Complications Of Endoscopic Polypectomy

The role of early colonoscopy in patients presenting with acute lower gastrointestinal bleeding: a systematic review and meta-analysis

OBJECTIVE

The use of early colonoscopy in the management of acute lower gastrointestinal bleeding (LGIB) is controversial, with disparate evidence. We aim to formally characterize the utility of early colonoscopy (within 24 h) in managing acute LGIB.

DESIGN

A systematic literature search to August 2016 identified fully published and abstracts of randomized controlled trials (RCTs) and observational studies assessing early colonoscopy in acute LGIB. Single-arm studies were also included to define incidence. Primary outcomes were overall rebleeding rates and time to rebleeding. Secondary outcomes included mortality, surgery, length of stay (LOS), definite cause of bleeding and adverse events (AEs). Odds ratios (OR) and weighted mean differences (WMD) were calculated.

RESULTS

Of 897 citations, 10 single-arm, 9 observational studies, and 2 RCTS were included (25,781 patients). Rebleeding was no different between patients undergoing early colonoscopy and controls (seven studies, OR = 0.89, 95% CI 0.49-1.62), or RCT data only (OR = 1.00, 95% CI 0.52-1.62). Early colonoscopy detected more definitive sources of bleeding (OR = 4.12, 95% CI 2.00-8.49), and was associated with shorter LOS colonoscopy (WMD = -1.52, 95% CI -2.54 to -0.50 days). No other differences were noted between early and late colonoscopy. AEs occurred in 4.0%, (95% CI 2.9%; 5.4%) of early colonoscopies. Included studies were of low quality, with significant heterogeneity for some outcomes.

CONCLUSION

Early colonoscopy in acute LGIB does not decrease rebleeding, mortality or need for surgery, but is associated with increased detection of definitive sources of bleeding, shorter LOS, with low complication incidence. However, the quality of evidence is low, highlighting the need for additional high-level studies.

Serum C-reactive protein as a possible marker to predict delayed hemorrhage after colonoscopic polypectomy

BACKGROUND

Post-polypectomy hemorrhage is one of the complications of colonscopic polypectomy. And there is no definitive and convenient laboratory test that could be used to predict risk of delayed post-polypectomy hemorrhage. This research aimed to study risk prediction of delayed post-polypectomy hemorrhage using serum C-reactive protein (CRP) level as a marker.

MATERIAL/METHODS

In a retrospective, case-controlled study, 302 cases of post-polypectomy patients were divided into hemorrhage group and non-hemorrhage group. The CRP levels 24-hours after colonscopic treatment were compared between the two groups to assess whether elevated serum CRP levels in addition to other risk factors such as age, gender, smoking, alcohol consumption, hypertension (AHT) and size of polyps may predict risk of delayed post-polypectomy hemorrhage.

RESULTS

The hemorrhage group had significantly higher levels of serum CRP (32.50±17.34 mg/L vs. 6. 32±6.02 mg/dL) and were also having a higher incidence of hypertension compared to the non- hemorrhage group (both P<0.05). Patients with elevated serum CRP levels (≥10 mg/L) after colonscopic treatment are at a higher risk of developing post-polypectomy hemorrhage (OR 1.329, 95%CI 1.125-1.571) as compared with patients whose CRP levels were not increased.

CONCLUSIONS

A higher level of serum CRP may serve as an indicator of delayed post-polypectomy hemorrhage and there appears to be a direct relationship between the serum CRP levels and the risk of post-polypectomy hemorrhage: the higher CRP levels the higher the risk of post-polypectomy hemorrhage.

