such as hemorrhoids, anal fissures, anal polyps, condylomas, and anal squamous cell carcinoma. It is important to know the main features of these conditions and relevant information to report in order to help guide patient treatment and follow-up.

Frequency of Use and Outcomes of Colonoscopy in Individuals Older Than 75 Years

Importance

The benefits from colorectal cancer (CRC) screening may take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health.

Objective

To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure.

Design

This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded.

Exposures

Life expectancy based on a prediction model from previous literature.

Main Outcomes and Measures

The primary outcome was the percentage of screened patients who had limited (<10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure.

Results

A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age-82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated.

Conclusions and Relevance

In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.

The Association Between Low Body-Mass Index and Serious Post-endoscopic Adverse Events

BACKGROUND

Low body mass index (LBMI) was associated with longer colonoscopy procedure time and procedural failure, and commonly considered to be a risk factor for post-endoscopic adverse events, but evidence is lacking.

AIM

We aimed to assess the association between serious adverse events (SAE) and LBMI.

METHODS

A single center retrospective cohort of patients with LBMI (BMI ≤ 18.5) undergoing an endoscopic procedure was matched (1:2 ratio) to a comparator group (19 ≤ BMI ≤ 30). Matching was performed according to age, gender, inflammatory bowel disease or malignancy diagnoses, previous abdomino-pelvic surgery, anticoagulation therapy and type of endoscopic procedure. The primary outcome was SAE, defined as bleeding, perforation, aspiration or infection, following the procedure. The attribution between each SAE and the endoscopic procedure was determined. Secondary outcomes included each complication alone and endoscopy-attributed SAEs. Univariate and multivariate analyses were applied.

RESULTS

1986 patients were included (662 in the LBMI group). Baseline characteristics were mostly similar between the groups. The primary outcome occurred in 31/662 (4.7%) patients in the LBMI group and in 41/1324 (3.1%) patients in the comparator group (p = 0.098). Among the secondary outcomes, infections (2.1% vs. 0.8%, p = 0.016) occurred more frequently in the LBMI group. Multivariate analysis revealed an association between SAE and LBMI (OR 1.76, 95% CI 1.07-2.87), male gender, diagnosis of malignancy, high-risk endoscopic procedure, age > 40 years, and ambulatory setting.

CONCLUSION

Low BMI was associated with higher post-endoscopic serious adverse events. Special attention is required when performing endoscopy in this fragile patient population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Application of a multispecies probiotic reduces gastro-intestinal discomfort and induces microbial changes after colonoscopy

Even after decades of research and pharmaceutical development, cancer is still one of the most common causes of death in the western population and the management of cancer will remain a major challenge of medical research. One of the most common types of cancer is colorectal cancer (CRC). Prevention by detection of early-stage precursors is the most reliable method to prevent CRC development. In dependence of age, familial predisposition, and other risk factors the preventative routine screening for CRC by colonoscopy should be performed at least twice in intervals of about ten years. Although colonoscopy is a life-saving clinical examination reducing both incidence and mortality of CRC significantly, it has still a bad reputation in the population as an uncomfortable procedure with unpleasant side effects lasting sometimes over days to weeks. These effects are most likely caused by the bowel preparation before colonoscopy, which is crucial for a successful colonoscopy with high quality. Beside pain, bleeding and other rare but severe complications of colonoscopy, cleaning of the intestinal mucosa alters the gut microbiome significantly and consistently. Abdominal pain, cramps, diarrhea, nausea, bloating, and constipation are common adverse events which can continue to affect patients for days or even weeks after the procedure. In this multicenter, placebo controlled, double blind clinical trial, we investigated the effect of an intervention with a multispecies probiotic formulation for 30 days on the adverse events due to bowel preparation. We show that the treatment of participants with the multispecies probiotic formulation decreases the number of days with constipation significantly, and reduced pain, bloating, diarrhea, and general discomfort. 16S based amplicon analyses reveal recovery of administered probiotic strains from stool samples and differences in alpha diversity dynamics with higher variability in the probiotic group compared to the placebo group. In conclusion, the probiotic ameliorates the side effects after colonoscopy and might be an important supplement to increase acceptance of this life-saving preventative examination. Further, we present here for the first time that probiotic intervention of only 30 days affects alpha diversity parameters in stool samples.

