Minimizing endoscopic complications: colonoscopic polypectomy

Endoscopy in pediatric polyposis syndromes: why, when and how

Single or multiple polyps are frequently encountered during colonoscopy among children and adolescents and may be indicative of hereditary polyposis syndrome (HPS). The management of children with single or multiple polyps is guided by the number of polyps, their distribution and the histological findings. Children with HPS carry a high risk of complications, including intestinal and extra-intestinal malignancies. The goals of surveillance in pediatric HPS are to treat symptoms, monitor the burden of polyps and prevent short- and long-term complications. Therefore, the management of children with HPS is based on therapeutic endoscopy. The strategy of therapeutic endoscopy is a careful assessment and characterization of the polyps and performing polypectomies using advanced endoscopic techniques. A multidisciplinary approach, comprising clinical, interventional endoscopy, cancer surveillance and support of familial and emotional aspects is essential in the management of children with HPS.

A Novel Bipolar Polypectomy Snare Can Be an Alternative Choice for Endoscopic Resection

Objective: Endoscopic resection (ER) is more difficult and has a higher rate of complications, such as perforation and bleeding. The aim of this study was to evaluate the safety and feasibility of a bipolar polypectomy snare for ER.

Methods: Initial ER procedures in live pigs were carried out. Then, a human feasibility study was performed in patients with colorectal polyps. Finally, the finite element method was used to evaluate the safety and effectiveness of the new bipolar snare.

Results: In the live animal model, there were no significant differences in wound size and cutting time between monopolar and bipolar groups. The histological results (histological scores) of the two groups in porcine experiments were almost the same except that the incision flatness of bipolar group was better than that of the monopolar group. Incidence of bleeding and perforation was similar between the two groups in pigs' and patients' study. At last, the finite element model showed that the vertical thermal damage depth produced by bipolar snare system was approximately 71–76% of that produced by monopolar snare system at the same power.

Conclusions: The novel bipolar snare is feasible in patients with colorectal polyps and can be an alternative choice for ERs.

Recognizing Post-Endoscopy Complications: A Database Filter Reduces Quality Assurance Workload for Inpatients

BACKGROUND AND AIMS

Documentation of complications of gastrointestinal endoscopy within the commonly used endoscopy documentation systems are mostly limited to acute complications during endoscopy included in the post-procedural endoscopy report. We tested a documentation system-based filter to reduce the workload by maintaining a high sensitivity to recognize post-endoscopy complications.

METHODS

Of all inpatient endoscopic resections during 1 year and all endoscopic retrograde cholangiopancreatography (ERCP) procedures during 4 months in 1 tertiary referral centre, post-procedural complications during hospital stay were individually analyzed retrospectively from the hospital databases (gold standard). In comparison, information technology-based filters were assessed searching for specific tests and data within 2 days after endoscopy and/or until discharge. These were second endoscopy, surgery, or an abdominal computed tomography (CT) or haemoglobin drop ≥2 g/dL for endoscopic resection. For ERCP cases, any case with lipase determination and post-ERCP CT scan was selected. Main outcomes were the sensitivity of these filters to recognize post-endoscopy complications and the percentage of workload reduction.

RESULTS

Three hundred twenty-two inpatients who underwent endoscopic resections and 302 ERCP cases (all inpatients) were included. Post-endoscopy complications occurred in 7.14% (endoscopic resection) and 3.7% (ERCP). The above-mentioned filters identified 100% of all resection and post-ERCP complications compared to detailed case file analysis, at the same time reducing the quality management workload to 14 and 31%, respectively.

CONCLUSIONS

Post-procedural monitoring of advanced endoscopic procedures performed on inpatient procedures has a high sensitivity (100%) and reduces case-by-case screening workload for complications by 70-85%. Outpatient interventions, however, require a different system for monitoring of post-endoscopy complications after discharge.

Management of colonoscopic perforation: a systematic review and treatment algorithm

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Histological Comparison of Cold versus Hot Snare Resections of the Colorectal Mucosa

BACKGROUND

Delayed postpolypectomy bleeding occurs more frequently after hot resection than after cold resection.

OBJECTIVE

To elucidate the underlying mechanism, we performed a histological comparison of tissue after cold and hot snare resections.

DESIGN

This is a prospective study, registered in the University Hospital Medical Information Network (UMIN000020104).

SETTING

This study was conducted at Aizu Medical Center, Fukushima Medical University, Japan.

PATIENTS

Fifteen patients scheduled to undergo resection of colorectal cancer were enrolled.

INTERVENTION

On the day before surgery, 2 mucosal resections (hot and cold) of normal mucosa were performed on each patient using the same snare without saline injection. The difference was only the application of electrocautery or not. Resection sites were placed close to the cancer to be included in the surgical specimen.

