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Wehbe H, Gutta A, Gromski MA. Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon. Gastrointest Endosc Clin N Am 2024; 34:363-381. [PMID: 38395489 DOI: 10.1016/j.giec.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.
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Affiliation(s)
- Hisham Wehbe
- Department of Internal Medicine, Indiana University School of Medicine, 550 University Boulevard, UH 3533, Indianapolis, IN 46202, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA
| | - Mark A Gromski
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA.
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2
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Whitfield AM, Burgess NG, Bahin FF, Kabir S, Pellisé M, Sonson R, Subramanian V, Mahajan H, McLeod D, Byth K, Bourke MJ. Histopathological effects of electrosurgical interventions in an in vivo porcine model of colonic endoscopic mucosal resection. Gut 2022; 71:864-870. [PMID: 34172512 DOI: 10.1136/gutjnl-2021-324140] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR) in the colon has been widely adopted, but there is limited data on the histopathological effects of the differing electrosurgical currents (ESCs) used. We used an in vivo porcine model to compare the tissue effects of ESCs for snare resection and adjuvant margin ablation techniques. DESIGN Standardised EMR was performed by a single endoscopist in 12 pigs. Two intersecting 15 mm snare resections were performed. Resections were randomised 1:1 using either a microprocessor-controlled current (MCC) or low-power coagulating current (LPCC). The lateral margins of each defect were treated with either argon plasma coagulation (APC) or snare tip soft coagulation (STSC). Colons were surgically removed at 72 hours. Two specialist pathologists blinded to the intervention assessed the specimens. RESULTS 88 defects were analysed (median 7 per pig, median defect size 29×17 mm). For snare ESC effects, 156 tissue sections were assessed. LPCC was comparable to MCC for deep involvement of the colon wall. For margin ablation, 172 tissue sections were assessed. APC was comparable to STSC for deep involvement of the colon wall. Islands of preserved mucosa at the coagulated margin were more likely with APC compared with STSC (16% vs 5%, p=0.010). CONCLUSION For snare resection, MCC and LPCC did not produce significantly different tissue effects. The submucosal injectate may protect the underlying tissue, and technique may more strongly dictate the depth and extent of final injury. For margin ablation, APC was less uniform and complete compared with STSC.
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Affiliation(s)
- Anthony M Whitfield
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Farzan F Bahin
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Sharir Kabir
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - María Pellisé
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Vishnu Subramanian
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Hema Mahajan
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Duncan McLeod
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia.,WSLHD Research and Education Network, Westmead Hospital, Westmead, New South Wales, Australia
| | - Michael J Bourke
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia .,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
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Rashid MU, Alomari M, Afraz S, Erim T. EMR and ESD: Indications, techniques and results. Surg Oncol 2022; 43:101742. [DOI: 10.1016/j.suronc.2022.101742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/21/2022] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
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Yang JK, Hyun JJ, Lee TH, Choi JH, Lee YN, Choe JW, Park JS, Kwon CI, Jeong S, Kim HJ, Moon JH, Park SH. Can prophylactic argon plasma coagulation reduce delayed post-papillectomy bleeding? A prospective multicenter trial. J Gastroenterol Hepatol 2021; 36:467-473. [PMID: 32677716 DOI: 10.1111/jgh.15186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. METHODS In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate. RESULTS The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications. CONCLUSION Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).
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Affiliation(s)
- Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Chang-Il Kwon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hong Ja Kim
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
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Martines G, Picciariello A, Dibra R, Trigiante G, Jambrenghi OC, Chetta N, Altomare DF. Efficacy of cyanoacrylate in the prevention of delayed bleeding after endoscopic mucosal resection of large colorectal polyps: a pilot study. Int J Colorectal Dis 2020; 35:2141-2144. [PMID: 32577871 DOI: 10.1007/s00384-020-03678-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative bleeding is a common complication after endoscopic polypectomy, particularly after endoscopic mucosal resection (EMR) of large non-pedunculated polyps, despite prophylactic clipping can reduce its occurrence. Cyanoacrylate glue has recently been proposed as a useful tool in reducing bleeding in surgery because of its adhesive and haemostatic properties. The aim of this study is to evaluate the usefulness of endoscopic application of a modified cyanoacrylate glue in the prevention of early or delayed post EMR bleeding. METHODS This is a pilot study. Inclusion criteria were patients between 18 and 75 years old affected by sessile or flat colonic polyps larger than 2 cm. Patients enrolled in the study were randomized in two groups: group A (EMR) and group B (EMR with the application of 0.3 ml of N-butyl-2-cyanoacrylate + methacryloxysulfolane-Glubran 2®). RESULTS Fifteen patients in both group A and B were enrolled. There were no intraoperative complications but haemostatic clipping was necessary in 3 patients in each group because of active bleeding. Delayed (after 24 h) bleeding occurred in two patients (13.3%) in group A requiring hospital readmission and re-do endoscopy with apposition of haemostatic clips. No case of bleeding was recorded in group B (p = 0.48). CONCLUSION The results of this pilot study suggest a potential role of local spray application of Glubran®2 in reducing post-procedural bleeding.
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Affiliation(s)
- Gennaro Martines
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Arcangelo Picciariello
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Rigers Dibra
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Giuseppe Trigiante
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - O Caputi Jambrenghi
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Nicola Chetta
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Donato Francesco Altomare
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy. .,IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy. .,Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Piazza G Cesare, 11, 70124, Bari, Italy.
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Andalib I, Gress FG. Polypectomy Using Blended vs Forced Currents: Blue or Yellow? That Is the Question! Gastroenterology 2020; 159:32-33. [PMID: 32407809 DOI: 10.1053/j.gastro.2020.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/06/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Iman Andalib
- Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Gastroenterology & Hepatology, Mount Sinai South Nassau, Long Island, New York
| | - Frank G Gress
- Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Gastroenterology & Hepatology, Mount Sinai South Nassau, Long Island, New York.
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Pohl H, Grimm IS, Moyer MT, Hasan MK, Pleskow D, Elmunzer BJ, Khashab MA, Sanaei O, Al-Kawas FH, Gordon SR, Mathew A, Levenick JM, Aslanian HR, Antaki F, von Renteln D, Crockett SD, Rastogi A, Gill JA, Law RJ, Elias PA, Pellise M, Mackenzie TA, Rex DK. Effects of Blended (Yellow) vs Forced Coagulation (Blue) Currents on Adverse Events, Complete Resection, or Polyp Recurrence After Polypectomy in a Large Randomized Trial. Gastroenterology 2020; 159:119-128.e2. [PMID: 32173478 PMCID: PMC8262363 DOI: 10.1053/j.gastro.2020.03.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/19/2020] [Accepted: 03/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is debate over the type of electrosurgical setting that should be used for polyp resection. Some endoscopists use a type of blended current (yellow), whereas others prefer coagulation (blue). We performed a single-blinded, randomized trial to determine whether type of electrosurgical setting affects risk of adverse events or recurrence. METHODS Patients undergoing endoscopic mucosal resection of nonpedunculated colorectal polyps 20 mm or larger (n = 928) were randomly assigned, in a 2 × 2 design, to groups that received clip closure or no clip closure of the resection defect (primary intervention) and then to either a blended current (Endocut Q) or coagulation current (forced coagulation) (Erbe Inc) (secondary intervention and focus of the study). The study was performed at multiple centers, from April 2013 through October 2017. Patients were evaluated 30 days after the procedure (n = 919), and 675 patients underwent a surveillance colonoscopy at a median of 6 months after the procedure. The primary outcome was any severe adverse event in a per patient analysis. Secondary outcomes were complete resection and recurrence at first surveillance colonoscopy in a per polyp analysis. RESULTS Serious adverse events occurred in 7.2% of patients in the Endocut group and 7.9% of patients in the forced coagulation group, with no significant differences in the occurrence of types of events. There were no significant differences between groups in proportions of polyps that were completely removed (96% in the Endocut group vs 95% in the forced coagulation group) or the proportion of polyps found to have recurred at surveillance colonoscopy (17% and 17%, respectively). Procedural characteristics were comparable, except that 17% of patients in the Endocut group had immediate bleeding that required an intervention, compared with 11% in the forced coagulation group (P = .006). CONCLUSIONS In a randomized trial to compare 2 commonly used electrosurgical settings for the resection of large colorectal polyps (Endocut vs forced coagulation), we found no difference in risk of serious adverse events, complete resection rate, or polyp recurrence. Electrosurgical settings can therefore be selected based on endoscopist expertise and preference. Clinicaltrials.gov ID NCT01936948.