Colonoscopias realizadas por médicos residentes em hospital universitário: análise consecutiva de 1000 casos

RACIONAL: A colonoscopia tem indicação para diagnóstico em pacientes sintomáticos e é eficaz no rastreamento e vigiância de pacientes assintomáticos. Tem potencial terapêutico em diversas situções, principalmente na remoção das lesões polipóides. A proficiência e a competência do endoscopista é o esteio para o sucesso da colonoscopia diagnóstica e terapêutica. OBJETIVO: Analisar as indicações, os achados diagnósticos, e as complicações de colonoscopias realizadas por médicos residentes em um hospital universitário. MÉTODOS: Foram avaliadas 1.000 colonoscopias consecutivas realizadas por residentes de quarto ano, sob supervisão direta de colonoscopistas experientes. Foram obtidas informações sobre os dados demográficos dos pacientes, o preparo intestinal, as indicações para o procedimento, o sucesso do procedimento, os achados diagnósticos e as complicações. RESULTADOS: Foram examinados total de 596 (59,6%) mulheres e 404 (40,4%) homens. A idade variou de três a 99 anos (média 53,8). O preparo intestinal foi realizado com solução de manitol a 10% em 978 pacientes (97,8%), sendo considerada adequada em 97,6% dos casos. Principais indicações foram: diagnóstico (56,4%), terapêutica (9,6%), rastreamento (17,3%) e vigilância (22%). Taxas de intubação do ceco e válvula ileocecal foram 90,3 e 58,6%, respectivamente. A colonoscopia foi normal em 45,8% dos casos. O diagnóstico mais comum foi diverticulose (18,5%), seguido por pólipos (17%) e neoplasias (6,8%). Achados consistentes com um processo inflamatório foram identificados em 122 pacientes (12,2%) e anomalias vasculares foram detectadas em 11 pacientes (1,1%). Outros diagnósticos representaram 3,9% dos casos. Houve dois casos (0,2%) de complicações (hematoma e hemorragia submucosa), ambos após polipectomia, sem necessidade de intervenção cirúrgica. CONCLUSÃO: Os residentes sob supervisão e orientação de especialistas podem realizar colonoscopias com excelente resultado, baixo índice de complicações e com dados finais comparáveis aos obtidos por endoscopistas experientes.

Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center

BACKGROUND

Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy.

METHODS

A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy.

RESULTS

The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25-93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention.

CONCLUSION

The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Colonoscopic polypectomy in anticoagulated patients

AIM: To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation.

METHODS: Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically.

RESULTS: One patient (0.8%, 95% CI: 0.1%-4.5%) developed major post-polypectomy bleeding that required transfusion. Two others (1.6%, 95% CI: 0.5%-5.7%) had self-limited hematochezia at home and did not seek medical attention. The average polyp size was 5.1 ± 2.2 mm.

CONCLUSION: Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.

Endoloop-assisted polypectomy for large pedunculated colorectal polyps

BACKGROUND

The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps. This study aimed to assess the safety and efficacy of colonoscopic ligation of the stalk of large pedunculated polyps by means of an endoloop technique, and to focus particular attention on the instances in which the use of this device was unsuccessful.

METHODS

This study retrospectively evaluated attempted endoloop endoscopic polypectomy in 33 patients (19 men and 14 women; mean age, 62.5 years) with large pedunculated polyps.

RESULTS

Application of the endoloop was impossible in four patients, and the snare became entangled with the loop in one patient. The remaining 28 patients underwent endoloop-assisted polypectomy. Bleeding occurred in four patients, either because the loop slipped of the stalk after polypectomy (2 patients) or because a thin stalk (< or = 4 mm) was transected by the loop before polypectomy (2 patients).

CONCLUSION

Colonoscopic polypectomy with an endoloop may be safer than conventional polypectomy. The reasons for technical failure of this technique include a narrow left colon lumen, a thin stalk (< or = 4 mm), and close cutting in relation to the site of encirclement by the loop.

Colonoscopy with polypectomy in anticoagulated patients

BACKGROUND

According to current practice guidelines for performance of colonoscopy in patients requiring long-term anticoagulation, polypectomy is considered a high-risk procedure for which anticoagulation must temporarily be discontinued. However, these guidelines are based on expert opinion, and the bleeding risk after polypectomy in anticoagulated patients is not known.

OBJECTIVE

Measure the risk of postpolypectomy bleeding in patients who undergo colonoscopic polypectomy while anticoagulated.

DESIGN

Retrospective review of patients who underwent polypectomy without discontinuation of anticoagulation.

SETTING

Veterans Administration Palo Alto Health Care System.