MAIN OUTCOME MEASURES

The primary outcome measure was the depth of destruction. Secondary outcome measures included the width of destruction, depth of the remaining submucosa, and number of vessels remaining at the resection sites. The number and diameter of vessels in undamaged submucosa were also evaluated.

RESULTS

All cold resections were limited to the shallow submucosa, whereas 60% of hot resections advanced to the deep submucosa and 20% to the muscularis propria (p < 0.001). There was no significant difference in the width of destruction. The number of remaining large vessels after hot resections trended toward fewer (p = 0.15) with a decreased depth of remaining submucosa (p = 0.007). In the deep submucosa, the vessel diameter was larger (p < 0.001) and the number of large vessels was greater (p = 0.018).

LIMITATIONS

Histological assessment was not blinded to the 2 reviewers. Normal mucosa was used instead of adenomatous tissue.

CONCLUSIONS

Hot resection caused damage to deeper layers involving more large vessels. This may explain the mechanism for the reduced incidence of hemorrhage after cold snare polypectomy. See Video Abstract at http://links.lww.com/DCR/A631.

Hot snare polypectomy with or without saline solution/epinephrine lift for the complete resection of small colorectal polyps

BACKGROUND AND AIMS

The criteria for a standard polypectomy technique for complete removal of small colorectal polyps has not yet been established. This study aimed to compare the complete resection rate of hot snare polypectomy (HSP) with that of EMR for small, sessile, or flat polyps.

METHODS

Patients with 5- to 9-mm non-pedunculated colorectal polyps were prospectively randomized to the HSP or EMR group. The presence of residual polyps was assessed by performing histologic assessment of 4-quadrant forceps biopsy specimens taken from the edges of the polypectomy site. The primary outcome was the complete resection rate after HSP or EMR; the secondary outcomes were the proportion of procedure-related adverse events and specimen-loss rate. Sample size was estimated using a superiority trial design. We assumed that the complete resection rate of the EMR group would be at least 8% higher than that of the HSP group.

RESULTS

A total of 382 polyps in 269 patients were assessed and randomly assigned to each method using 4 × 4 block randomization. Of these, 353 polyps were finally analyzed based on the pathology results. The mean polyp size was 6.3 ± 1.3 mm. The complete resection rate did not differ between the HSP and EMR groups (88.4% [152/172] vs 92.8% [168/181], respectively; P = .2). The intraprocedural bleeding rate, immediately after polypectomy, was significantly higher in the HSP group than in the EMR group (5.2% vs 0.6%, respectively; P = .009). However, clinically significant bleeding and tissue retrieval failure rates did not differ between the groups. In the multivariate logistic regression analysis, sessile serrated adenoma/polyps or hyperplastic polyps were almost 3 times (odds ratio, 2.824; 95% confidence interval, 1.03-7.75; P = .044) more likely to be incompletely resected compared with other conventional adenomatous polyps. Except for pathology, we found no significant independent predictors for incomplete resection.

CONCLUSION

EMR for small non-pedunculated colorectal polyps is not superior to HSP in terms of complete resection or safety. Both methods can be performed according to the endoscopist's preference. (Clinical trial registration number: KCT0001640; cris.nih.go.kr.).

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.

Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

A prospective comparison of cold snare polypectomy using traditional or dedicated cold snares for the resection of small sessile colorectal polyps

BACKGROUND AND STUDY AIMS

 The evidence for efficacy and safety of cold snare polypectomy is limited. The aim of this study was to assess the completeness of resection and safety of cold snare polypectomy, using either traditional or dedicated cold snares.

PATIENTS AND METHODS

 This was a prospective, non-randomized study performed at a single tertiary hospital. Adult patients with at least one colorectal polyp (size ≤ 10 mm) removed by cold snare were included. In the first phase, all patients had polyps removed by traditional snare without diathermy. In the second phase, all patients had polyps removed by dedicated cold snare. Complete endoscopic resection was determined from histological examination of quadrantic polypectomy margin biopsies. Immediate or delayed bleeding within 2 weeks was recorded.

RESULTS

 In total, 181 patients with 299 eligible polyps (n = 93 (173 polyps) traditional snare group, n = 88 (126 polyps) dedicated cold snare group) were included. Patient demographics and procedure indications were similar between groups. Mean polyp size was 6 mm in both groups ( P  = 0.25). Complete polyp resection was 165 /173 (95.4 %; 95 %CI 90.5 - 97.6 %) in the traditional snare group and 124/126 (98.4 %; 95 %CI 93.7 - 99.6 %) in the dedicated cold snare group ( P  = 0.16). Serrated polyps, compared with adenomatous polyps, had a higher rate of incomplete resection (7 % vs. 2 %, P  = 0.03). There was no statistically significant difference in the rate of immediate bleeding (3 % vs. 1 %, P  = 0.41) and there were no delayed hemorrhages or perforations.