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Affiliation(s)
- Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Veterans Affairs Medical Center White River Junction, Vermont.
| | - Ian S. Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew T. Moyer
- Matthew T. Moyer, Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Muhammad K. Hasan
- Muhammad K. Hasan, Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Douglas Pleskow
- Douglas Pleskow, Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Mouen A. Khashab
- Mouen A. Khashab, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Omid Sanaei
- Mouen A. Khashab, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Firas H. Al-Kawas
- Mouen A. Khashab, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland,Sibley Memorial Hospital, Washington, DC
| | - Stuart R. Gordon
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire,Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Abraham Mathew
- Matthew T. Moyer, Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - John M. Levenick
- Matthew T. Moyer, Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Harry R. Aslanian
- Section of Digestive Diseases, Yale-New Haven Hospital, New Haven, Connecticut
| | - Fadi Antaki
- Division of Gastroenterology, John D. Dingell Veterans Affairs Medical Center and Wayne State University, Detroit, Michigan
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Medical Center and Research Center, Montreal, Quebec, Canada
| | - Seth D. Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas City, Kansas
| | - Jeffrey A. Gill
- Division of Gastroenterology James A. Haley Veterans Affairs Medical Center, University of South Florida, Tampa, Florida
| | - Ryan J. Law
- Division of Gastroenterology and Hepatology University of Michigan, Ann Arbor, Michigan
| | - Pooja A. Elias
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Maria Pellise
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Todd A. Mackenzie
- The Dartmouth Institute, Department for Biomedical Data Science, Lebanon, New Hampshire
| | - Douglas K. Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Willems P, Orkut S, Ditisheim S, Pohl H, Barkun A, Djinbachian R, Bouin M, von Renteln D. An international polypectomy practice survey. Scand J Gastroenterol 2020; 55:497-502. [PMID: 32267187 DOI: 10.1080/00365521.2020.1749297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and study aims: In recent years, cold snare polypectomy (CSP) has been recommended as the preferred approach for removal of small and diminutive colorectal polyps. We conducted an international survey among endoscopists to understand the uptake of CSP and changes in polypectomy practice during recent years.Patients and methods: Endoscopists were invited through gastroenterology, colorectal surgery and endoscopy societies to participate in an online survey. The primary outcome was to identify the predominant polypectomy approach used to remove 4‒10 mm colorectal polyps. Secondary outcomes included the uptake of CSP in the past 5 years, current polypectomy practice patterns for 1‒20 mm polyps, practice changes in recent years, and perceived benefits/concerns related to different polypectomy techniques.Results: The survey was distributed internationally by nine societies and completed by 808 endoscopists (response rate 3.7%). CSP was the predominant polypectomy technique for 4‒5 mm polyps (67.0%, 95% CI, 63.7-70.2%) and 6‒10 mm polyps (55.2%, 95% CI, 51.8-58.6%). For 1‒3 mm polyps, cold forceps remained the predominant technique (78.4%, 95% CI, 75.6-81.3%), whereas hot snare polypectomy (HSP) remained the predominant technique for 10‒20 mm polyps (92.5%, 95% CI, 90.7-94.3%). 87.5% (95% CI, 85.2-89.8%) of endoscopists reported an increase in CSP use during the past 5 years.Conclusions: This survey found a substantial increase in CSP use during recent years. CSP has become the predominant polypectomy approach for 4‒10 mm colorectal polyps, while HSP remained the predominant approach for larger (10‒20 mm) polyps. Clinical practice patterns are well aligned with recently issued guideline recommendations.
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Affiliation(s)
- Philippe Willems
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sinan Orkut
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Saskia Ditisheim
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Hartford, VT, USA.,Dartmouth, Geisel School of Medicine, Hanover, NH, USA
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Mickael Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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Goldis A, Goldis R, Chirila TV. Biomaterials in Gastroenterology: A Critical Overview. ACTA ACUST UNITED AC 2019; 55:medicina55110734. [PMID: 31726779 PMCID: PMC6915447 DOI: 10.3390/medicina55110734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 02/07/2023]
Abstract
In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.
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Affiliation(s)
- Adrian Goldis
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | | | - Traian V. Chirila
- Queensland Eye Institute, South Brisbane, QL 4101, Australia;
- Science & Engineering Faculty, Queensland University of Technology, Brisbane, QL 4000, Australia
- Faculty of Medicine, University of Queensland, Herston, QL 4029, Australia
- Australian Institute for Bioengineering and Nanotechnology, University of Queensland, St Lucia, 4072 QL, Australia
- Faculty of Science, University of Western Australia, Crawley, WA 6009, Australia
- University of Medicine, Pharmacy, Sciences and Technology, 540139 Targu Mures, Romania
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10
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Yao C, Chiu Y, Wu K, Tai W, Hu M, Chou Y, Liang C, Lu L, Chuah S. The effect of discontinuation of aspirin on colonoscopic postpolypectomy bleeding. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Chih‐Chien Yao
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Yi‐Chun Chiu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Keng‐Liang Wu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
- Graduate Institute of Clinical Medical SciencesChang Gung University Taoyuan Taiwan
| | - Wei‐Chen Tai
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Ming‐Luen Hu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Yeh‐Pin Chou
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Chih‐Ming Liang
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Lung‐Sheng Lu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
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11
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Marín-Gabriel JC, Romito R, Guarner-Argente C, Santiago-García J, Rodríguez-Sánchez J, Toyonaga T. Use of electrosurgical units in the endoscopic resection of gastrointestinal tumors. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:512-523. [PMID: 31326105 DOI: 10.1016/j.gastrohep.2019.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/31/2019] [Accepted: 04/05/2019] [Indexed: 12/18/2022]
Abstract
Electrosurgical units (ESUs) are indispensable devices in our endoscopy units. However, many endoscopists are not well-trained on their use and their physical bases are usually not properly studied or understood. In addition, comparative data concerning the settings that may be applied in different circumstances are scarce in the medical literature. Given that it is important to be aware of their strengths and risks, we conducted a review of the available information and research on this topic.
