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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality indicators for colonoscopy. Gastrointest Endosc 2024; 100:352-381. [PMID: 39177519 DOI: 10.1016/j.gie.2024.04.2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/25/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Department of Medicine/Division of Gastroenterology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine/Division of Gastroenterology, White River Junction VAMC, White River Junction, Vermont, USA; University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco; Chief Medical Officer, University of California San Francisco Health System
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA; VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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2
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Saraidaridis JT, Gaetani RS, Marcello PW. Dual Channel Endoscopic Mucosal Resection. Clin Colon Rectal Surg 2024; 37:295-301. [PMID: 39132201 PMCID: PMC11309799 DOI: 10.1055/s-0043-1770943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Endoscopic mucosal resection (EMR) is the recommended technique for colon polypectomy for nonpedunculated lesions that are >20 mm in size not requiring excision. Dual-channel EMR (DC-EMR) uses an endoscope with two working channels to facilitate easier submucosal injection, snare resection, and clip closure of polypectomy defects. There is also promising early literature indicating that this endoscopic modality can reduce the overall learning curve present for single-channel colonoscopy EMR. This chapter will describe the steps and techniques required to perform DC-EMR, potential complications, recommended postprocedure surveillance, and future directions.
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Affiliation(s)
- Julia T. Saraidaridis
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Racquel S. Gaetani
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Peter W. Marcello
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality Indicators for Colonoscopy. Am J Gastroenterol 2024:00000434-990000000-01296. [PMID: 39167112 DOI: 10.14309/ajg.0000000000002972] [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: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Chief Medical Officer, University of California San Francisco Health System, San Francisco, California, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Podboy A, Wang AY. Electrosurgical Principles: Beyond Blue and Yellow Pedal. Am J Gastroenterol 2024; 119:1445-1448. [PMID: 38275235 DOI: 10.14309/ajg.0000000000002681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
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Imai K, Hotta K, Ito S, Kishida Y, Takada K, Suwa T, Ashizawa H, Minamide T, Yamamoto Y, Yoshida M, Maeda Y, Kawata N, Sato J, Ishiwatari H, Matsubayashi H, Oishi T, Sugino T, Mori K, Ono H. A novel low-power pure-cut hot snare polypectomy for 10-14 mm colorectal adenomas: An ex vivo and a clinical prospective feasibility study (SHARP trial). J Gastroenterol Hepatol 2024; 39:667-673. [PMID: 38149747 DOI: 10.1111/jgh.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/10/2023] [Accepted: 12/03/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIM Hot snare polypectomy using blend or coagulation current is widely used; however, it causes deeper tissue heat injury, leading to adverse events. We hypothesized that hot polypectomy using low-power pure cut current (PureCut, effect 1 10 W) could reduce deeper tissue heat injury. We conducted animal experiments to evaluate the deeper tissue heat injury and conducted a prospective clinical study to examine its cutting ability. METHODS In a porcine rectum, hot polypectomy using Blend current (EndoCut, effect 3 40 W) and low-power pure cut current was performed. The deepest part of heat destruction and thickness of the non-burned submucosal layer were evaluated histologically. Based on the results, we performed low-power pure cut current hot polypectomy for 10-14 mm adenoma. The primary endpoint was complete resection defined as one-piece resection with negative for adenoma in quadrant biopsies from the defect margin. RESULTS In experiments, all low-power pure-cut resections were limited within the submucosal layer whereas blend current resections coagulated the muscular layer in 13% (3/23). The remaining submucosal layer was thicker in low-power pure cut current than in blend current resections. In the clinical study, low-power pure-cut hot polypectomy removed all 100 enrolled polyps. For 98 pathologically neoplastic polyps, complete resection was achieved in 84 (85.7%, 95% confidence interval, 77-92%). The lower limit of the 95% confidence interval was not more than 15% below the pre-defined threshold of 86.6%. No severe adverse events occurred. CONCLUSIONS A novel low-power pure-cut hot polypectomy may be feasible for adenoma measuring 10-14 mm. (UMIN000037678).