CONCLUSIONS

 Cold snare polypectomy is effective and safe for the complete endoscopic resection of small (≤ 10 mm) colorectal polyps with either traditional or dedicated cold snares.

Colorectal endoscopic mucosal resection (EMR)

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

Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators

The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification.

Recognition of Extraperitoneal Colonic Perforation following Colonoscopy: A Review of the Literature

Colon perforation is an uncommon but serious complication of colonoscopy. It may occur as either intraperitoneal or extraperitoneal perforation or in combination. The majority of colonic perforations are intraperitoneal, causing air and intracolonic contents to leak into the peritoneal space. Rarely, colonic perforation can be extraperitoneal, leading to the passage of air into the retroperitoneal space causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. A literature review revealed that 31 cases of extraperitoneal perforation exist, out of which 20 cases also reported concomitant intraperitoneal perforation. We report the case of a young female with a history of ulcerative colitis who developed combined intraperitoneal and extraperitoneal perforation after colonoscopy. We also report the duration of onset of symptoms, clinical features, imaging findings, site of leak, and treatment administered in previously reported cases of extraperitoneal colonic perforation.

Laparoscopic vs. open surgery for the treatment of iatrogenic colonoscopic perforations: a systematic review and meta-analysis

AIMS

Iatrogenic colonoscopy perforations (ICP) are a rare but severe complication of diagnostic and therapeutic colonoscopies. The present systematic review and meta-analysis aims to investigate the operative and post-operative outcomes of laparoscopy vs. open surgery performed for the management of ICP.

METHODS

A literature search was carried out on Medline, EMBASE, and Scopus databases from January 1990 to June 2016. Clinical studies comparing the outcomes of laparoscopic and open surgical procedures for the treatment for ICP were retrieved and analyzed.

RESULTS

A total of 6 retrospective studies were selected, including 161 patients with ICP who underwent surgery. Laparoscopy was used in 55% of the patients, with a conversion rate of 10%. The meta-analysis shows that the laparoscopic approach was associated with significantly fewer post-operative complications compared to open surgery (18.2% vs. 53.5% respectively; Relative risk, RR: 0.32 [95%CI: 0.19-0.54; p < 0.0001; I² = 0%]) and shorter hospital stay (mean difference -5.35 days [95%CI: -6.94 to -3.76; p < 0.00001; I² = 0%]). No differences between the two surgical approaches were observed for postoperative mortality, need of re-intervention, and operative time.

CONCLUSION

The present study highlights the outcomes of the surgical management of an endoscopic complication that is not yet considered in clinical guidelines. Based on the current available literature, the laparoscopic approach appears to provide better outcomes in terms of postoperative complications and length of hospital stay than open surgery in the case of ICP surgical repair. However, the creation of large prospective registries of patients with ICP would be a step forward in addressing the lack of evidence concerning the surgical treatment of this endoscopic complication.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

The diminutive colon polyp: biopsy, snare, leave alone?

PURPOSE OF REVIEW

Diminutive polyps, measuring between 1 and 5 mm, represent the vast majority of colorectal polyps encountered during screening colonoscopy. Although the chance of harboring advanced adenoma or neoplastic cells is low, ensuring a complete polyp resection with clear margins is crucial to reduce the risk of interval colorectal cancer. The purpose of this review was to evaluate the different methods applied for polypectomy of diminutive polyps and clarify whether a diminutive polyp should be retrieved or left in place.

RECENT FINDINGS

Cold biopsy polypectomy is indicated for resection of polyps measuring 1-3 mm and removal of 4-5 mm polyps should be ensured by cold snare polypectomy. Over the last decade, hot biopsy polypectomy has been gradually abandoned because of an increased risk of diathermic injury. The resect and discard strategy and the diagnose and disregard strategy should be performed only by expert endoscopists, who should use validated scales and document the polyp features by storing several endoscopic images.

SUMMARY

Nowadays, complete resection of diminutive polyps, following the most appropriate technique, is recommended in clinical practice. The resect and discard strategy and the diagnose and disregard strategy should be reserved to expert endoscopists.

Risk factors for incomplete polyp resection during colonoscopic polypectomy

Background/Aims

Colonoscopic polypectomy is highly efficient in preventing colorectal cancer, but polyps may not always be completely removed. Improved knowledge of the risk factors for incomplete polyp resection after polypectomy may decrease the cancer risk and additional costs. The aim of this study was to investigate the conditions that can cause incomplete polyp resection (IPR) after colonoscopic polypectomy.