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Affiliation(s)
- José C Marín-Gabriel
- Department of Gastroenterology, Endoscopy Unit, High Risk GI Cancer Clinic, Research Institute, 12 de Octubre (i+12), "12 de Octubre" University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - Raffaella Romito
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca - IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Guarner-Argente
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca - IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Santiago-García
- Department of Gastroenterology, Endoscopy Unit, "Puerta de Hierro-Majadahonda" University Hospital, Autonomous University of Madrid (UAM), Majadahonda (Madrid), Spain
| | - Joaquín Rodríguez-Sánchez
- Department of Gastroenterology, Endoscopy Unit, Hospital Universitario de Ciudad Real, Ciudad Real, Spain
| | - Takashi Toyonaga
- Department of Endoscopy, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
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12
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Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm: a systematic review and pooled-analysis. Gastrointest Endosc 2019; 89:929-936.e3. [PMID: 30639542 DOI: 10.1016/j.gie.2018.12.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 12/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Hot snare polypectomy and EMR are the standard of care in resecting colorectal polyps ≥10 mm. To avoid the risk of electrocautery-induced damage, there is recent evidence about using cold snare polypectomy and cold EMR for such lesions. The aim of this pooled analysis is to report outcomes of cold snare resection for polyps ≥10 mm. METHODS PubMed/Medline, Embase, Google Scholar, and Cochrane databases were searched up to July 2018 to identify studies that performed cold snare resection for colorectal polyps ≥10 mm. Primary outcomes were adverse events (bleeding, perforation, and postpolypectomy abdominal pain), and secondary outcomes were the rates of complete resection, overall residual polyp rates, and rates for adenomas versus sessile serrated polyps (SSPs). Subgroup analysis was performed focusing on lesion size, location, and resection technique. RESULTS Eight studies were included in the final analysis that included 522 colorectal polyps with a mean polyp size of 17.5 mm (range, 10-60). The overall adverse event rate was 1.1% (95% confidence interval, CI, 0.2%-2.0%; I2 = 0%). Intra- and postprocedural bleeding rates were .7% (95% CI, 0%-1.4%) and .5% (95% CI, .1%-1.2%), respectively, with abdominal pain rate being .6% (95% CI, .1%-1.3%). Polyps ≥20 mm had a higher intraprocedural bleeding rate of 1.3% (95% CI, .7%-3.3%) and abdominal pain rate of 1.2% (95% CI, .7%-3.0%) but no delayed bleedings. No perforations were reported. The complete resection rate was 99.3% (95% CI, 98.6%-100%). Overall pooled residual rates of polyps of any histology, adenomas, and SSPs were 4.1% (95% CI, .2%-8.4%), 11.1% (95% CI, 4.1%-18.1%), and 1.0% (95% CI, .4%-2.4%), respectively, during a follow-up period ranging from 154 to 258 days. CONCLUSIONS The results of this systematic review and pooled analysis were excellent with cold snare resection of colorectal polyps >10 mm in terms of postpolypectomy bleeding, complete resection, and residual polyp rates. Randomized controlled trials comparing cold snare resection with hot snare resections of polyps ≥10 mm are required for further investigation.
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13
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Chang LC, Shun CT, Hsu WF, Tu CH, Chen CC, Wu MS, Chiu HM. Risk of delayed bleeding before and after implementation of cold snare polypectomy in a screening colonoscopy setting. Endosc Int Open 2019; 7:E232-E238. [PMID: 30705958 PMCID: PMC6353650 DOI: 10.1055/a-0810-0439] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Cold snare polypectomy (CSP) is considered to be effective in reducing risk of delayed bleeding but randomized trials fail to support this owing to the small sample size. The current study aimed to compare risk of delayed bleeding before and after implementation of CSP in a screening colonoscopy setting. Patients and methods This study retrospectively analyzed a prospectively maintained screening colonoscopy database in a university hospital in Taiwan. We compared the rate of delayed bleeding before and after implementation within similar periods (18 months and 15 months) and the respective number of polypectomies (1,304 and 1,255) performed to remove small and diminutive polyps. The main outcome measurement was delayed bleeding within the two periods. Multivariate analysis was performed to adjust for major confounders. Results A total of 1,304 and 1,225 subjects received hot snare polypectomy (HSP) and CSP in two separate periods, respectively. Compared with the HSP, the CSP had a lower rate of delayed bleeding (0.1 % vs . 1.1 %, P < 0.001), severe bleeding (0 % vs. 0.7 %, P < 0.01), need for second-look colonoscopy (0 % vs. 0.8 %, P < 0.01), and emergency service visits (0.1 % vs . 1.0 %, P < 0.01). Total procedure time (12.60 ± 11.45 vs . 16.48 ± 14.27 min/person, P < 0.01) and duration of hospital stay (1.18 ± 0.50 vs . 1.53 ± 5.78 hour/person, P < 0.03) were also shorter after CSP implementation. Multivariate analysis showed that HSP was an independent risk factor for delayed bleeding after adjusting for age, gender, and number of polyps (adjusted odds ratio 14.4;95 % confidence interval = 1.88 - 110.6). Conclusion Implementation of CSP significantly reduces risk of delayed bleeding associated with removing small and diminutive polyps in screening colonoscopy.
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Affiliation(s)
- Li-Chun Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Health Management Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chia-Tung Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wen-Feng Hsu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chia-Hong Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Health Management Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chieh-Chang Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Health Management Center, National Taiwan University Hospital, Taipei, Taiwan.
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14
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Popa P, Gheonea DI, Săftoiu A, Calița M. No Interval Cancers in Endoscopic Practice. CURRENT HEALTH SCIENCES JOURNAL 2019; 45:5-18. [PMID: 31297257 PMCID: PMC6592672 DOI: 10.12865/chsj.45.01.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/12/2019] [Indexed: 11/18/2022]
Abstract
Colonoscopy is long time the most preferred method for CRC screening along with diagnosis and treatment for a range of colon diseases. Based on its difficulty in visualizing precursor CRC lesions, mostly those located on the right colon, this method can be subject of improvement. The colonoscopy quality can be influenced by many factors such as colon preparation, retraction time, the colonoscopists medical training and knowledges as well as the performance of endoscopy equipment. The bad quality of colonoscopy will result in the emergence of interval cancers defined, based on the author, as cancers that appear at 3-5 years up to 10 years from the colonoscopy procedure. Interval cancers have predominantly incriminated both the colonoscopy quality and the clinician competences and less the tumor biology. Subsequently there were set quality indicators of colonoscopy in order to raise the quality of the exploration. Among the important indicators, proving their utility in studies, the ADR (adenoma detection rate) is most commonly used along with PDR (polyp detection rate) and APC (adenoma per colonoscopy). Following the purpose of obtaining a higher colonoscopy quality the medical units should keep in check all indicators. Furthermore, there should be an active involvement in an additional training of non-conforming medical personnel or even restrain of practice, given the medical legal actions that have interval cancers as a main cause.
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Affiliation(s)
- P Popa
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - D I Gheonea
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - A Săftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - M Calița
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
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Abstract
BACKGROUND Delayed postpolypectomy bleeding occurs more frequently after hot resection than after cold resection. OBJECTIVE To elucidate the underlying mechanism, we performed a histological comparison of tissue after cold and hot snare resections. DESIGN This is a prospective study, registered in the University Hospital Medical Information Network (UMIN000020104). SETTING This study was conducted at Aizu Medical Center, Fukushima Medical University, Japan. PATIENTS Fifteen patients scheduled to undergo resection of colorectal cancer were enrolled. INTERVENTION On the day before surgery, 2 mucosal resections (hot and cold) of normal mucosa were performed on each patient using the same snare without saline injection. The difference was only the application of electrocautery or not. Resection sites were placed close to the cancer to be included in the surgical specimen. MAIN OUTCOME MEASURES The primary outcome measure was the depth of destruction. Secondary outcome measures included the width of destruction, depth of the remaining submucosa, and number of vessels remaining at the resection sites. The number and diameter of vessels in undamaged submucosa were also evaluated. RESULTS All cold resections were limited to the shallow submucosa, whereas 60% of hot resections advanced to the deep submucosa and 20% to the muscularis propria (p < 0.001). There was no significant difference in the width of destruction. The number of remaining large vessels after hot resections trended toward fewer (p = 0.15) with a decreased depth of remaining submucosa (p = 0.007). In the deep submucosa, the vessel diameter was larger (p < 0.001) and the number of large vessels was greater (p = 0.018). LIMITATIONS Histological assessment was not blinded to the 2 reviewers. Normal mucosa was used instead of adenomatous tissue. CONCLUSIONS Hot resection caused damage to deeper layers involving more large vessels. This may explain the mechanism for the reduced incidence of hemorrhage after cold snare polypectomy. See Video Abstract at http://links.lww.com/DCR/A631.
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16
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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17
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Córdova H, Argüello L, Loras C, Naranjo Rodríguez A, Riu Pons F, Gornals JB, Nicolás-Pérez D, Andújar Murcia X, Hernández L, Santolaria S, Leal C, Pons C, Pérez-Cuadrado-Robles E, García-Bosch O, Papo Berger M, Ulla Rocha JL, Sánchez-Montes C, Fernández-Esparrach G. Rate of adverse events of gastroduodenal snare polypectomy for non-flat polyp is low: A prospective and multicenter study. World J Gastroenterol 2017; 23:8405-8414. [PMID: 29308000 PMCID: PMC5743511 DOI: 10.3748/wjg.v23.i47.8405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/03/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the rate of adverse events (AEs) during consecutive gastric and duodenal polypectomies in several Spanish centers.