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Kazunori Takada
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Tetsuya Suwa
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Hiroshi Ashizawa
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Tatsunori Minamide
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Yoichi Yamamoto
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Yuki Maeda
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | | | | | - Takuma Oishi
- Division of Pathology, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Takashi Sugino
- Division of Pathology, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
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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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Cavassola PRP, Moura DTHD, Hirsch BS, Landim DL, Bernardo WM, Moura EGHD. HOT VERSUS COLD SNARE FOR COLORECTAL POLYPECTOMIES SIZED UP TO 10MM: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. ARQUIVOS DE GASTROENTEROLOGIA 2024; 61:e23143. [PMID: 38511795 DOI: 10.1590/s0004-2803.246102023-143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/19/2023] [Indexed: 03/22/2024]
Abstract
BACKGROUND Colorectal cancer is the third most common cancer, and prevention relies on screening programs with resection complete resection of neoplastic lesions. OBJECTIVE We aimed to evaluate the best snare polypectomy technique for colorectal lesions up to 10 mm, focusing on complete resection rate, and adverse events. METHODS A comprehensive search using electronic databases was conducted to identify randomized controlled trials comparing hot versus cold snare resection for polyps sized up to 10 mm, and following PRISMA guidelines, a meta-analysis was performed. Outcomes included complete resection rate, en bloc resection rate, polypectomy, procedure times, immediate, delayed bleeding, and perforation. RESULTS Nineteen RCTs involving 8720 patients and 17588 polyps were included. Hot snare polypectomy showed a higher complete resection rate (RD, 0.02; 95%CI [+0.00,0.04]; P=0.03; I 2=63%), but also a higher rate of delayed bleeding (RD 0.00; 95%CI [0.00, 0.01]; P=0.01; I 2=0%), and severe delayed bleeding (RD 0.00; 95%CI [0.00, 0.00]; P=0.04; I 2=0%). Cold Snare was associated with shorter polypectomy time (MD -46.89 seconds; 95%CI [-62.99, -30.79]; P<0.00001; I 2=90%) and shorter total colonoscopy time (MD -7.17 minutes; 95%CI [-9.10, -5.25]; P<0.00001; I 2=41%). No significant differences were observed in en bloc resection rate or immediate bleeding. CONCLUSION Hot snare polypectomy presents a slightly higher complete resection rate, but, as it is associated with a longer procedure time and a higher rate of delayed bleeding compared to Cold Snare, it cannot be recommended as the gold standard approach. Individual analysis and personal experience should be considered when selecting the best approach.
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Affiliation(s)
- Paulo Ricardo Pavanatto Cavassola
- Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas, Departamento de Gastroenterologia, Serviço de Endoscopia Gastrointestinal, Sao Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux de Moura
- Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas, Departamento de Gastroenterologia, Serviço de Endoscopia Gastrointestinal, Sao Paulo, SP, Brasil
| | - Bruno Salomão Hirsch
- Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas, Departamento de Gastroenterologia, Serviço de Endoscopia Gastrointestinal, Sao Paulo, SP, Brasil
| | - Davi Lucena Landim
- Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas, Departamento de Gastroenterologia, Serviço de Endoscopia Gastrointestinal, Sao Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas, Departamento de Gastroenterologia, Serviço de Endoscopia Gastrointestinal, Sao Paulo, SP, Brasil
| | - Eduardo Guimarães Hourneaux de Moura
- Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas, Departamento de Gastroenterologia, Serviço de Endoscopia Gastrointestinal, Sao Paulo, SP, Brasil
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Copland AP, Kahi CJ, Ko CW, Ginsberg GG. AGA Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review. Clin Gastroenterol Hepatol 2024; 22:470-479.e5. [PMID: 38032585 DOI: 10.1016/j.cgh.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
DESCRIPTION In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.