Quality indicators in colonoscopy: observational study in a supplementary health system

PURPOSE

Colorectal cancer is responsible for 9.4% of cancer deaths, and low polyp detection rate and cecal intubation rate increase the risks of interval colorectal cancer. Despite several population studies that address colonoscopy quality measures, there is still a shortage of these studies in Latin America. The aim of this study was to assess quality indicators in colonoscopy, enabling future strategies to improve colorectal cancer prevention.

METHODS

An observational retrospective study, in which all colonoscopies performed in 11 hospitals were evaluated through a review of medical records. Information such as procedure indication, colorectal polyp detection rate, cecal intubation rate, quality of colonic preparation, and immediate adverse events were collected and analyzed.

RESULTS

In 17,448 colonoscopies performed by 86 endoscopists, 57.9% were in patients aged 50 to 74 years old. Colon preparation was adequate in 94.4% procedures, with rates of cecal intubation and polyp detection of 94 and 36.6%, respectively. Acute adverse events occurred in 0.2%. In 53.9%, high-definition imaging equipment was used. The procedure location, colon preparation and high-definition equipment influenced polyp detection rates (p < 0.001).

CONCLUSIONS

The extraction and analysis of electronic medical records showed that there are opportunities for improvement in colonoscopy quality indicators in the participating hospitals.

Endoscopic severity and classification of lesions with pan-enteric capsule endoscopy and ileocolonoscopy in ileocolonic Crohn's disease

Background and study aims  Recent evidence supports the use of pan-enteric capsule endoscopy (CE) for the diagnosis and follow-up of Crohn's disease (CD). The aim of this study was to examine the agreement between CE and ileocolonoscopy (IC) for determining the severity and classification of lesions in ileocolonic CD. Patients and methods  In a prospective blinded multicenter study, patients with suspected CD were examined with CE and IC within 2 weeks. Ninety-nine participants with a full IC and CE were included in the analysis. The ileocolonic disease severity was assessed with the Simple Endoscopic Score for Crohn's Disease (SES-CD). Results  CD was diagnosed in 30 patients with IC and CE. The mean SES-CD was 9.8 (CI 7.9-11.8) and 10.6 (CI 8.2-13.1), respectively ( P  = 0.69). There was a substantial agreement (ICC 0.83, CI 0.68-0.92) and a strong correlation between SES-CD assessed with IC and CE (r _s  = 0.78, P  < 0.001). 55 bowel segments had ulcerations with both modalities (terminal ileum 24, right colon 12, transverse colon eight, left colon eight and rectum three). Mean sub-scores for ulcer size, area of ulcerated surface and area of affected surface did not differ between modalities. The inter-modality agreement (κ) was 0.46, 0.34 and 0.43, respectively ( P  < 0.001). Conclusions  There is a strong correlation between IC and CE for the severity of ileocolonic CD. The agreement for SES-CD sub-scores is fair to moderate. CE could be an alternative to IC for the assessment of endoscopic severity in selected patients with suspected CD.

Detection of cytomegalovirus (CMV) by digital PCR in stool samples for the non-invasive diagnosis of CMV gastroenteritis

Background

CMV gastroenteritis is common in patients receiving allogeneic hematopoietic stem cell transplantation and it is difficult to distinguish from acute graft-versus-host disease (aGvHD), which has very similar symptoms but needs quite different treatment. CMV gastroenteritis is caused by local infection or reactivation of CMV in the gastrointestinal tract while aGvHD is due to immune rejection. The gold standard of diagnosis of CMV gastroenteritis and aGvHD is gastrointestinal biopsy under endoscopy, which is invasive and can potentially lead to severe side effects. Stool samples testing with quantitative polymerase chain reaction (qPCR) may be an alternative, while the application in trace level measurements and precision are not all satisfactory enough in reported research.