METHODS Polypectomies of protruded gastric or duodenal polyps ≥ 5 mm using hot snare were prospectively included. Prophylactic measures of hemorrhage were allowed in predefined cases. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy. Patients were followed for 48 h, one week and 1 mo after the procedure.
RESULTS 308 patients were included and a single polypectomy was performed in 205. Only 36 (11.7%) were on prior anticoagulant therapy. Mean polyp size was 15 ± 8.9 mm (5-60) and in 294 cases (95.4%) were located in the stomach. Hemorrhage prophylaxis was performed in 219 (71.1%) patients. Nine patients presented AEs (2.9%), and 6 of them were bleeding (n = 6, 1.9%) (in 5 out of 6 AE, different types of endoscopic treatment were performed). Other 24 hemorrhagic episodes could be managed without any change in the outcome of the endoscopy and, consequently, were considered incidents. We did not find any independent risk factor of bleeding.
CONCLUSION Gastroduodenal polypectomy using prophylactic measures has a rate of AEs small enough to consider this procedure a safe and effective method for polyp resection independently of the polyp size and location.
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Affiliation(s)
- Henry Córdova
- Endoscopy Unit. Institut de Malalties Digestives, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona 08036, Spain
| | - Lidia Argüello
- Digestive Endoscopy Unit, Digestive Diseases Department, Gastrointestinal Endoscopy Research Group, IIS, La Fe Polytechnic University Hospital, Valencia 46026, Spain
| | - Carme Loras
- Hospital Universitari Mútua de Terrassa, CIBERehd, Terrassa 08221, Spain
| | | | | | - Joan B Gornals
- Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona 08907, Spain
| | | | | | - Luis Hernández
- Hospital Santos Reyes, Aranda de Duero, Burgos 09400, Spain
| | | | - Carles Leal
- Consorci Hospitalari de Vic, Universitat de Vic, Vic 08500, Spain
| | - Carles Pons
- Hospital de Viladecans, Viladecans, Barcelona 08840, Spain
| | | | | | | | | | - Cristina Sánchez-Montes
- Endoscopy Unit. Institut de Malalties Digestives, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona 08036, Spain
| | - Gloria Fernández-Esparrach
- Endoscopy Unit. Institut de Malalties Digestives, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona 08036, Spain
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Frost J, Sheldon F, Kurup A, Disney BR, Latif S, Ishaq S. An approach to acute lower gastrointestinal bleeding. Frontline Gastroenterol 2017; 8:174-182. [PMID: 28839906 PMCID: PMC5558275 DOI: 10.1136/flgastro-2015-100606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/01/2015] [Accepted: 06/10/2015] [Indexed: 02/04/2023] Open
Abstract
Lower gastrointestinal bleeding (LGIB) is a common problem that can be treated via a number of endoscopic, radiological and surgical approaches. Although traditionally managed by the colorectal surgeons, surgery should be considered a last resort given the variety of endoscopic and radiological approaches available. This article provides an overview on the common causes of acute LGIB and the various techniques at our disposal to control it.
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Affiliation(s)
- John Frost
- Gastroenterology Department, Russells Hall Hospital, Dudley, UK
| | - Faye Sheldon
- Gastroenterology Department, Russells Hall Hospital, Dudley, UK
| | - Arun Kurup
- Gastroenterology Department, Russells Hall Hospital, Dudley, UK
| | | | - Sherif Latif
- Radiology Department, Russells Hall Hospital, Dudley, UK
| | - Sauid Ishaq
- Gastroenterology Department, Russells Hall Hospital, Dudley, UK
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Schett B, Wallner J, Weingart V, Ayvaz A, Richter U, Stahl J, Allescher HD. Efficacy and safety of cold snare resection in preventive screening colonoscopy. Endosc Int Open 2017; 5:E580-E586. [PMID: 28670614 PMCID: PMC5482746 DOI: 10.1055/s-0043-105491] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 02/10/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND AIM Removal of polyps during colonoscopy effectively prevents the development of colorectal cancer. So far, snare resection with high frequency current with or without prior submucosal saline injection is the method of choice. The aim of this study was to evaluate the feasibility, safety, and outcome of cold snare resection during routine endoscopy. METHODS In this prospective study, 522 patients undergoing outpatient colonoscopy were included. Cold snare resection for diminutive (< 6 mm), small (6 - 9 mm), and larger polyps (> 9 - 15 mm) was performed using a dedicated cold snare device (Exacto ® ) without prior submucosal injection. Outcome parameters included bleeding rate, perforation rate, procedure time, histologic evaluation of polyp margins, and success rates. The data were compared to a group of patients undergoing hot snare resection. RESULTS Overall, 1233 polyps were removed using cold snare resection with an overall success rate of 99.4 %. All failures of cold snare resection occurred in the cecum (8/82, failure rate 9.8 %). In the remaining colon, the success rate was 100 %. Immediate post-polypectomy bleeding occurred in 0.49 % of all patients and was most frequently seen in polyps larger than 9 mm. The procedure time was significantly shorter using cold snare resection compared with hot snare resection (27.6 min vs. 35.7 min, P < 0.01). CONCLUSION Cold snare resection can be performed safely in outpatients for removal of small polyps in screening colonoscopy. It does not require prior saline injection and reduces procedure time without an increased risk of bleeding.
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Affiliation(s)
- B. Schett
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany,Corresponding author Dr. B. Schett Zentrum Innere MedizinKlinikum Garmisch-PartenkirchenAuenstraße 682467 Garmisch-PartenkirchenGermany+49-8821-771502
| | - J. Wallner
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany
| | - V. Weingart
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany
| | - A. Ayvaz
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany
| | - U. Richter
- Institut für Pathologie, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany
| | - J. Stahl
- Institut für Pathologie, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany
| | - H.-D. Allescher
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany
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20
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Tullavardhana T, Akranurakkul P, Ungkitphaiboon W, Songtish D. Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies. Ann Med Surg (Lond) 2017; 19:65-73. [PMID: 28652912 PMCID: PMC5476974 DOI: 10.1016/j.amsu.2017.05.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Bleeding is the most common major complication following colonoscopic polypectomy. The purpose of this study is to evaluate whether submucosal epinephrine injections could prevent the occurrence of postpolypectomy bleeding. Method The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for appropriate randomized controlled studies published before April 2015. A meta-analysis was conducted to investigate the preventative effect of submucosal epinephrine injection for overall, early, and delayed postpolypectomy bleeding. Results The final analysis examined the findings of six studies, with data from 1388 patients. The results demonstrated that prophylactic treatment with epinephrine injection significantly reduced the occurrence of overall (OR = 0.38, 95% CI: 0.21, 0.66; p = 0.0006) and early bleeding (OR = 0.38, 95% CI: 0.20, 0.69; p = 0.002). However, for delayed bleeding complications, epinephrine injections were not found to be any more effective than treatment with saline injection or no injection (OR = 0.45, 95% CI: 0.11, 1.81; p = 0.26). Moreover, for patients with polyps larger than 20 mm, mechanical hemostasis devices (endoloops or clips) were found to be more effective than epinephrine injection in preventing overall bleeding (OR = 0.33, 95% CI: 0.13, 0.87; p = 0.03) and early bleeding (OR = 0.29, 95% CI: 0.08, 1.02; p = 0.05). This was not established for delayed bleeding. Conclusion The routine use of prophylaxis submucosal epinephrine injection is safe and beneficial preventing postpolypectomy bleeding.