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Affiliation(s)
- Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Charles J Kahi
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Cynthia W Ko
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Jacques J, Schaefer M, Wallenhorst T, Rösch T, Lépilliez V, Chaussade S, Rivory J, Legros R, Chevaux JB, Leblanc S, Rostain F, Barret M, Albouys J, Belle A, Labrunie A, Preux PM, Lepetit H, Dahan M, Ponchon T, Crépin S, Marais L, Magne J, Pioche M. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial. Ann Intern Med 2024; 177:29-38. [PMID: 38079634 DOI: 10.7326/m23-1812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Endoscopic resection of adenomas prevents colorectal cancer, but the optimal technique for larger lesions is controversial. Piecemeal endoscopic mucosal resection (EMR) has a low adverse event (AE) rate but a variable recurrence rate necessitating early follow-up. Endoscopic submucosal dissection (ESD) can reduce recurrence but may increase AEs. OBJECTIVE To compare ESD and EMR for large colonic adenomas. DESIGN Participant-masked, parallel-group, superiority, randomized controlled trial. (ClinicalTrials.gov: NCT03962868). SETTING Multicenter study involving 6 French referral centers from November 2019 to February 2021. PARTICIPANTS Patients with large (≥25 mm) benign colonic lesions referred for resection. INTERVENTION The patients were randomly assigned by computer 1:1 (stratification by lesion location and center) to ESD or EMR. MEASUREMENTS The primary end point was 6-month local recurrence (neoplastic tissue on endoscopic assessment and scar biopsy). The secondary end points were technical failure, en bloc R0 resection, and cumulative AEs. RESULTS In total, 360 patients were randomly assigned to ESD (n = 178) or EMR (n = 182). In the primary analysis set (n = 318 lesions in 318 patients), recurrence occurred after 1 of 161 ESDs (0.6%) and 8 of 157 EMRs (5.1%) (relative risk, 0.12 [95% CI, 0.01 to 0.96]). No recurrence occurred in R0-resected cases (90%) after ESD. The AEs occurred more often after ESD than EMR (35.6% vs. 24.5%, respectively; relative risk, 1.4 [CI, 1.0 to 2.0]). LIMITATION Procedures were performed under general anesthesia during hospitalization in accordance with the French health system. CONCLUSION Compared with EMR, ESD reduces the 6-month recurrence rate, obviating the need for systematic early follow-up colonoscopy at the cost of more AEs. PRIMARY FUNDING SOURCE French Ministry of Health.
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Affiliation(s)
- Jérémie Jacques
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Marion Schaefer
- Hépato-Gastro-Entérologie, CHRU de Nancy, Nancy, France (M.S., J.-B.C.)
| | | | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital, Hamburg-Eppendorf, Hamburg, Germany (T.R.)
| | - Vincent Lépilliez
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | | | - Jérôme Rivory
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Romain Legros
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | | | - Sarah Leblanc
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | - Florian Rostain
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Maximilien Barret
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Jérémie Albouys
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Arthur Belle
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Anaïs Labrunie
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Pierre-Marie Preux
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Hugo Lepetit
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Martin Dahan
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Thierry Ponchon
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Sabrina Crépin
- Service de Pharmacologie-Toxicologie et Pharmacovigilfance-Unité de Vigilance des Essais Cliniques, CHU de Limoges, Limoges, France (S.C.)
| | - Loïc Marais
- Direction de la Recherche et de l'Innovation, CHU de Limoges, Limoges, France (L.M.)