Methods

In this study, we designed a novel method that extracted the cell free DNA (cfDNA) from the fecal supernatant to perform digital PCR (dPCR) for the detection of CMV, analyzed the performance and compared it with the total DNA extracted by the current procedure.

Results

Twenty-two paired stool samples using two DNA extraction methods proved that the cfDNA extraction method had markedly higher DNA concentrations and control gene copy number, suggesting that cfDNA may be more informative and more useful for the detection of CMV DNA segment. The dPCR approach in detecting CMV DNA segment also exhibit good linearity (R2 = 0.997) and higher sensitivity (limit of detection at 50% was 3.534 copies/μL). Eighty-two stool samples from 44 immunocompromised patients were analyzed, CMV-positive rate was 28%, indicating that more than one-quarter of the gastrointestinal symptoms within these patients may be caused by CMV infection or reactivation.

Conclusion

The combined results suggest that detection of CMV by dPCR in cfDNA of stool supernatant is a powerful method to identify CMV gastroenteritis and helps in clinical treatment decision making.

AGA White Paper: Challenges and Gaps in Innovation for the Performance of Colonoscopy for Screening and Surveillance of Colorectal Cancer

In 2018, the American Gastroenterological Association's Center for GI Innovation and Technology convened a consensus conference, entitled "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The conference participants, which included more than 60 experts in colorectal cancer, considered recent improvements in colorectal cancer screening rates and polyp detection, persistent barriers to colonoscopy uptake, and opportunities for performance improvement and innovation. This white paper originates from that conference. It aims to summarize current patient- and physician-centered gaps and challenges in colonoscopy, diagnostic and therapeutic challenges affecting colonoscopy uptake, and the potential use of emerging technologies and quality metrics to improve patient outcomes.

Colonoscopy induced ischemic colitis: An endoscopic and histological assay

Colonoscopy is a safe and effective diagnostic modality for various ileo-colonic diseases. Though the procedure itself is a rare cause of ischaemic colitis. Fewer than 30 cases of ischaemic colitis caused by colonoscopy procedure have been reported in the literature to date. The colon is susceptible to ischemia due to its minor blood flow compared to other organs in the abdomen. The etiology of colon ischemia after colonoscopy is multifactorial. Endoscopists must be aware of this condition and its risk factors for risk minimization, early diagnosis and proper treatment.

Diagnostic accuracy of pan-enteric capsule endoscopy and magnetic resonance enterocolonography in suspected Crohn's disease

BACKGROUND AND AIMS

Magnetic resonance enterocolonography (MREC) and pan-enteric capsule endoscopy (CE) offers visualization of the entire gastrointestinal tract in a single examination. We examined the diagnostic accuracy of MREC and CE in patients with suspected Crohn's disease (CD).

METHOD

In a prospective, blinded, multicenter study, we included patients with clinically suspected CD. Patients were examined with MREC, CE, and ileocolonoscopy (IC) within 2 weeks. The primary outcome was per patient sensitivity, specificity, and diagnostic accuracy for ileocolonic CD. IC served as reference standard.

RESULTS

153 patients were included in the study and IC, MREC, and CE was performed in 152, 151, 133 patients, respectively. CD was diagnosed with IC in 59 (39%) patients (terminal ileum (TI) 22, colon 20, TI and colon 17). The sensitivity and specificity for diagnosing ileocolonic CD with MREC was 67.9% (CI 53.7-80.1) and 76.3% (CI 65.2-85.3) (TI 76.9% and 85.6%; colon 27% and 93%) compared to 87.5% (CI 73.2-95.8) and 87.8% (CI 78.2-94.3) with CE (TI 96.6% and 87.5%; colon 75.0% and 93.0%). The sensitivity of CE was superior to that of MREC (p = 0.02). The patient experienced discomfort was equal with CE and MREC and significantly less than with IC.