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Affiliation(s)
- Thawatchai Tullavardhana
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Prinya Akranurakkul
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Withoon Ungkitphaiboon
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Dolrudee Songtish
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
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Shibuya T, Nomura O, Kodani T, Murakami T, Fukushima H, Tajima Y, Matsumoto K, Ritsuno H, Ueyama H, Inami Y, Ishikawa D, Matsumoto K, Sakamoto N, Osada T, Nagahara A, Ogihara T, Watanabe S. Continuation of antithrombotic therapy may be associated with a high incidence of colonic post-polypectomy bleeding. Dig Endosc 2017; 29:314-321. [PMID: 27809364 DOI: 10.1111/den.12760] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/31/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Post-polypectomy bleeding (PPB) is the most common complication of endoscopic procedures. To reduce the risk of thromboembolic incidents, Japanese guidelines for gastroenterological endoscopy were revised to indicate that antithrombotic agents were not to be discontinued for endoscopic treatment. However, carrying out endoscopic procedures under antithrombotic medication potentially increases the incidence of hemorrhagic complications. The present study investigated the impact of the revised guidelines on the frequency of complications after colonoscopic procedures. METHODS The surveillance period comprised the year before the initiation of the new guidelines (2012), which served as a control period, and 2 years after initiation of the new guidelines (2013 and 2014). During the control period, 3955 cases were examined colonoscopically and 1601 lesions were treated endoscopically. During the 2-year period under the new guidelines, 8749 colonoscopies and 3768 endoscopic treatments were carried out. Changes in treatment methods and rates of complications were compared. RESULTS PPB rate was not significantly different before and after the revision (0.87% vs 1.01%). With the new guidelines, PPB rates in antithrombotic non-users and users were 0.60% and 3.13%, respectively (OR 5.11, P = 0.000). Multivariable analysis showed that the risks for PPB were as follows: heparin bridging therapy (OR 6.34, P = 0.0002); low-dose aspirin (LDA) continuation (OR 5.30, P = 0.0079); and lesion size (OR 1.06, P < 0.0001). CONCLUSION The present study showed that the overall PPB rate under the new guidelines was not significantly higher when compared with the previous data obtained before the new guidelines were introduced.
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Affiliation(s)
- Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Osamu Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomohiro Kodani
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hirofumi Fukushima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuzuru Tajima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kohei Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hideaki Ritsuno
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshihiro Inami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Taro Osada
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tatsuo Ogihara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Sumio Watanabe
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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Kim EH, Park SW, Nam E, Eun CS, Han DS, Park CH. Role of second-look endoscopy and prophylactic hemostasis after gastric endoscopic submucosal dissection: A systematic review and meta-analysis. J Gastroenterol Hepatol 2017; 32:756-768. [PMID: 27796052 DOI: 10.1111/jgh.13623] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although several studies have shown that second-look endoscopy does not affect the incidence of bleeding after gastric endoscopic submucosal dissection (ESD), the potential roles of second-look endoscopy have not been fully evaluated. This study aimed to determine the role of second-look endoscopy after ESD through a systematic review and meta-analysis. METHODS This study conducted a systematic literature search of MEDLINE, EMBASE, and the Cochrane Library through March 2016 using the keywords "second-look," "prophylactic hemostasis," "prophylactic haemostasis," "prevention," "prophylaxis," and "endoscopic submucosal dissection." Studies were included if they evaluated the incidence of post-ESD bleeding according to second-look endoscopy or prophylactic hemostasis during second-look endoscopy. RESULTS Four randomized controlled trials on post-ESD bleeding between second-look endoscopy and no second-look endoscopy and 12 non-randomized studies with a cohort design on post-ESD bleeding were included. On meta-analysis, second-look endoscopy did not affect delayed post-ESD bleeding (odds ratio [95% confidence interval] = 1.27 [0.80-2.00], I2 = 0%). During second-look endoscopy, patients who were considered as high-risk for post-ESD bleeding underwent prophylactic hemostasis. Delayed post-ESD bleeding was more common in patients who were treated with hemostasis during second-look endoscopy compared with those who were not (odds ratio [95% confidence interval] = 3.40 [1.87-6.18], I2 = 62%). In patients who underwent prophylactic hemostasis, the number needed to prolong a hospitalization period to avoid one additional post-ESD bleeding after discharge was 25. CONCLUSION Second-look endoscopy after ESD could not reduce the risk of delayed post-ESD bleeding. Delayed post-ESD bleeding was more common in patients who underwent prophylactic hemostasis than in those who did not.
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Affiliation(s)
- Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Eunwoo Nam
- Biostatistics Consulting and Research Lab, Medical Research Coordinating center, Hanyang University, Seoul, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
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Okamoto K, Muguruma N, Kagemoto K, Mitsui Y, Fujimoto D, Kitamura S, Kimura T, Sogabe M, Miyamoto H, Takayama T. Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases. Dig Endosc 2017; 29 Suppl 2:45-52. [PMID: 28425649 DOI: 10.1111/den.12863] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/07/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD), which provides a higher en bloc resection rate than conventional endoscopic mucosal resection (EMR), is considered to be a useful treatment option for large colorectal tumors. However, colorectal ESD is not widely used because of its technical difficulty, risk of complications and time required. To overcome these drawbacks, a simpler modified technique, ESD with snaring (hybrid ESD), has been developed. The aim of the present study was to retrospectively compare the safety and efficacy of hybrid ESD and conventional ESD for colorectal tumors. METHODS Between September 2008 and June 2016, ESD was carried out on 137 lesions and hybrid ESD on 27 lesions. All hybrid ESD cases were carried out as a rescue treatment in difficult ESD cases. We retrospectively investigated procedure time, and the rates of en bloc resection, perforation, bleeding, and local recurrence. RESULTS In the hybrid ESD group, procedure time was shorter compared with the ESD group (108 ± 59.5 min vs 122 ± 72.2 min), but the en bloc resection rate was lower (66.7% vs 94.2%). However, there were no significant differences in procedure time, or in rates of en bloc resection, perforation and bleeding between the two groups. Local recurrence did not develop in any of our cases. CONCLUSIONS Hybrid ESD as a rescue treatment in difficult ESD cases may be less effective for en bloc resection of large colorectal tumors. Indication for hybrid ESD may be limited to scheduled treatment from the outset and emergency cases with patients who present unstable vital signs during ESD.
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Affiliation(s)
- Koichi Okamoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Naoki Muguruma
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Kaizo Kagemoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Yasuhiro Mitsui
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Daisaku Fujimoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Shinji Kitamura
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Tetsuo Kimura
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Masahiro Sogabe
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Hiroshi Miyamoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Tetsuji Takayama
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Ponugoti PL, Rex DK. Clip retention rates and rates of residual polyp at the base of retained clips on colorectal EMR sites. Gastrointest Endosc 2017; 85:530-534. [PMID: 27460391 DOI: 10.1016/j.gie.2016.07.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/01/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Prophylactic endoscopic clipping may be effective in preventing delayed post-polypectomy hemorrhage after EMR of large colorectal lesions. The rate of retention of hemoclips on EMR sites has not been fully described. The aim of this study was to evaluate the adherence rates of hemoclips placed after EMR of large colorectal lesions. METHODS This was a retrospective review of a prospectively maintained database of large colorectal polyps (≥20 mm) referred to Indiana University Hospital between June 2006 and August 2015. Sites were closed with a mean of 4 clips. Patients were followed up for 3 to 6 months after EMR with a second follow-up 1 year later. Biopsy specimens of EMR scars were examined at follow-up, including the tissue at the base of retained clips. RESULTS There were 479 EMR sites in 424 patients that had first follow-up at our center with high-quality photographs of the EMR sites taken immediately after clip placement and at follow-up. Of 1407 Boston Scientific Resolution clips placed, 59 (4.2%) were retained at follow-up. Of 532 Cook Instinct clips placed, 46 (8.6%) were retained at first follow-up (P = .0001). There was no difference in the follow-up interval for the 2 clips. No patient had residual polyp by biopsy at the base of a retained clip. CONCLUSIONS Clip retention at first follow-up at 3 to 6 months after EMR was twice as high for the Cook Instinct clip compared with Boston Resolution clip but retention rates were low for both clips. Residual polyp at the base of retained clips was not a significant clinical problem.