| | - Julien Magne
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Mathieu Pioche
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
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Tamate M, Matsuura M, Saito T. Cervical conization with endoCUT mode applying gastrointestinal endoscopic polypectomy technique. Obstet Gynecol Sci 2023; 66:584-586. [PMID: 37381884 PMCID: PMC10663400 DOI: 10.5468/ogs.23066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/25/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVE To show how endoCUT mode can be safely managed with cervical conization. METHODS Demonstration of the technique and explanation of endoCUT and soft coagulation mode with narrated video footage. Cervical conization is a therapeutic and diagnostic procedure performed for the diagnosis of cervical intraepithelial lesions and cervical cancer. Specific. METHODS include cold scalpel, ultrasonically activated device and laser, and loop electrosurgical excision procedure (LEEP), which involves transpiration and partial excision. The endoCUT mode and soft coagulation in VIO3® (ERBE, Tübingen, Germany) were used to perform cervical conical resection safely and at low cost. The endoCUT mode was originally developed for polypectomy in gastrointestinal endoscopy, where no counter traction can be applied. RESULTS The endoCUT mode approach to cervical conization with several key strategies to minimize blood loss and ensure safety: 1) incisions can be made in close contact; 2) resection can be performed with minimal contact with the lesion; 3) control of bleeding from the resected transection by soft coagulation; and 4) low running cost of endoCUT mode. CONCLUSION Conventionally, cervical conical resection has been performed by using a device capable of making a close incision (cold scalpel, ultrasonically activated device and laser, and LEEP etc.), but there have been issues with bleeding control and cost. Here, we present a new technique using the endoCUT mode and several strategies for safe and effective resection.
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Affiliation(s)
- Masato Tamate
- Department of Obstetrics and Gynecology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Motoki Matsuura
- Department of Obstetrics and Gynecology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University Hospital, Sapporo, Japan
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11
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Abuelazm M, Mohamed I, Jaber FS, Katamesh BE, Shaikhkhalil H, Elzeftawy MA, Mahmoud A, Afifi AM, Abdelazeem B, Othman M. Cold Versus Hot Snare Polypectomy for Colorectal Polyps: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2023; 57:760-773. [PMID: 36787428 DOI: 10.1097/mcg.0000000000001837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Endoscopic polypectomy is an excellent tool for colon cancer prevention. With the innovation of novel resection techniques, the best method is still being investigated. Hence, we aim to evaluate the efficacy and safety of cold snare polypectomy (CSP) versus hot snare polypectomy (HSP) for colorectal polyp resection. METHODS A systematic review and meta-analysis synthesizing evidence from randomized controlled trials retrieved from PubMed, EMBASE, WOS, SCOPUS, and CENTRAL until July 16, 2022. We pooled dichotomous outcomes using risk ratio (RR) with the corresponding CI. This review's protocol was prospectively registered in PROSPERO with ID: CRD42022347496. RESULTS We included 18 randomized controlled trials with a total of 4317 patients and 7509 polyps. Pooled RR favored HSP regarding the complete resection rate (RR: 0.96 with 95% CI: 0.95, 1, P = 0.03) and local recurrence incidence (RR: 5.74 with 95% CI: 1.27, 25.8, P = 0.02). Pooled RR favored CSP regarding the colonoscopy time (mean difference: -6.50 with 95% CI: -7.55, -5.44, P = 0.00001) and polypectomy time (mean difference: -57.36 with 95% CI: -81.74, -32.98, P = 0.00001). There was no difference regarding the incidence of immediate bleeding ( P = 0.06) and perforation ( P = 0.39); however, HSP was associated with more incidence of delayed bleeding ( P = 0.01), abdominal pain ( P = 0.007), and postresection syndrome ( P = 0.02). DISCUSSION HSP is associated with a higher complete resection and lower recurrence rates; however, HSP is also associated with a higher incidence of adverse events. Therefore, improving the complete resection rate with CSP still warrants more innovation, giving the technique safety and shorter procedure duration.