CONCLUSION

In patients with suspected CD, CE has a high sensitivity for diagnosing CD in the TI and colon, which is superior to that of MREC. The sensitivity of MREC for diagnosing CD in the colon is poor. CE could be a patient-friendly alternative to IC in selected patients with suspected CD. Registered at ClinicalTrials.gov: NCT03134586.

Medical malpractice and gastrointestinal endoscopy

PURPOSE OF REVIEW

Medical liability is a perennial issue that most physicians will face at some point in their careers. Gastroenterologists routinely perform endoscopic procedures to aid in the diagnosis and treatment of their patients. Advances in endoscopic techniques and technology have accelerated movement of the field into a more surgical realm. These developments warrant consideration of pitfalls that may expose gastroenterologists to liability. This review will explore trends in malpractice facing gastroenterologists and offer strategies to deliver high quality and safe patient care.

RECENT FINDINGS

Despite being a procedure-oriented subspeciality, only a minority of malpractice claims against gastroenterologists are related to procedures. Diagnostic error is among the most prevalent reason for lawsuits. The consequences of malpractice are costly due litigation and indemnity as well as the increase in defensive medical practice. Improving diagnostic quality, optimizing informed consent, and enhancing patient-physician communication are important elements of risk mitigation.

SUMMARY

Understanding the important role that diagnosis plays in medical liability allows physicians to better evaluate risk and apply deliberate decision-making in order to practice confidently.

Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report

BACKGROUND

Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare.

CASE SUMMARY

A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT).

CONCLUSION

For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.

Yield of Surveillance Colonoscopy in Older Adults with a History of Polyps: A Systematic Review and Meta-Analysis

BACKGROUND

The benefit of surveillance colonoscopy in older adults is not well described.

AIMS

To quantify the detection of colorectal cancer (CRC) and advanced polyps during surveillance colonoscopy in older adults with a history of colon polyps.

METHODS

We conducted a systematic review (MEDLINE, Cochrane Library, Web of Science, and Embase) for all published studies through May 2020 in adults age > 70 undergoing surveillance colonoscopy. The main outcome was CRC and advanced polyps detection. We performed meta-analysis to pool results by age (>70 vs. 50-70).

RESULTS

The search identified 6239 studies, of which 569 underwent full-text review and 64 data abstraction, of which 19 were included. The risk of detecting CRC (N = 11) was higher in those >70 compared to 50-70 (risk ratio 1.5 (95% CI 1.1-2.2); risk difference 0.8% (95% CI -0.2%-1.8%)). Similarly, the risk of detecting advanced polyps (N = 8) was higher in those >70 compared to 50-70 (risk ratio 1.3 (95% CI 1.2-1.3), risk difference 2.7% (95% CI 1.3%-4.0%)). Most studies did not stratify results by baseline polyp risk.

CONCLUSIONS

The detection of CRC and advanced polyps during surveillance colonoscopy in older individuals was higher than in younger controls; however, the absolute risk increase for both was small. These differences must be weighed against competing medical problems and limited life expectancy in older adults when making decisions about surveillance colonoscopy. More primary data on the risks of CRC and advanced polyps accounting for number of past colonoscopies, prior polyp risk, and duration of time since last polyp are needed.

From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s

Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.

Safety and effectiveness of underwater cold snare resection without submucosal injection of large non-pedunculated colorectal lesions

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.

[Factors Associated with the Clinical Outcomes of Iatrogenic Colonic Perforation]

Background/Aims

This study evaluated the incidence of iatrogenic colonic perforation (ICP) in a high-volume center and analyzed the clinical outcomes and associated factors.

Methods

As a retrospective study of the electronic medical records, the whole data of patients who underwent colonoscopy from June 2004 to May 2020 were reviewed.