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Affiliation(s)
- Prasanna L Ponugoti
- Indiana University School of Medicine, Division of Gastroenterology and Hepatology, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Indiana University School of Medicine, Division of Gastroenterology and Hepatology, Indianapolis, Indiana, USA
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Plumé Gimeno G, Bustamante-Balén M, Satorres Paniagua C, Díaz Jaime FC, Cejalvo Andújar MJ. Endoscopic resection of colorectal polyps in patients on antiplatelet therapy: an evidence-based guidance for clinicians. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:49-59. [PMID: 27809553 DOI: 10.17235/reed.2016.4114/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Due to the rising prevalence of coronary heart disease, endoscopists are more frequently performing a polypectomy in patients on antiplatelet therapy (APT) and dual antiplatelet therapy (DATP). Despite the availability of several guidelines with regard to the management of antiplatelet drugs during the periprocedure period, there is still variability in the current clinical practice. This may be influenced by the low quality of the evidence supporting recommendations, because most of the studies dealing with APT and polypectomy are observational and retrospective, and include mainly small (< 10 mm) polyps. However, some recommendations can still be made. An estimation of the bleeding and thrombotic risk of the patient should be made in advance. In the case of DAPT the procedure should be postponed, at least until clopidogrel can be safely withheld. If possible, non-aspirin antiplatelet drugs should be withheld 5-7 days before the procedure. Polyp size is the main factor related with post-polypectomy bleeding and it is the factor that should drive clinical decisions regarding the resection method and the use of endoscopic prophylactic measures. Non-aspirin antiplatelet agents can be reintroduced 24-48 hours after the procedure. In conclusion, there is little data with regard to the management of DAPT in patients with a scheduled polypectomy. Large randomized controlled trials are needed to support clinical recommendations.
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Suchanek S, Grega T, Zavoral M. The role of equipment in endoscopic complications. Best Pract Res Clin Gastroenterol 2016; 30:667-678. [PMID: 27931628 DOI: 10.1016/j.bpg.2016.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/17/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
The role of the surrounding equipment in endoscopic complications has not been published widely. However, an adequate understanding of the advantages and disadvantages of such devices might be helpful to avoid unnecessary problems during endoscopy. This is an overview of the basic principles, benefits and possible harms of electrical power units, medical gases and vital sign monitoring equipment. The aim of this review is to summarize current knowledge about the approach to the electrosurgical unit settings; periprocedural precautions, minimizing the risk of interference between endoscopic equipment and other electrical devices; the appropriate selection of instruments regarding the electrosurgical outcome and the role of carbon dioxide, argon plasma coagulation, pulse oximetry and capnography.
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Affiliation(s)
- Stepan Suchanek
- Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, U Vojenske nemocnice 1200, Prague 6, 169 02, Czech Republic.
| | - Tomas Grega
- Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, U Vojenske nemocnice 1200, Prague 6, 169 02, Czech Republic.
| | - Miroslav Zavoral
- Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, U Vojenske nemocnice 1200, Prague 6, 169 02, Czech Republic.
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Huang RJ, Perumpail RB, Thosani N, Cheung R, Friedland S. Colonoscopy with polypectomy is associated with a low rate of complications in patients with cirrhosis. Endosc Int Open 2016; 4:E947-52. [PMID: 27652299 PMCID: PMC5025305 DOI: 10.1055/s-0042-111317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 06/23/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Cirrhotic patients are at a theoretically increased risk of bleeding. The safety of polypectomy in cirrhosis is poorly defined. PATIENTS AND METHODS We performed a retrospective review of patients with cirrhosis who underwent colonoscopic polypectomy at a tertiary-care hospital. Patient characteristics and polyp data were collected. Development of complications including immediate bleeding, delayed bleeding, hospitalization, blood transfusion, perforation, and death were recorded to 30-day follow-up. Clinical characteristics between bleeders and non-bleeders were compared, and predictors of bleeding were determined. RESULTS A total of 307 colonoscopies with 638 polypectomies were identified. Immediate bleeding occurred in 7.5 % (95 % CI 4.6 % - 10.4 %) and delayed bleeding occurred in 0.3 % (95 % CI 0.0 % - 0.9 %) of colonoscopies. All cases of immediate bleeding were controlled endoscopically and none resulted in serious complication. The rate of hospitalization was 0.7 % (95 % CI 0.0 % - 1.6 %) and repeat colonoscopy 0.3 % (95 % CI 0.0 % - 0.9 %); no cases of perforation, blood transfusion, or death occurred. Lower platelet count, higher INR, presence of ascites, and presence of esophageal varices were associated with increased risk of bleeding. Use of electrocautery was associated with a lower risk of immediate bleeding. There was no significant difference between bleeding and non-bleeding polyps with regard to size, morphology, and histology. CONCLUSIONS Colonoscopy with polypectomy appears safe in patients with cirrhosis. There is a low risk of major complications. The risk of immediate bleeding appears higher than an average risk population; however, most bleeding is self-limited or can be controlled endoscopically. Bleeding tends to occur with more advanced liver disease. Both the sequelae of portal hypertension and coagulation abnormalities are predictive of bleeding.
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Affiliation(s)
- Robert J. Huang
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | - Ryan B. Perumpail
- Department of Medicine, Stanford University Medical Center, Stanford, CA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, Houston, TX
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
- Gastroenterology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
- Gastroenterology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
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Park CH, Jung YS, Nam E, Eun CS, Park DI, Han DS. Comparison of Efficacy of Prophylactic Endoscopic Therapies for Postpolypectomy Bleeding in the Colorectum: A Systematic Review and Network Meta-Analysis. Am J Gastroenterol 2016; 111:1230-43. [PMID: 27402502 DOI: 10.1038/ajg.2016.287] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/09/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although various endoscopic therapies have been suggested for preventing bleeding after colorectal polypectomy, the optimal therapy has yet to be fully clarified. We assessed the comparative efficacy of prophylactic therapies for postpolypectomy bleeding through a network meta-analysis combining direct and indirect comparisons. METHODS We searched for all relevant randomized controlled trials published up until January 2016 examining the effects of prophylactic therapy for bleeding after colorectal polypectomy. The types of prophylactic therapy were classified as mechanical therapy, epinephrine-saline injection therapy, coagulation therapy, combined therapy, or no prophylactic therapy. Combined therapy was defined as a combination of two or more types of therapy including mechanical therapy, epinephrine-saline injection therapy, and coagulation therapy. We performed a Bayesian network meta-analysis for all prophylactic therapies. RESULTS Fifteen studies with 3,462 patients were included in the meta-analysis. Compared with no prophylactic therapy, both epinephrine-saline injection and mechanical therapy showed superiority for preventing early postpolypectomy bleeding with a moderate quality of evidence (injection therapy, risk ratio (RR; 95% credible interval (CrI))=0.32 (0.11-0.67); mechanical therapy, RR (95% CrI)=0.13 (0.03-0.37)). Combined therapy did not show a statistically significant difference for decreasing the risk of early bleeding compared with injection or mechanical therapies, respectively (combined vs. injection therapy: RR (95% CrI)=0.35 (0.10-1.00); combined vs. mechanical therapy: RR (95% CrI)=0.88 (0.23-3.00)). In cases of delayed bleeding, no type of prophylactic therapy decreased the risk of bleeding compared with no prophylactic therapy. CONCLUSIONS Either mechanical therapy or injection therapy reduced the risk of early postpolypectomy bleeding. As for delayed bleeding, none of the prophylactic therapies was associated with a lower risk of bleeding compared with no prophylactic therapy.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yoon Suk Jung
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Dong Il Park
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Saunders BP, Tsiamoulos ZP. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 2016; 13:486-96. [PMID: 27353401 DOI: 10.1038/nrgastro.2016.96] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.