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Affiliation(s)
| | - Islam Mohamed
- Department of Medicine, University of Missouri, Kansas City, USA
| | - Fouad S Jaber
- Department of Medicine, University of Missouri, Kansas City, USA
| | | | | | | | | | - Ahmed M Afifi
- Department of Medicine, University of Texas, MD Anderson Cancer Center, Texas
| | - Basel Abdelazeem
- Department of Internal Medicine, McLaren Health Care, Flint, Michigan
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
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12
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Herman T, Megna B, Pallav K, Bilal M. Endoscopic mucosal resection: tips and tricks for gastrointestinal trainees. Transl Gastroenterol Hepatol 2023; 8:25. [PMID: 37601741 PMCID: PMC10432230 DOI: 10.21037/tgh-23-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/15/2023] [Indexed: 08/22/2023] Open
Abstract
Endoscopic mucosal resection (EMR) is a minimally invasive, specialized endoscopic technique that is useful in resecting superficial gastrointestinal lesions that are unable to be removed by standard polypectomy. This is typically accomplished using a submucosal injection that lifts the lesion away from the muscularis propria to allow for safe resection of the polyp, either via piecemeal or en bloc resection. Over the years, several techniques exist to perform EMR including conventional EMR or hot EMR, cold EMR and underwater EMR. Despite its established advantages and safety over conventional techniques such as surgery, the adoption of endoscopic resection (and thus the education and training of gastroenterology trainees) is lagging. The goal of this article is to offer a comprehensive review of the basic principles of colonic EMR. We review the concepts of optical diagnosis including the various polyp classification systems available to determine the polyp morphology and histology. We also discuss the technical aspects of performing colonic EMR. We also outline the common adverse events associated with EMR including bleeding, perforation, postpolypectomy syndrome, and residual or recurrent polyps, and discuss preventative measures that can be taken to mitigate adverse events. Lastly, we offer practical tips for trainees who want to undertake EMR in their clinical practice.
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Affiliation(s)
- Tessa Herman
- Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Bryant Megna
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Kumar Pallav
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Mohammad Bilal
- Advanced Endoscopy, Division of Gastroenterology & Hepatology, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minneapolis, MN, USA
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13
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Jena A, Jain S, Sundaram S, Singh AK, Chandnani S, Rathi P. Electrosurgical unit in GI endoscopy: the proper settings for practice. Expert Rev Gastroenterol Hepatol 2023; 17:825-835. [PMID: 37497836 DOI: 10.1080/17474124.2023.2242243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/14/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Electrosurgical unit (ESU) is integral to the endoscopy unit. The proper knowledge of the Mode with setting is essential for good therapeutic outcomes and the safety of the patients. AREAS COVERED ESU generates high-frequency electric current, which could perform cutting and coagulation for various therapeutic interventions. We review the proper settings for common endoscopic interventions like hemostasis, polypectomy, sphincterotomy, and advanced procedures like endoscopic ultrasound-guided cysto-gastrostomy, bile duct drainage, and endoscopic Ampullectomy. We review the various waveforms of ESU in practice in endoscopy, including special conditions like patients with pacemakers. EXPERT OPINION Knowledge of the waveforms' duty cycle and crest factor is necessary. A high-duty cycle and lower crest factor lead to a good cutting effect on the tissue. Endocut is the most commonly used Mode in ESU in endoscopic practices like sphincterotomy and polypectomy. Endocut I mode (effect 1-2, duration 3, interval 3) is used for endoscopic sphincterotomy, while Forced Coag mode (Effect 2, 60 W) controls post-sphincterotomy bleeding. Endocut Q mode (Effect 2-3, duration 1, interval 3) is used for cutting the polyp, while Forced Coag mode (Effect 2, 60 W) is used before cutting for pre-coagulation of the stalk.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Shubham Jain
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Chandnani
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Pravin Rathi
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
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14
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King W, Draganov P, Gorrepati VS, Hayat M, Aihara H, Karasik M, Ngamruengphong S, Aadam AA, Othman MO, Sharma N, Grimm IS, Rostom A, Elmunzer BJ, Yang D. Safety and feasibility of same-day discharge after endoscopic submucosal dissection: a Western multicenter prospective cohort study. Gastrointest Endosc 2023; 97:1045-1051. [PMID: 36731578 DOI: 10.1016/j.gie.2023.01.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/05/2022] [Accepted: 01/22/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Recent Western studies support the safety and efficacy of endoscopic submucosal dissection (ESD) for lesions throughout the GI tract. Although admission for observation after ESD is standard in Asia, a more selective approach may optimize resource utilization. We aimed to evaluate the safety and feasibility of same-day discharge (SDD) after ESD and factors associated with admission. METHODS This was a post hoc analysis of a multicenter, prospective cohort of patients undergoing ESD (2016-2021). The primary end points were safety of SDD and factors associated with post-ESD admission. RESULTS Of 831 patients (median age, 67 years; 57% male) undergoing 831 ESDs (240 performed in the esophagus, 126 in the stomach, and 465 in the colorectum; median lesion size, 44 mm), 588 (71%) were SDD versus 243 (29%) admissions. Delayed bleeding and perforation occurred in 12 (2%) and 