Results

During 16 years, 69,458 procedures were performed, of which 60,288 were diagnostic and 9,170 were therapeutic. ICP occurred in 0.027% (16/60,288) for diagnostic colonoscopies and in 0.076% (7/9,170) for therapeutic purposes (p=0.015; hazard ratio 2.878; 95% CI, 1.184-6.997). Fifty-two percent (12 cases) were managed with endoscopic clip closure, and 43.5% (10 cases) required surgery. The reasons for the procedure and the procedure timing appeared to affect the treatment decision. Perforations during therapeutic colonoscopy were treated with surgery more often than those for diagnostic purposes (66.7% [4/6] vs. 37.5% [6/16], p=0.221). Regarding the timing of the procedure, ICP that occurred in the afternoon session was more likely treated surgically (56.3% [9/16] vs. 0/5, p=0.027). Mortality occurred in two patients (2/23, 8.7%). Both were aged (mean age 84.0±1.4 vs. 65.7±10.5, p<0.001) and lately recognized (mean elapsed time [hours], 43.8±52.5 vs. 1.5±3.0, p<0.001) than the surviving patients.

Conclusions

ICP occurs in less than 0.1% of cases. The events that occurred during the morning session were more likely managed endoscopically. Age over 80 years and a longer time before perforation recognition were associated with mortality.

Advanced endoscopic resection for colorectal dysplasia in inflammatory bowel disease: a meta-analysis

Background and study aims  Little is known about outcomes of advanced endoscopic resection (ER) for patients with inflammatory bowel disease (IBD) with dysplasia. The aim of our meta-analysis was to estimate the safety and efficacy of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for dysplastic lesions in patients with IBD. Methods  We performed a systematic review through Jan 2021 to identify studies of IBD with dysplasia that was treated by EMR or ESD. We estimated the pooled rates of complete ER, adverse events, post-ER surgery, and recurrence. Proportions were pooled by random effect models. Results  Eleven studies including 506 patients and 610 lesions were included. Mean lesion size was 23 mm. The pooled rate of complete ER was 97.9 % (95 % confidence interval [CI]: 95.3 % to 99.7 %). The pooled rate of endoscopic perforation was 0.8 % (95 % CI:0.1 % to 2.2 %) while bleeding occurred in 1.6 % of patients (95 %CI:0.4 % to 3.3 %). Overall, 6.6 % of patients (95 %CI:3.6 % to 10.2 %) underwent surgery after an ER. Among 471 patients who underwent surveillance, local recurrence occurred in 4.9 % patients (95 % CI:1.0 % to 10.7 %) and metachronous lesions occurred in 7.4 % patients (95 %CI:1.5 % to 16 %) over a median follow-up of 33 months. Metachronous colorectal cancer (CRC) was detected in 0.2 % of patients (95 %CI:0 % to 2.2 %) during the surveillance period. Conclusions  Advanced ER is safe and effective in the management of large dysplastic lesions in IBD and warrants consideration as first-line therapy. Although the risk of developing CRC after ER is low, meticulous endoscopic surveillance is crucial to monitor for local or metachronous recurrence of dysplasia.

Adverse Event Fatalities Related to GI Endoscopy

BACKGROUND

Death after endoscopy is rare, under-reported, and has variable causes. This study aimed to evaluate the incidence and causes of fatal endoscopic adverse events (AEs) across two academic medical centers and to identify patient-, procedure-, and sedation-related risk factors.

METHODS

This is a retrospective cohort study of fatal adverse events causally related to endoscopy at Denver Health Medical Center and the University of Colorado Hospital from 2011 to 2020. Fatal AEs were retrieved from the physician-reported database. Electronic medical records were then reviewed to determine medical history, procedure details, subsequent treatments, and time and cause of death.

RESULTS

From January 2011 to January 2020, 146,010 GI endoscopy procedures were performed. Median patient age was 70 [51-78] and 57% were male. Thirty-one deaths were identified, 28 of which were attributed to endoscopy, yielding a procedure-related fatality rate of 0.018%. Procedures included 11 EGDs, one colonoscopy, two flexible sigmoidoscopies, six ERCPs, seven upper EUS, and one PEG-J tube placement. Specific causes of death included aspiration in four patients (14%); cardiac arrest or myocardial infarction in seven patients (25%); perforation in nine patients (32%); bleeding in four patients (14%); cholangitis or sepsis without perforation in three patients (11%); and acute pancreatitis in one patient (3.6%).