Methods

A total of 12,970 polyps that were removed by colonoscopic polypectomy were investigated. Among them, we identified 228 cases with a positive resection margin and 228 controls with a clear resection margin that were matched for age, gender, and polyp size. We investigated the location, morphology, and histological type of the polyps and evaluated the skills of the endoscopist and assisting nurse.

Results

Multivariate analysis revealed that the polyps, which were located in the proximal part of the colon and rectum, were at significant risk of IPR. Histologically, an advanced polyp and an inexperienced assistant were also independent risk factors for IPR.

Conclusions

Polypectomy should be performed more carefully for polyps suspected to be cancerous and polyps located in the proximal part of the colon or rectum. A systematic training program for inexperienced assistants may be needed to decrease the risk of IPR.

Endoscopic management of iatrogenic perforations during endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for colorectal polyps: a case series

BACKGROUND

Iatrogenic perforation during therapeutic colonoscopy, reported in up to 1% of endoscopic mucosal resections (EMRs) and up to 14% of endoscopic submucosal dissections (ESDs), has conventionally been an indication for surgery.

AIMS

We present a case series of successful endoscopic management of iatrogenic colorectal perforation during EMR and ESD, demonstrating the feasibility and safety of the method.

METHODS

Retrospective analysis of a database of patients undergoing EMR and ESD for colorectal polyps in a tertiary referral centre in the United Kingdom.

RESULTS

Four cases of perforation were identified (two EMRs and two ESDs) in a series of 218 procedures (1.8%), all detected at the time of endoscopy and managed with endoscopic clips. Patients were observed in hospital and treated with antibiotics. Their median length of stay was 3 days (range 2-6 days), with no mortality or need for surgery.

CONCLUSION

Surgery is no longer the first choice in the management of iatrogenic perforations during EMR and ESD for colorectal polyps; in selected patients with small perforations and minimal extraluminal contamination, conservative management with application of endoscopic clips, antibiotics and close patient monitoring constitute a safe and effective treatment option, avoiding the morbidity of major surgery.

Diminutive colorectal polyp resection comparing hot and cold snare and cold biopsy forceps polypectomy. Results of a pilot randomized, single-center study (with videos)

BACKGROUND

The optimal method of diminutive polypectomy (< 6 mm) is unknown.

OBJECTIVE

To assess the rates of incomplete resection of diminutive polyps of the colon using three standard polyp resection techniques (hot snare, cold snare, and cold biopsy forceps).

DESIGN

Randomized, pilot study.

SETTINGS

Single-center endoscopy center.

PATIENTS

PATIENTS undergoing routine outpatient colonoscopies.

INTERVENTIONS

Polypectomy was performed using the method to which the patient was randomized. Following retrieval of the polyp, the polypectomy base was lifted by submucosal injection of normal saline and then excised using the cold snare device. If no tissue could be removed, then at least four cold biopsies using forceps of the remaining margin were obtained.

MAIN OUTCOME MEASURES

Adequacy of resection of diminutive polyps, which was defined as no visible adenoma or hyperplastic tissue seen in the base tissue on histology.

RESULTS

A total of 60 patients were enrolled (57 % male), the mean age was 60 (range 33 - 82), and 62 polyps were randomized from 37 patients. The mean polyp size was 3.6 mm (range 2 - 5 mm) and 37 polyps (60 %) were adenomatous. Overall incomplete polyp resection rate was 9 % (95 %CI 3 - 19 %), 5 of 37 (14 %) for adenomas. By the study arm, the incomplete resection rates were 1 of 18 (6 %) for hot snare, 2 of 21 (10 %) for cold snare, and 2 of 18 (11 %) for cold biopsy forceps. The majority of polyp bases were removed with cold biopsy forceps since most of the endoscopists did not feel that the saline lift cold snare method was feasible or appropriate.

LIMITATIONS

Small sample size; endoscopic mucosal resection (EMR) of the polyp base tissue was not routinely performed.

CONCLUSIONS

Recruiting patients to a pilot study that randomized polyps to one of three common methods of polypectomy for diminutive polyps was feasible, and approximately 1 in 10 diminutive polyps found on colonoscopy were incompletely resected by standard polypectomy methods.

Only the size of resected polyps is an independent risk factor for delayed postpolypectomy hemorrhage: a 10-year single-center case-control study

Purpose

A colonoscopic polypectomy is an important procedure for preventing colorectal cancer, but it is not free from complications. Delayed hemorrhage after a colonoscopic polypectomy is one infrequent, but serious, complication. The aim of this study was to identify the risk factors for delayed hemorrhage after a colonoscopic polypectomy.