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Affiliation(s)
- Brian P Saunders
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
| | - Zacharias P Tsiamoulos
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
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30
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Park HJ. Endoscopic Instruments and Electrosurgical Unit for Colonoscopic Polypectomy. Clin Endosc 2016; 49:350-4. [PMID: 27399313 PMCID: PMC4977736 DOI: 10.5946/ce.2016.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/12/2016] [Accepted: 06/23/2016] [Indexed: 11/14/2022] Open
Abstract
Colorectal polypectomy is an effective method for prevention of colorectal cancer. Many endoscopic instruments have been used for colorectal polypectomy, such as snares, forceps, endoscopic clips, a Coagrasper, retrieval net, injector, and electrosurgery generator unit (ESU). Understanding the characteristics of endoscopic instruments and their proper use according to morphology and size of the colorectal polyp will enable endoscopists to perform effective polypectomy. I reviewed the characteristics of endoscopic instruments for colorectal polypectomy and their appropriate use, as well as the basic principles and settings of the ESU.
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Affiliation(s)
- Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Abstract
Electrosurgery allows both cutting and coagulation of tissue and is an essential tool for therapeutic endoscopy. Electrosurgery is also the most commonly used and misunderstood technology by all surgical and medical disciplines. In other words, everyone uses it, but few understand it! The aims of this article are to (1) present a useful review of the fundamentals of electrosurgery technology; (2) relate the fundamentals to commonly performed flexible endoscopy procedures; and (3) provide a review of the safe application of grounding pads, careful management of accessories, and special patient safety considerations.
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Rutter MD, Chattree A, Barbour JA, Thomas-Gibson S, Bhandari P, Saunders BP, Veitch AM, Anderson J, Rembacken BJ, Loughrey MB, Pullan R, Garrett WV, Lewis G, Dolwani S. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut 2015; 64:1847-73. [PMID: 26104751 PMCID: PMC4680188 DOI: 10.1136/gutjnl-2015-309576] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/25/2015] [Accepted: 05/29/2015] [Indexed: 02/07/2023]
Abstract
These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.
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Affiliation(s)
- Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton on Tees, UK School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Amit Chattree
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Jamie A Barbour
- Department of Gastroenterology, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | | | | | - Rupert Pullan
- Department of Colorectal Surgery, Torbay Hospital, Torquay, UK
| | - William V Garrett
- Department of Colorectal Surgery, Medway Maritime Hospital, Gillingham, UK
| | - Gethin Lewis
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
| | - Sunil Dolwani
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
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Choksi N, Elmunzer BJ, Stidham RW, Shuster D, Piraka C. Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm. Endosc Int Open 2015; 3:E508-13. [PMID: 26528509 PMCID: PMC4612226 DOI: 10.1055/s-0034-1392214] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/13/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Endoscopic removal of duodenal and colorectal adenomas is currently considered to be the standard of care for prevention of adenocarcinoma. The use of cautery carries a risk of delayed bleeding, post-polypectomy syndrome, and perforation. We examined the safety and feasibility of removing colonic and duodenal polyps ≥ 1 cm using a piecemeal cold snare polypectomy technique. PATIENTS The study included 15 patients with duodenal polyps ≥ 1 cm and 15 patients with colonic polyps ≥ 1 cm. MAIN OUTCOME MEASUREMENTS Bleeding, perforation, abdominal pain, or hospitalization occurring within 2 weeks of polypectomy. RESULTS Between 24 August 2011 and 29 April 2013, 15 patients had removal of duodenal polyps ≥ 1 cm. Mean patient age was 64 years and 9/15 patients were male. The mean polyp size was 24 mm (10 - 60 mm). All polyps were removed with a cold snare and some required cold biopsy forceps. One patient required hospitalization for gastrointestinal blood loss 7 days post-polypectomy; this patient was using Coumadin. Between 27 February 2012 and 30 May 2013, 15 patients underwent resection of a ≥ 1 cm colonic polyp. Mean patient age was 68 years and 9/15 were male. The mean polyp size was 20 mm (10 - 45 mm). All polyps were primarily removed with a cold snare. None of the patients required hemostatic clips for control of immediate bleeding. One patient presented to the emergency department with abdominal pain 1 day after initial endoscopy. CT scan showed no abnormalities and the patient was discharged. CONCLUSIONS Cold snare polypectomy for large duodenal and colonic polyps is technically feasible and may have a favorable safety profile compared to standard electrocautery-based endoscopic resection. Comparative trials are required to determine the relative safety and efficacy of cold snare techniques for complete and durable resection of large polyps compared to standard hot snare methods.
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Affiliation(s)
- Neel Choksi
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan W. Stidham
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, USA
| | - Dmitry Shuster
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, USA
| | - Cyrus Piraka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA,Corresponding author Cyrus Piraka, MD Division of GastroenterologyHenry Ford Hospital2799 West Grand BoulevardDetroitMI 48202USA
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Complications during colonoscopy: prevention, diagnosis, and management. Tech Coloproctol 2015; 19:505-13. [PMID: 26162284 DOI: 10.1007/s10151-015-1344-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/07/2015] [Indexed: 02/08/2023]
Abstract
Colonoscopy is largely performed in daily clinical practice for both diagnostic and therapeutic purposes. Although infrequent, different complications may occur during the examination, mostly related to the operative procedures. These complications range from asymptomatic and self-limiting to serious, requiring a prompt medical, endoscopic or surgical intervention. In this review, the complications that may occur during colonoscopy are discussed, with a particular focus on prevention, diagnosis, and therapeutic approaches.
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Burgess NG, Bahin FF, Bourke MJ. Colonic polypectomy (with videos). Gastrointest Endosc 2015; 81:813-35. [PMID: 25805461 DOI: 10.1016/j.gie.2014.12.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/04/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.
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Affiliation(s)
- Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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Hong YM, Kim HW, Park SB, Choi CW, Kang DH. Endoscopic mucosal resection with circumferential incision for the treatment of large sessile polyps and laterally spreading tumors of the colorectum. Clin Endosc 2015; 48:52-8. [PMID: 25674527 PMCID: PMC4323433 DOI: 10.5946/ce.2015.48.1.52] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 05/12/2014] [Accepted: 06/02/2014] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Endoscopic mucosal resection (EMR) is the standard treatment for colorectal polyps such as adenomas and early cancers with no risk of lymph node metastasis. However, endoscopic resection of large colorectal polyps (≥20 mm diameter) is difficult to perform. We evaluated the clinical outcomes of EMR with circumferential incision (EMR-CI) for the resection of large sessile polyps (Is) and laterally spreading tumors (LSTs) in the colorectum. Methods Between February 2009 and March 2011, we resected 80 large colorectal polyps by EMR-CI. We retrospectively investigated the en bloc resection rate, histologic complete resection rate, recurrence rate, and complications. Results The median polyp size was approximately 25 mm (range, 20 to 50), and the morphologic types included Is (13 cases), LST-granular (37 cases), and LST-nongranular (30 cases). The en bloc and complete histologic resection rates were 66.3% and 45.0%, respectively. The recurrence rate was 0% (median follow-up duration, 23 months), and perforation occurred in five cases (6.3%). Conclusions EMR-CI is an effective treatment modality for 20 to 30 mm-sized colorectal polyps, and may be considered as a second line therapeutic option if ESD is difficult.
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Affiliation(s)
- Young Mi Hong
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Sethi A, Song LMWK. Adverse events related to colonic endoscopic mucosal resection and polypectomy. Gastrointest Endosc Clin N Am 2015; 25:55-69. [PMID: 25442958 DOI: 10.1016/j.giec.2014.09.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Colonoscopy is a commonly performed procedure. The rate of adverse events is 2.8 per 1000 screening colonoscopies. These adverse events include cardiovascular and pulmonary events, abdominal pain, hemorrhage, perforation, postpolypectomy syndrome, infection, and death. Serious adverse events, such as hemorrhage and perforation, occur most frequently when colonoscopy is performed with polypectomy. This article highlights the prevention and management of adverse events associated with polypectomy and endoscopic mucosal resection of colonic lesions.
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Affiliation(s)
- Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University, 161 Fort Washington Avenue, Herbert Irving Pavilion, Suite 862, New York, NY 10032, USA.