PATIENTS

Forty-one polypectomies were performed in 21 patients. All patients had been receiving long-term anticoagulation with warfarin; the average international normalized ratio was 2.3 (range 1.4-4.9; normal 0.9-1.2). To prevent supratherapeutic anticoagulation, warfarin was withheld for 36 hours before the procedure while the patients were on a liquid diet. The average polyp size was 5 mm (range 3-10 mm).

INTERVENTIONS

All patients underwent polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding.

MAIN OUTCOME MEASUREMENTS

Rate of postpolypectomy bleeding.

RESULTS

There were no episodes of postpolypectomy bleeding. The 95% CI for the risk of bleeding was 0% to 8.6% when analyzed per polypectomy and 0% to 15% when analyzed per patient.

LIMITATIONS

Small single-center retrospective study.

CONCLUSIONS

Our experience suggests that small polyps can be removed with a very low risk of bleeding when clips are applied immediately after polypectomy. If these results can be confirmed in a larger multicenter study, our protocol may become an alternative to withholding anticoagulation in patients at high risk of thrombosis.

Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study

BACKGROUND

Endoscopic polypectomy is a standard method of treatment of gastrointestinal polyps, but is associated with substantial risk of complications. The most common is hemorrhage, the rate of which varied between 0.3%, and 6%. Various prophylactic techniques have been used to reduce this incidence. The aim of this study was to establish whether the prophylactic injection of adrenaline-saline solution reduces the risk of postpolypectomy bleeding in colonoscopic polypectomy.

METHODS

Between May 2000 and June 2002, patients with colorectal polyps of size > or =1 cm were randomized to receive submucosal epinephrine injection (group A) or no injection (group B). The polypectomies were carried out using the conventional method. In group A, epinephrine (1/10,000) was injected into the stalk or base of the polyp. The patients were observed for complications.

RESULTS

A total of 69 patients with 100 polyps were enrolled in this study: n = 50 in group A, and n = 50 in group B, according to randomization. There were a total of nine episodes of postpolypectomy hemorrhage, one in the epinephrine group and eight in the control group (1/50 vs 8/50, p < 0.05). The bleeding correlated with the size of the polyps and the diameter of the stalks.

CONCLUSIONS

Epinephrine injection prior to colonoscopic polypectomy is effective in preventing bleeding.

Perforation during colonoscopy in endoscopic ambulatory surgical centers

BACKGROUND

Perforation as a complication of colonoscopy is estimated to occur in 0.01% to 0.3% of procedures, but the frequency in ambulatory settings is unknown. This study determined the number of perforations occurring within a network of endoscopic ambulatory surgery centers.

METHODS

A total of 116,000 colonoscopies were performed within one network of 45 endoscopic ambulatory surgery centers in the United States during 1999. All identified perforations were reported to the network clinical director and reviewed by a panel of 3 gastroenterologists.

RESULTS

There were 37 (0.03%) perforations; 27 in women and 10 in men. Median patient age was 75 years (range 39-87 years); 18 patients (49%) had diverticular disease and 20 (54%) had a history of pelvic or colonic surgery. Twenty-four (65%) procedures were diagnostic, and 13 (35%) were therapeutic. The most common site of perforation was the sigmoid colon (62%); followed by the ascending colon (16%); cecum, transverse colon, and splenic flexure (11%); and rectum, anastomotic, or unknown (11%). The time to diagnosis ranged from immediate to 72 hours (29 <1 hour, 8 >1 hour). All patients were hospitalized; 35 (95%) underwent exploratory laparotomy, and 2 (5%) were treated conservatively. No patient died.

CONCLUSIONS

Reported perforations for procedures performed in endoscopic ambulatory surgery centers occurred most frequently during diagnostic colonoscopy in older woman with a history of surgery or diverticular disease. Reported perforations in endoscopic ambulatory surgery centers were uncommon.

Laparoscopic "radical appendectomy" is an effective alternative to endoscopic removal of cecal polyps

BACKGROUND

The endoscopic removal of cecal polyps can be complicated by hemorrhage, perforation, or incomplete resection. Laparoscopic radical appendectomy represents a safe alternative for the definitive resection and accurate pathologic evaluation of selected cecal polyps.