Methods

This was a retrospective case-control study based on medical records from a single gastroenterology center. The records of 7,217 patients who underwent a colonoscopic polypectomy between March 2002 and March 2012 were reviewed, and 92 patients and 276 controls were selected. Data collected included comorbidity, use of antiplatelet agents, size and number of resected polyps, histology and gross morphology of resected polyps, resection method, and use of prophylactic hemostasis.

Results

The average time between the procedure and bleeding was 2.71 ± 1.55 days. Univariate and multivariate analyses revealed that the size of the polyps was the only and most important predictor of delayed hemorrhage after a colonoscopic polypectomy (odds ratio, 2.06; 95% confidence interval, 1.12-1.27; P = 0.03).

Conclusion

The size of resected polyps was the only independent risk factor for delayed bleeding after a colonoscopic polypectomy. The size of a polyp, as revealed by the colonoscopic procedure, may aid in making decisions, such as the decision to conduct a prophylactic hemostatic procedure.

Postpolypectomy Fever, a rare adverse event of polypectomy: nested case-control study

BACKGROUND/AIMS

Although postpolypectomy fever (PPF) without colon perforation or hemorrhage is rare, its incidence and risk factors have not been investigated. The objective of this study was to analyze the incidence and risk factors for PPF among inpatients.

METHODS

Seven patients with PPF were matched with 70 patients without PPF from a total of 3,444 patients who underwent colonoscopic polypectomy. The PPF incidence during index hospitalization after colonoscopy was calculated, and univariate and multivariate analyses were performed to calculate the adjusted odds ratios (ORs) for risk factors.

RESULTS

PPF without bleeding or perforation in the colon occurred in seven patients (0.2%). The median age was 58 years for cases and 61 years for controls. The median interval from polypectomy to occurrence of fever was 7 hours, and the median duration of fever was 9 hours. Polyp size >2 cm (adjusted OR, 1.08; 95% confidence interval [CI], 1.01 to 1.15; p=0.02) and hypertension (adjusted OR, 14.40; 95% CI, 1.23 to 180.87; p=0.03) were associated with a significantly increased risk of PPF. PPF increased the length of hospitalization.

CONCLUSIONS

Although the crude incidence of PPF is low, PPF may prolong hospitalization. Risk factors for PPF include hypertension and large polyps.

The prophylactic placement of hemoclips to prevent delayed post-polypectomy bleeding: an unnecessary practice? A case control study

BACKGROUND

With the recent, widespread availability of endoscopic hemoclips, it has become common clinical practice to apply hemoclips to some non-bleeding polypectomy sites "prophylactically" to prevent delayed post-polypectomy bleeding (PPB). Few published data support this practice, however.

AIM

The aim of this study was to compare rates of delayed PPB in matched patients who had polypectomies performed with and without the prophylactic placement of hemoclips.

METHODS

We reviewed medical records of patients who had elective colonoscopy at our VA Medical Center between July 2008 and December 2009. We identified patients who had hemoclips applied prophylactically (cases) and compared their rate of delayed PPB within 30 days to that of patients who had polypectomy without hemoclipping (controls). Controls were matched 1:1 to cases based on age and on factors known to contribute to the risk of PPB including polyp size, morphology, technique of polyp removal, number of polyps removed, and use of anticoagulants.

RESULTS

We identified 184 patients (cases) who underwent prophylactic hemoclipping and 184 well-matched controls. An average of 3.8 polyps per patient were removed in the case group compared to 3.3 polyps per patient in controls (p = 0.6). Delayed PPB occurred in three patients in the prophylactic hemoclip group and in one patient in the control group (1.6 vs. 0.5 %, p = 0.62).

CONCLUSIONS

We found no significant difference in the rate of delayed PPB between patients who had prophylactic hemoclipping of polypectomy sites and a well-matched control group of patients who had polypectomy without prophylactic hemoclipping. These data call into question the expensive practice of prophylactic hemoclipping.

Differences in the endoscopic closure of colonic perforation due to diagnostic or therapeutic colonoscopy

OBJECTIVE

To describe the experience of a single center regarding the feasibility of endoscopic closure of iatrogenic colonic perforations and to elucidate differences between the efficacy of endoscopic clip closure due to diagnostic or therapeutic colonoscopy.

MATERIAL AND METHODS

A retrospective institutional computer-based search of records of colonoscopic perforation occurring between January 2004 and December 2011 was undertaken. Data on patients undergoing colonoscopy were entered into a clinical database. To further improve the detection of all cases of colon perforations, the authors also searched their separate surgical database for every patient with a colon perforation treated or operated on in the surgery department. Statistical significance was tested using either Fortran-Subroutine Fytest, chi-square testing or t-test.