4 (.7%) of SDD patients, respectively; only 1 (.2%) required surgery. Of the 243 admissions, 223 (92%) were discharged after ≤24 hours of observation. Interestingly, larger lesion size (>44 mm) was not associated with higher admission rate (odds ratio [OR], .5; 95% confidence interval [CI], .3-.8; P = .001). Lesions in the upper GI tract versus colon (OR, 1.7; 95% CI, 1.1-2.6; P = .01), invasive cancer (OR, 1.9; 95% CI, 1.2-3.1; P = .01), and adverse events (OR, 2.7; 95% CI, 1.5-4.8; P = .001) were independent factors for admission. Admissions were more likely performed by endoscopists with ESD volume <50 cases (OR, 2.1; 95% CI, 1.3-3.3; P = .001) with procedure time >75 minutes (OR, 13.5; 95% CI, 8.5-21.3; P < .0001). CONCLUSIONS SDD after ESD can be safe and feasible. Patients with invasive cancer, lesions in the upper GI tract, longer procedure times, or procedures performed by low-volume ESD endoscopists are more likely to be admitted postprocedure. Risk stratification of patients for SDD after ESD should help optimize resource utilization and enhance ESD uptake in the West. (Clinical trial registration number: NCT02989818.).
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Affiliation(s)
- William King
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Peter Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - V Subhash Gorrepati
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Karasik
- Division of Gastroenterology and Hepatology, Hartford Hospital, Hartford, Connecticut, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern Medicine Digestive Health Center, Chicago, Illinois, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, USA
| | - Neil Sharma
- Division of Interventional Endoscopic Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Alaa Rostom
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.
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15
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in flexible sigmoidoscopy. Frontline Gastroenterol 2023; 14:181-200. [PMID: 37056324 PMCID: PMC10086722 DOI: 10.1136/flgastro-2022-102259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionJoint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).MethodsA modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.ResultsIn total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Vathsan Ravindran
- Department of Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Ian L P Beales
- University of East Anglia, Norwich, UK
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Elizabeth Ratcliffe
- Department of Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
- Division of Diabetes, Endocrinology and Gastroenterology Faculty of Biology, Medicine and Health School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Catherine Regan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, UK
| | - Eleanor Wood
- Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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16
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in colonoscopy. Frontline Gastroenterol 2023; 14:201-221. [PMID: 37056319 PMCID: PMC10086724 DOI: 10.1136/flgastro-2022-102260] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionIn the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.MethodsUnder the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.ResultsIn total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate–severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, Greater London, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, UK
| | - John Anderson
- Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Vathsan Ravindran
- Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Ian L P Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
- University of East Anglia, Norwich, Norfolk, UK
| | | | - Nicholas I Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Edinburgh, UK
| | - Elizabeth Ratcliffe
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, Manchester, UK
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, Wigan, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Catherine Regan
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, Tyne and Wear, UK
| | - Eleanor Wood
- Department of Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, Gloucestershire, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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17
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Motchum L, Levenick JM, Djinbachian R, Moyer MT, Bouchard S, Taghiakbari M, Repici A, Deslandres É, von Renteln D. EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos). Gastrointest Endosc 2022; 96:840-848.e2. [PMID: 35724695 DOI: 10.1016/j.gie.2022.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR. METHODS Adult patients (aged 18-89 years) undergoing EMR of nonpedunculated colorectal polyps ≥20 mm were enrolled in a prospective multicenter study. h-APC was used to ablate all defect margins and also the resection surface in selected cases. The primary study outcome was recurrence rates found during the first follow-up colonoscopy. Secondary outcomes were technical success and adverse event rates. RESULTS EMR with h-APC ablation was used in 101 polyps (84 patients, 46.4% women). EMR with h-APC ablation was technically successful in all cases (median EMR time, 15 minutes; median h-APC ablation time, 4 minutes). Median polyp size was 30 mm (range, 20-60). Resected polyps were either adenomas (68/101 [67.3%]), sessile serrated lesions (27/101 [27%]), or adenocarcinomas (6/101 [6%]). The post-EMR recurrence rate was 2.2% (2/91) (95% confidence interval, .27-7.71). All 6 patients with cancer (intramucosal cancer, 4; T1sm cancer, 2) were found to have complete eradication of the primary tumor after EMR with h-APC, and none had lymph node metastasis. Four serious adverse events occurred in 3 patients (2 delayed bleeding [2.4%], 1 abdominal pain [1.2%], and 1 microperforation [1.2%]. All serious adverse events resolved with either endoscopic or antibiotic treatment only. CONCLUSIONS EMR with h-APC showed a high technical success rate, low adverse event rate, and very low post-EMR recurrence rates. (Clinical trial registration number: NCT04015765.).