CONCLUSIONS

Fatal endoscopic AEs were rare but tended to occur in older patients with major comorbidities. Most deaths occurred from aspiration pneumonia, cardiac arrest, or perforation-related sepsis within 1 week of the procedure.

Continuous monitoring of colonoscopy performance in the Netherlands: first results of a nationwide registry

BACKGROUND

To optimize colonoscopy quality, several performance measures have been developed. These are usually assessed without distinction between the indications for colonoscopy. This study aimed to assess the feasibility of linking two national registries (one for colonoscopy and one for adverse events of gastrointestinal endoscopies in the Netherlands), and to describe the results of colonoscopy quality per indication.

METHODS

This retrospective study was conducted with prospectively collected data of the Dutch Gastrointestinal Endoscopy Audit (DGEA) and the Dutch Registration of Complications in Endoscopy (DRCE). Data between 01-01-2016 and 01-01-2019 were analyzed. To calculate adverse event rates, data were linked at the level of endoscopy service.

RESULTS

During the 3-year study period, 266 981 colonoscopies were recorded in DGEA. Of all indications, cecal intubation rate was highest in fecal immunochemical test (FIT)-positive screening colonoscopies (97.1 %), followed by surveillance (93.2 %), diagnostic (90.7 %), and therapeutic colonoscopies (83.1 %). The highest rate of adequate bowel preparation was observed in FIT-positive screening colonoscopies (97.1 %). A total of 1540 colonoscopy-related adverse events occurred (0.58 % of all colonoscopies). Bleeding and perforation and rates were highest for therapeutic (1.56 % and 0.51 %, respectively) and FIT-positive screening (0.72 % and 0.06 %, respectively) colonoscopies. The colonoscopy-related mortality was 0.006 %.

CONCLUSION

This study describes the first results of the Dutch national colonoscopy registry, which was successfully linked to data from the national registry for adverse events of gastrointestinal endoscopies. In this large dataset, performance varied between indications. Our results emphasize the importance of defining benchmarks per indication in future guidelines.

An Estimate of the US Rate of Overuse of Screening Colonoscopy: a Systematic Review

BACKGROUND

This study aims to assess the rate at which screening colonoscopy is performed on patients younger or older than the age range specified in national guidelines, or at shorter intervals than recommended. Such non-indicated use of the procedure is considered low-value care, or overuse. This study is the first systematic review of the rate of non-indicated completed screening colonoscopy in the USA.

METHODS

PubMed and Embase were queried for relevant studies on overuse of screening colonoscopy published from January 1, 2002, until January 23, 2019. English-language studies that were conducted for screening colonoscopy after 2001 for average-risk patients were included. Studies must have followed national guidelines for detecting rates of overuse. We followed methods outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the reporting recommendations of the Meta-analysis of Observational Studies in Epidemiology group (MOOSE).

RESULTS

A total of 772 papers were reviewed for inclusion; 42 were reviewed in full text. Of those reviewed, six studies met eligibility criteria, including a total of 459,503 colonoscopies of which 242,756 were screening colonoscopies. The rate of overuse ranged credibly from 17 to 25.7%.

DISCUSSION

This study demonstrates that screening colonoscopy is regularly performed in the USA more often, and in populations older or younger, than recommended by national guidelines. Such overuse wastes resources and places patients at unnecessary risk of harm. Efforts to reduce non-indicated screening colonoscopy are needed.

Faecal immunochemical tests safely enhance rational use of resources during the assessment of suspected symptomatic colorectal cancer in primary care: systematic review and meta-analysis

OBJECTIVE

Implementation of faecal immunochemical tests (FIT) as a triage test in primary healthcare may improve the efficiency of referrals without missing cases of colorectal cancer (CRC). We aim to summarise the performance characteristics of FITs for CRC in symptomatic patients presenting to primary healthcare.