RESULTS

Over 8 years, 22,924 patients underwent colonoscopy, of which 105 consecutive patients suffered iatrogenic perforation. Clip application was possible in 62 patients (81.58%) after perforation due to a therapeutic colonoscopy, whereas clip application was only possible in 9 patients (31.03%) after perforation due to a diagnostic colonoscopy. 4 out of 9 patients (44.44%) in the diagnostic group compared with 7 out of 62 patients (11.29%) after clipping a perforation during a therapeutic colonoscopy were sent to surgery.

CONCLUSIONS

The authors' data indicate significant differences in the potential for and success of endoscopic closure of iatrogenic perforations occurring during diagnostic or therapeutic colonoscopy. The frequency of surgery was significantly greater after clipping a perforation during a diagnostic colonoscopy.

[Risk factors of delayed bleeding after colonoscopic polypectomy: case-control study]

BACKGROUND/AIMS

Colonoscopic polypectomy is a valuable procedure for preventing colorectal cancer, but is not without complications. Delayed bleeding after colonoscopic polypectomy is a rare, but serious complication. The aim of this study was to identify risk factors of delayed bleeding after colonoscopic polypectomy.

METHODS

A retrospective case-control study was conducted in a single university hospital. Forty cases and 120 controls were included. Data collected included comorbidity, use of antiplatelet agents, size and number of resected polyps, histology and gross morphology of resected polyps, endoscopist's experience, resection method, use of sedation, and use of prophylactic hemostasis.

RESULTS

In univariate analysis, size, histology and number of resected polyps, endoscopist's experience, resection method and use of prophylactic hemostasis were significant risk factors for delayed bleeding after colonoscopic polypectomy. In multivariate analysis, risk of delayed bleeding increased by 11.6% for every 1 mm increase in resected polyp diameter (OR, 1.116; 95% CI 1.041-1.198; p=0.002). Number of resected polyps (OR, 1.364; 95% CI, 1.113-1.671; p=0.003) and endoscopist's experience (OR, 6.301; 95% CI, 2.022-19.637; p=0.002) were significant risk factors for delayed bleeding after colonoscopic polypectomy.

CONCLUSIONS

Size and numbers of resected polyps, and endoscopist's experience were independent risk factors for delayed bleeding after colonoscopic polypectomy. More caution would be necessary when removing polyps with these factors.

Postpolypectomy bleeding: incidence, risk factors, prevention, and management

Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.

Prevalence and risk factors for colonic perforation during colonoscopy in hospitalized end-stage renal disease patients on hemodialysis

BACKGROUND AND AIMS

Colonic perforation is a rare complication during colonoscopy. A recent single center study reported a high incidence of colonic perforation in end-stage renal disease (ESRD) patients on hemodialysis (HD) who underwent colonoscopy. We sought to determine nationwide, population-based prevalence in rates of colonic perforation during colonoscopy among ESRD inpatients on HD in the US, and to assess risk factors for colonic perforation in this patient population.

METHODS

We obtained patient data from the Nationwide Inpatient Sample and used the International Classification of Diseases, the 9th revision, clinical modification codes, to identify ESRD patients on HD who had undergone colonoscopy in 2006. The control group consisted of inpatients who had colonoscopy without ESRD.

RESULTS

Colonic perforations occurred in 51/17,000 ESRD hospitalizations on HD (0.3%) and 3,951/564,428 controls without ESRD (0.7%). The risk of colonic perforation among the study group was not significantly higher than the control group even after adjusting for patient demographics like age, gender and comorbid conditions (adjusted odds ratio [aOR] -0.55; 95% confidence interval [CI], 0.30-0.97). Older age (OR -1.007; 95% CI, 1.002-1.011) and female gender (OR -1.18; 95% CI, 1.03-1.36) were identified as independent risk factors for the risk of perforation in this population group.

CONCLUSIONS

There appeared no increased risk of colonic perforation during colonoscopy among inpatients who received HD in our study. Increasing age and female patients appeared to be associated with procedure-related colonic perforation.

Clipping for the prevention of immediate bleeding after polypectomy of pedunculated polyps: a pilot study

Background/Aims

Immediate postpolypectomy bleeding (IPPB) increases the procedure time and it may disturb performing a safe polypectomy. The purpose of this study is to investigate whether clipping before snare polypectomy of large pedunculated polyps is useful for the prevention of IPPB.

Methods

This is a single arm, pilot study. We enrolled patients with pedunculated colorectal polyps that were 1 cm in size or more from 4 university hospitals between June 2009 and June 2010. Clips were applied at the stalk and snare polypectomy was then performed. The complications, including IPPB, were investigated.