METHODS

Patients with cecal cap polyps not involving the ileocecal valve were candidates for laparoscopic radical appendectomy. Intraoperative colonoscopy and resection of the appendix and cecum to the level of the ileocecal valve were accomplished via three midline ports. For each patient, histologic evaluation by frozen section ruled out malignancy and ensured complete resection.

RESULTS

Five patients, four of whom had significant medical comorbidities, presented with large adenomatous polyps contained within the cecum. Each polyp was determined to be unresectable endoscopically; therefore, a laparoscopic radical appendectomy was performed. One patient with cirrhosis also underwent intraoperative liver ultrasonography and biopsies, which contributed to the longest operative time and hospital stay. The histologic diagnosis by frozen section was benign for each patient. The mean operative time was 95 minutes, and the mean length of hospital stay was 1.8 days. No postoperative complications were observed during a mean follow-up of 6 months.

CONCLUSION

Laparoscopic "radical appendectomy" is an effective treatment for selected cecal adenomatous polyps. Our ability to resect the polyps completely and avoid a standard right hemicolectomy supports this approach.

Pathogenesis and clinical management of hereditary non-polyposis colorectal cancer

BACKGROUND

Hereditary non-polyposis colorectal cancer (HNPCC) is an inherited genetic condition associated with microsatellite instability; it accounts for around 5 per cent of all cases of colorectal cancer. This review examines recent data on management strategies for this condition.

METHODS

A Medline-based literature search was performed using the keywords 'HNPCC' and 'microsatellite instability'. Additional original papers were obtained from citations in articles identified by the initial search.

RESULTS AND CONCLUSION

The Amsterdam criteria identify patients in whom the presence of an inherited mutation should be investigated. Those with a mutation should be offered counselling and screening. The role of prophylactic surgery has been superseded by regular colonoscopy, which dramatically reduces the risk of colorectal cancer. Screening for extracolonic malignancy is also advocated, but the benefits are uncertain. Chemoprevention may be of value in lowering the incidence of bowel cancer in affected patients, but further studies are required.

Acute pancreatitis after gastrointestinal endoscopy

Acute pancreatitis is a well-recognized complication of endoscopic retrograde cholangiopancreatography but is not considered to be a complication associated with other endoscopic procedures. We present a case of acute pancreatitis that occurred after uneventful upper and lower gastrointestinal endoscopy. The temporal relationship of the endoscopic procedures and development of acute pancreatitis suggests a causal relation. Furthermore, the patient had none of the usual etiologic factors associated with pancreatitis, i.e., alcoholism, cholelithiasis, hypertriglyceridemia, hypercalcemia, or use of a drug associated with pancreatitis. The causal mechanism of acute pancreatitis is uncertain but might potentially involve local trauma to the pancreas during a procedure or release of as yet undefined inflammatory mediators. In summary, three previous reports of clinical pancreatitis associated with endoscopy, in addition to the current case, suggests that acute pancreatitis should be considered as a rare complication of routine upper endoscopy or colonoscopy.

A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines

BACKGROUND

The aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines.

METHODS

A prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed.

RESULTS

Between April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001).

CONCLUSIONS

This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe" colonoscopies.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Anticoagulant therapy, anti-platelet agents and gastrointestinal endoscopy

BACKGROUND

The increasing use of anticoagulant therapy and anti-platelet agents in the primary and secondary prevention of cardiovascular, cerebrovascular and venous thromboembolic disease has increased the need for guidelines for managing these agents prior to gastrointestinal endoscopy, particularly if therapeutic manoeuvres are required. The continuation of anticoagulant therapy increases the risk of haemorrhagic complications of gastrointestinal endoscopy. Temporary suspension of anticoagulant therapy exposes the patient to the risk of thromboembolism associated with the underlying condition requiring anticoagulant treatment.

CONCLUSIONS

This article reviews the literature and proposes guidelines for the management of patients taking anticoagulant and anti-platelet agents who require gastrointestinal endoscopy.