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
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Rex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb JG, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81:31-53. [PMID: 25480100 DOI: 10.1016/j.gie.2014.07.058] [Citation(s) in RCA: 752] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 02/07/2023]
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Abstract
Bleeding is a relatively rare complication occurring mainly after snare polypectomy. The majority of cases can be managed successfully by endoscopic means leaving very few cases which will ultimately need an operation. Colonic perforation, on the other hand is a serious complication that requires intensive and careful management. Prompt recognition of the perforation during the procedure allows, in selected cases, immediate endoscopic closure with an uneventful and full recovery followed by close monitoring and surgical management in case of clinical deterioration. The criteria for the right selection of perforation cases amenable to endoscopic treatment do still need to be confirmed by prospective studies and further experience is required before a standard algorithm on the endoscopic management of perforations is developed.
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Abstract
BACKGROUND/AIM Delayed bleeding is a serious complication that occurs after polypectomy. Many risk factors for delayed bleeding have been suggested, but there is little analysis of procedure-related risk factors. The purpose of this study is to identify a wide range of risk factors for delayed postpolypectomy bleeding (DPPB) and analyze the correlations of those potential DPPB risk factors. MATERIALS AND METHODS In this retrospective cohort study, 5981 polypectomies in 3788 patients were evaluated between January 2010 and February 2012. Patient-related, polyp-related, and procedure-related factors were evaluated as potential DPPB risk factors. RESULTS Delayed bleeding occurred in 42 patients (1.1%). Multivariate analysis revealed that polyp size >10 mm [odds ratio (OR), 2.785; 95% confidence interval (CI), 1.406-5.513; P=0.003], location in the right hemi-colon (OR, 2.289; 95% CI, 1.117-4.693; P=0.024), and endoscopist's experience (<300 total cases of colonoscopy performed; OR, 4.803; 95% CI, 2.631-8.766; P=0.001) were significant risk factors for DPPB. Especially protruded type polyps (Ip, Isp) larger than 1 cm in the right-side colon were associated with increased risk. Right-side polypectomy by a nonexpert endoscopist was a significant risk factor for DPPB, especially with procedures in the cecum area. Taking the 1.5% DPPB incidence as cutoff value, the learning curve of colonoscopic polypectomy may be estimated as 400 cases of polypectomy. CONCLUSIONS Polyp size, endoscopist's experience, and right hemi-colon location were identified as potential risk factors for DPPB development.
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Jacques J, Legros R, Chaussade S, Sautereau D. Endoscopic haemostasis: an overview of procedures and clinical scenarios. Dig Liver Dis 2014; 46:766-76. [PMID: 25022337 DOI: 10.1016/j.dld.2014.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/01/2014] [Accepted: 05/08/2014] [Indexed: 02/07/2023]
Abstract
Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.
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Affiliation(s)
- Jérémie Jacques
- Gastroenterology Department, University Hospital of Limoges, Limoges, France.
| | - Romain Legros
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
| | | | - Denis Sautereau
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
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Daly B, Lu M, Pickhardt PJ, Menias CO, Abbas MA, Katz DS. Complications of Optical Colonoscopy. Radiol Clin North Am 2014; 52:1087-99. [DOI: 10.1016/j.rcl.2014.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Wada Y, Kudo SE, Tanaka S, Saito Y, Iishii H, Ikematsu H, Igarashi M, Saitoh Y, Inoue Y, Kobayashi K, Hisabe T, Tsuruta O, Kashida H, Ishikawa H, Sugihara K. Predictive factors for complications in endoscopic resection of large colorectal lesions: a multicenter prospective study. Surg Endosc 2014; 29:1216-22. [DOI: 10.1007/s00464-014-3799-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/27/2014] [Indexed: 02/06/2023]
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Coleman KA, Berent AC, Weisse CW. Endoscopic mucosal resection and snare polypectomy for treatment of a colorectal polypoid adenoma in a dog. J Am Vet Med Assoc 2014; 244:1435-40. [DOI: 10.2460/javma.244.12.1435] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Burgess NG, Metz AJ, Williams SJ, Singh R, Tam W, Hourigan LF, Zanati SA, Brown GJ, Sonson R, Bourke MJ. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12:651-61.e1-3. [PMID: 24090728 DOI: 10.1016/j.cgh.2013.09.049] [Citation(s) in RCA: 184] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 09/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Wide-field endoscopic mucosal resection (WF-EMR) of large sessile colonic polyps is a safe and cost-effective outpatient treatment. Bleeding is the main complication. Few studies have examined risk factors for bleeding during the procedure (intraprocedural bleeding [IPB]) or after it (clinically significant post-endoscopic bleeding [CSPEB]). We investigated factors associated with IPB and CSPEB in a large prospective study. METHODS We analyzed data from WF-EMRs of sessile colorectal polyps ≥ 20 mm in size (mean size, 35.5 mm), which were performed on 1172 patients (mean age, 67.8 years) from June 2008-March 2013 at 7 tertiary hospitals as part of the Australian Colonic Endoscopic Resection Study. Data were collected on characteristics of patients and lesions, along with outcomes of procedures and clinical and histologic analyses. Independent predictors of IPB and CSPEB were identified by multiple logistic regression analysis. RESULTS Of the patients studied, 133 (11.3%) had IPB. Independent predictors included increasing lesion size (odds ratio, 1.24/10 mm; P < .001), Paris endoscopic classification of 0-IIa + Is (odds ratio, 2.12; P = .004), tubulovillous or villous histology (odds ratio, 1.84; P = .007), and study institutions that performed the procedure on fewer than 75 patients (odds ratio, 3.78; P < .001). All IPB was successfully controlled endoscopically. IPB prolonged procedures and was associated with early recurrence (relative risk, 1.68; P = .011). Seventy-three patients (6.2%) had CSPEB. On multivariable analysis, CSPEB was associated with proximal colon location (odds ratio, 3.72; P < .001), use of an electrosurgical current not controlled by a microprocessor (odds ratio, 2.03; P = .038), and IPB (odds ratio, 2.16; P = .016). Lesion size and comorbidities did not predict CSPEB. CONCLUSIONS In a prospective study of patients undergoing WF-EMR of large sessile colonic polyps, IPB is associated with larger lesions, lesion histology, and Paris endoscopic classification of type 0-IIa + Is. IPB prolongs the duration of the procedure, is a marker for recurrence, and is associated with CSPEB. CSPEB occurs most frequently in the proximal colon and less when current is controlled by a microprocessor.
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Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Andrew J Metz
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - William Tam
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, QLD, Australia
| | - Simon A Zanati
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, VIC, Australia
| | - Gregor J Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne VIC, Australia
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia.
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Clinical significance of intraperitoneal air on computed tomography scan after endoscopic submucosal dissection in patients with gastric neoplasms. Surg Endosc 2013; 28:307-13. [DOI: 10.1007/s00464-013-3188-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 08/07/2013] [Indexed: 12/28/2022]
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Abstract
Colonoscopic polypectomy is fundamental to effective colonoscopy. Through its impact on the polyp-cancer sequence, colonoscopic polypectomy reduces colorectal cancer incidence and mortality. Because it eliminates electrosurgical risk, cold snaring has emerged as the preferred technique for most small and all diminutive polyps. Few clinical trial data are available on the effectiveness and safety of specific techniques. Polypectomy technique seems highly variable between endoscopists, with some techniques more effective than others are. Further research is needed to investigate operator variation in polypectomy outcomes and establish an evidence base for best practice.
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Affiliation(s)
- David G Hewett
- School of Medicine, The University of Queensland, Mayne Medical Building, Herston Road, Herston, Brisbane, Queensland 4006, Australia.
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Abstract
The value of performing comprehensive screening colonoscopy with complete colon polypectomy is widely accepted. Colon cancer is a significant cause of worldwide mortality and prospective studies have proven that colonoscopic polypectomy reduces both the incidence and mortality related to this disease. Over the past few decades the array of instruments and techniques have greatly expanded to assist with the safe endoscopic removal of colon polyps. This article will review the published literature regarding efficacy and safety of standard polypectomy techniques such as snare polypectomy, electrocautery, and endoscopic mucosal resection along with newer techniques such as endoscopic submucosal dissection and combined laparoscopic techniques.
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