DESIGN

We performed a systematic literature review of Medline and EMBASE databases from May 2018 to November 2020. Previous related systematic searches were also adapted to this aim and completed with reference screening. We identified studies performed on adult patients consulting for abdominal symptoms in primary care which reported data such that the FIT diagnostic performance parameters for CRC could be obtained. Bivariate models were used to synthesise available evidence. Meta-regression analysis was performed to evaluate the causes of heterogeneity.

RESULTS

Twenty-three studies (69 536 participants) were included (CRC prevalence 0.3%-6.2%). Six studies (n=34 691) assessed FIT as rule in test (threshold of ≥150 µg Hb/g faeces) showing a sensitivity of 64.1% (95% CI 57.8% to 69.9%) and a specificity of 95.0% (95% CI 91.2% to 97.2%). A threshold of 10 µg/g (15 studies; n=48 872) resulted in a sensitivity of 87.2% (95% CI 81.0% to 91.6%) and a specificity of 84.4% (95% CI 79.4% to 88.3%) for CRC. At a 20 µg Hb/g faeces threshold (five studies; n=24 187) less than one additional CRC would be missed per 1000 patients investigated compared with 10 µg Hb/g faeces threshold (CRC prevalence 2%).

CONCLUSION

FIT is the test of choice to evaluate patients with new-onset lower gastrointestinal symptoms in primary healthcare.

A Soft Sensor for Bleeding Detection in Colonoscopies

Colonoscopies allow surgeons to detect common diseases i.e. colorectal cancer, ulcers and other ailments. However, there is a risk of bleeding in the lower gastrointestinal (GI) tract while maneuvering endoscopes. This may be due to perforations, hemorrhaging, polyps, diverticuli or post-biopsy complications. Thus, it is essential for the surgeon to be able to detect bleeding at the site and evaluate the severity of blood leakage. This paper presents a soft sensor that can detect the presence of blood at the bleeding site during colonoscopies. The sensor consists of optical waveguides that interface with a microfluidic channel. Blood flow causes absorption and scattering of incident light that can be picked up by the optical sensing apparatus via light transmission through the waveguide. The surgeon can be alerted when bleeding occurs through a graphical user interface. The device is compact and measures only 1 mm thick. This allows the sensor to be circumferentially mounted onto a colonoscope at different locations. The sensor is able to record the presence of blood as an optical loss, rapidly detect the presence of blood in under 100 milliseconds as it enters the microchannel, and differentiate between gastric fluid and blood through changes in measured optical loss.

Adherence to the bowel cleansing regimen for pan-enteric capsule endoscopy in patients with suspected Crohn's disease and factors affecting the image quality

OBJECTIVE

Pan-enteric capsule endoscopy (CE) is an attractive diagnostic approach in patients examined for Crohn's disease (CD). The aim of this study was to examine the adherence to the recommended bowel cleansing regimen and determine clinical factors affecting the image quality.

METHODS

In a prospective blinded trial, patients with suspected CD were examined with the PillCam Crohn's capsule after bowel preparation with 2 + 2 L of polyethylene glycol (PEG) and sodium phosphate booster. The image quality was graded on a four-point scale. A good or excellent image quality defined a diagnostic procedure.

RESULTS

Fifty-nine patients participated. The mean volume of PEG was 2.5 L (CI 2.3-2.8). Ten patients (17%) were able to drink all 4 L of PEG, and 44 patients (75%) ingested ≥2 L. The image quality was poor, fair, good or excellent in 0%, 29.3%, 29.3% and 41.4%, respectively. The mean volume of PEG was 1.9 L (CI 1.4-2.4), 2.2 L (CI 1.8-2.7) and 3.2 L (CI 2.8-3.5) in patients with a fair, good or excellent image quality (p < .001). In a regression analysis, only the volume of PEG was associated with the obtained image quality (r_s=0.52; p < .001). The diagnostic yield was equal in patients with a diagnostic or non-diagnostic procedure (43.9% and 47.1%, respectively).

CONCLUSIONS

In patients examined with pan-enteric CE for suspected CD, the volume of PEG is the major factor affecting the image quality. Although few patients are able to ingest the recommended volume, the diagnostic yield is not affected.