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Affiliation(s)
- Leslie Motchum
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Faculty of Medicine, Montreal University Montreal, Montreal, Quebec, Canada
| | - John M Levenick
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Roupen Djinbachian
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Matthew T Moyer
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Simon Bouchard
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Mahsa Taghiakbari
- Montreal University Medical Research Center, Montreal, Quebec, Canada
| | - Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Érik Deslandres
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Daniel von Renteln
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
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18
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Rotermund C, Djinbachian R, Taghiakbari M, Enderle MD, Eickhoff A, von Renteln D. Recurrence rates after endoscopic resection of large colorectal polyps: A systematic review and meta-analysis. World J Gastroenterol 2022; 28:4007-4018. [PMID: 36157546 PMCID: PMC9367239 DOI: 10.3748/wjg.v28.i29.4007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/11/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Complete polyp resection is the main goal of endoscopic removal of large colonic polyps. Resection techniques have evolved in recent years and endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) with margin ablation, cold snare polypectomy (CSP), cold EMR, and underwater EMR have been introduced. Yet, efficacy of these techniques with regard to local recurrence rates (LRRs) vs traditional hot snare polypectomy and standard EMR remains unclear.
AIM To analyze LRR of large colonic polyps in a systematic review and meta-analysis.
METHODS MEDLINE, EMBASE, EBM Reviews, and CINAHL were searched for prospective studies reporting LRR or incomplete resection rate (IRR) after colonic polypectomy of polyps ≥ 10 mm, published between January 2011 and July 2021. Primary outcome was LRR for polyps ≥ 10 mm.
RESULTS Six thousand nine hundred and twenty-eight publications were identified, of which 34 prospective studies were included. LRR for polyps ≥ 10 mm at up to 12 mo’ follow-up was 11.0% (95%CI, 7.1%-14.8%; 15 studies; 4904 polyps). ESD (1.7%; 95%CI, 0%-3.4%; 3 studies, 221 polyps) and endoscopic mucosal resection with margin ablation (3.3%; 95%CI, 2.2%-4.5%; 2 studies, 947 polyps) significantly reduced LRR vs standard EMR without (15.2%; 95%CI, 12.5%-18.0%; 4 studies, 650 polyps) or with unsystematic margin ablation (16.5%; 95%CI, 15.2%-17.8%; 6 studies, 3031 polyps).
CONCLUSION LRR is significantly lower after ESD or EMR with routine margin ablation; thus, these techniques should be considered standard for endoscopic removal of large colorectal polyps. Other techniques, such as CSP, cold EMR, and underwater EMR require further evaluation in prospective studies before their routine implementation in clinical practice can be recommended.