Results

Fifty six pedunculated polyps in 47 patients (Male:Female=36:11; age, 56±11 years) were included. The size of the polyp heads was 17±8 mm. Tubular adenoma was most common (57%). The number of clips used before snare polypectomy was 2±0.5. The procedure was successful in all cases. IPPB occurred in 2 cases (3.6%), and both of these were managed by additional clipping. Delayed bleeding occurred in another one case (1.8%), which improved with conservative treatment. No perforation occurred.

Conclusions

We suggest that clipping before snare polypectomy of pedunculated polyps may be an easy and effective technique for the prevention of IPPB, and this should be confirmed in large scale, prospective, controlled studies.

Management of delayed postpolypectomy bleeding: a decision analysis

OBJECTIVES

The benefit of repeat colonoscopy in managing delayed postpolypectomy bleeding is unknown. This study aimed to assess the outcome of repeat colonoscopy to achieve hemostasis.

METHODS

Endoscopic management of postpolypectomy bleeding is modeled as a decision tree, measuring the expected overall fraction of patients who benefit from therapeutic hemostasis and the number of patients needed to treat (NNT) in order to achieve one beneficial hemostasis.

RESULTS

A repeat colonoscopy to identify and treat postpolypectomy bleeding is beneficial in about 22% of patients, corresponding to an NNT of 4.5 patients. The outcome of the model is sensitive to assumptions underlying the fractions of patients who need treatment and would benefit from successful endoscopic hemostasis. Varying these probabilities over a broad range changes the fraction of patients benefiting from endoscopy between 3% and 33% and the NNT between 28 and 3 patients, respectively.

CONCLUSIONS

The expected outcome of repeat colonoscopy justifies the endoscopic attempts at therapeutic hemostasis. The results also suggest that in many patients expectant management aimed at spontaneous resolution of the bleeding remains a valid option.

Acute abdominal compartment syndrome complicating a colonoscopic perforation: a case report

Introduction

A perforation occurring during colonoscopy is an extremely rare complication that may be difficult to diagnose. It can be responsible for acute abdominal compartment syndrome, a potentially lethal complex pathological state in which an acute increase in intra-abdominal pressure may provoke the failure of several organ systems.

Case presentation

We report a case of acute abdominal compartment syndrome after perforation of the bowel during a colonoscopy in a 60-year-old North African man with rectal cancer, resulting in respiratory distress, cyanosis and cardiac arrest. Our patient was treated by needle decompression after the failure of cardiopulmonary resuscitation. An emergency laparotomy with anterior resection, including the perforated sigmoid colon, was then performed followed by immediate anastomosis. Our patient remains alive and free of disease three years later.

Conclusion

Acute abdominal compartment syndrome is a rare disease that may occasionally occur after a colonoscopic perforation. It should be kept in mind during colonoscopy, especially considering its simple salvage treatment.

Endoscopic treatment for lower gastrointestinal bleeding

Lower gastrointestinal bleeding is common and can result from several colonic causes including diverticulosis, arteriovenous malformations, ischemia, inflammatory bowel disease, infectious colitis, neoplasm, postpolypectomy, and anastomotic and radiation proctitis. Following resuscitation and evaluation, colonoscopy can be used for diagnosis and treatment. Most physicians prescribe a bowel preparation for their patients. Therapeutic options include injection, coagulation (monopolar or bipolar cautery, argon plasma coagulator), and mechanical (clips, bands, detachable loops) devices.

Analysis of delayed postpolypectomy bleeding in a colorectal clinic

PURPOSE

The colonoscopic polypectomy has become a valuable procedure for removing precursors of colorectal cancer, but some complications can be occurred. The most common complication after colonoscopic polypectomy is bleeding, which is reported to range from 1% to 6% and which can be immediate or delayed. Because the management of delayed postpolypectomy bleeding could be difficult, the use of preventive technique and reductions of risk factors are essential.

METHODS

From January 2007 to December 2008, delayed hemorrhage occurred in 18 of the 1,841 polypectomy patients examined by one endoscopist. These cases were reviewed retrospectively for risk factors, pathologic findings, and treatment methods.

RESULTS

Delayed bleeding occurred in 18/1,841 patients (0.95%). The mean age was 55.9 ± 10.9 years, and the male-to-female ratio was 8:1. The most common site was the right colon (11 cases, 61.1%), and the average polyp size was 9.2 ± 2.8 mm. Delayed bleeding was identified from 1 to 5 days after resection (mean, 1.6 ± 1.2 days). The most common macroscopic type of polyp was a sessile polyp (10 cases, 55.6%), and histologic finding was a tubular adenoma in 13 cases (72.2%). Seventeen cases were treated with clipping for hemostasis and 1 case with epinephrine injection.

CONCLUSION

The right colon and a sessile polyp were associated with an increase in delayed postpolypectomy bleeding. Reducing risk factors and close observation were essential in high risk patients, and prompt management with hemoclips was effective.

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

BACKGROUND

EMR of large sessile polyps and laterally spreading tumors (LSTs) of the colon is safe and cost-effective. Perforation remains a feared and well-recognized complication; however, endoscopic detection is often absent, and most commonly, diagnosis is delayed and depends on clinical signs and/or radiology findings. To date, an endoscopic sign to identify muscularis propria (MP) resection and potential perforation has not been described.

OBJECTIVE

To describe an endoscopic sign for prompt recognition of EMR-related MP resection.

DESIGN

Prospective analysis.

SETTINGS

Tertiary referral academic gastroenterology unit.

PATIENTS

Patients with the target sign were identified prospectively in 2 large prospective studies of EMR for colonic LSTs 20 mm or larger.

INTERVENTION

A standardized EMR approach was used. MP defects were closed endoscopically with clips.

MAIN OUTCOME MEASUREMENTS

The presence or absence of the target sign in the polypectomy specimen and its influence on subsequent endoscopic management of polypectomy complications.

RESULTS

A total of 445 patients with LSTs or sessile polyps 20 mm or larger (mean size 33 mm, range 20-85 mm) were prospectively enrolled in 2 studies. Ten patients (mean age 70.3 years, range 48-83 years, 50% male) with target lesions and histologically confirmed MP resection were identified prospectively at the time of EMR, with 3 having full-thickness resection. All cases were identified intraprocedurally by a target sign on the underside of the specimen and a mirror target evident in the mucosal defect. All patients were treated endoscopically with 1 to 5 endoscopic clips. None required operative management. Thirteen inpatient days were required to treat the 10 patients (mean 1.3 days).

LIMITATIONS

Nonrandomized study.

CONCLUSIONS

Careful analysis of the post-EMR specimen and resection defect may reveal a target sign, an easily recognized and reliable marker of either partial- or full-thickness MP resection and potential perforation. Prompt recognition of this sign facilitates endoscopic management.

Complications of colonoscopy: magnitude and management

Although complications of colonoscopy are rare, they are potentially serious and life threatening. In addition, less serious adverse events may occur frequently and may have an impact on a patient's willingness to undergo future procedures. This article reviews the magnitude of and risk factors for major and minor colonoscopy complications, discusses management of complications, and suggests ways to design quality improvement programs to reduce the risk of complications.

Endoscopic mucosal resection of colonic lesions: current applications and future prospects

The introduction of submucosal fluid injection has remarkably extended the range of endoscopically resectable polyps. The limiting factor for endoscopic resection is not polyp size, but polyp depth. Endoscopic ultrasound is a useful adjunctive diagnostic tool to assess the depth of invasion. The success of are section ultimately depends on pathologic confirmation of a benign nature of this lesion or of a cancer limited to the mucosa. Selected well-differentiated cancers without lymphovascular invasion of the superficial submucosa can be successfully resected endoscopically.

Colonoscopic polypectomy

Colonoscopic polypectomy is the most effective visceral cancer prevention tool in clinical medicine. In general, risks associated with the technique of polyp removal should match the likelihood that the polyp will become or already is malignant (eg, low-risk technique for low risk for malignant potential). Cold techniques are preferred for most diminutive polyps. Polypectomy techniques must be effective and minimize complications. Complications can occur even with proper technique, however. Aggressive evaluation and treatment of complications helps ensure the best possible outcome.

Reducing the incidence and mortality of colon cancer: mass screening and colonoscopic polypectomy

Most colon cancers arise from conventional adenomatous polyps (conventional adenoma-to-carcinoma sequence), while some colon cancers appear to arise from the recently recognized serrated adenomatous polyp (serrated adenoma-to-carcinoma theory). Because conventional adenomas and serrated adenomas are usually asymptomatic, mass screening of asymptomatic patients has become the cornerstone for detecting and eliminating these precursor lesions to reduce the risk of colon cancer. Colonoscopy has become the primary screening test because of its high sensitivity and specificity, and the ability to perform polypectomy. Other screening tests include guaiac tests or fecal immunochemical tests (FIT) for fecal occult blood, and flexible sigmoidoscopy. A minimal colonoscopic withdrawal time of 6 minutes is important to maximize polyp detection at colonoscopy. Chromoendoscopy is an experimental technique used to highlight abnormal colonic areas to identify neoplastic tissue and to potentially determine the histology of colonic polyps at colonoscopy based on superficial pit anatomy.