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Affiliation(s)
- Carola Rotermund
- Research and Basic Technologies, ERBE Elektromedizin GmbH, Tuebingen 72072, Germany
| | - Roupen Djinbachian
- Division of Internal Medicine, Montreal University Hospital Center, Montreal QC H2X 3E4, Canada
| | - Mahsa Taghiakbari
- Montreal University Hospital Research Center, Montreal University Hospital Center, Montreal QC H2X 3E4, Canada
| | - Markus D Enderle
- Research and Basic Technologies, ERBE Elektromedizin GmbH, Tuebingen 72072, Germany
| | - Axel Eickhoff
- Department of Internal Medicine II, Klinikum Hanau, Hanau 63450, Germany
| | - Daniel von Renteln
- Montreal University Hospital Research Center, Montreal University Hospital Center, Montreal QC H2X 3E4, Canada
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19
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Clip Closure Does Not Reduce Risk of Bleeding After Resection of Large Serrated Polyps: Results From a Randomized Trial. Clin Gastroenterol Hepatol 2022; 20:1757-1765.e4. [PMID: 34971811 DOI: 10.1016/j.cgh.2021.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Serrated polyps are important colorectal cancer precursors and are most commonly located in the proximal colon, where post-polypectomy bleeding rates are higher. There is limited clinical trial evidence to guide best practices for resection of large serrated polyps (LSPs). METHODS In a multicenter trial, patients with large (≥20 mm) non-pedunculated polyps undergoing endoscopic mucosal resection (EMR) were randomized to clipping of the resection base or no clipping. This analysis is stratified by histologic subtype of study polyp(s), categorized as serrated [sessile serrated lesions (SSLs) or hyperplastic polyps (HPs)] or adenomatous, comparing clip vs control groups. The primary outcome was severe post-procedure bleeding within 30 days of colonoscopy. RESULTS A total of 179 participants with 199 LSPs (191 SSLs and 8 HPs) and 730 participants with 771 adenomatous polyps were included in the study. Overall, 5 patients with LSPs (2.8%) experienced post-procedure bleeding compared with 42 (5.8%) of those with adenomas. There was no difference in post-procedure bleeding rates between patients in the clip vs control group among those with LSPs (2.3% vs 3.3%, respectively, difference 1.0%; P = NS). However, among those with adenomatous polyps, clipping was associated with a lower risk of post-procedure bleeding (3.9% vs 7.6%, difference 3.7%; P = .03) and overall serious adverse events (5.5% vs 10.6%, difference 5.1%; P = .01). CONCLUSION The post-procedure bleeding risk for LSPs removed via EMR is low, and there is no discernable benefit of prophylactic clipping of the resection base in this group. This study indicates that the benefit of endoscopic clipping following EMR may be specific for >2 cm adenomatous polyps located in the proximal colon. CLINICALTRIALS gov, Number: NCT01936948.
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20
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Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions. Am J Gastroenterol 2022; 117:1080-1088. [PMID: 35765907 DOI: 10.14309/ajg.0000000000001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/27/2022] [Indexed: 12/11/2022]
Abstract
The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.
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21
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Dang DT, Suresh S, Vance RB, Singla S, Javia S, Watson A, Chathadi KV, Katukuri V, Pompa R, Stidham RW, Zuchelli T, Piraka C. Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study. Gastrointest Endosc 2022; 95:1176-1182. [PMID: 34971667 DOI: 10.1016/j.gie.2021.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 12/17/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Nonampullary small-bowel adenomas ≥10 mm are typically resected using cautery-based polypectomy, which is associated with significant adverse events. Studies have demonstrated the safety and efficacy of piecemeal cold snare EMR for removing large colon polyps. Our aim was to assess the safety and efficacy of cold snare EMR for removal of large adenomas in the small bowel. METHODS A retrospective study of patients who underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm between January 2014 and March 2019 was conducted at a tertiary care medical center. Polyp characteristics at the time of index and surveillance endoscopy were collected. Primary outcomes were residual or recurrent adenoma (RRA) seen on surveillance endoscopy, polyp eradication rate, and number of endoscopic procedures required for eradication. Adverse events including immediate and delayed bleeding, perforation, stricture, pancreatitis, and postpolypectomy syndrome were assessed. RESULTS Of 43 patients who underwent piecemeal cold snare EMR, 39 had follow-up endoscopy. Polyps ranged in size from 10 to 70 mm (mean, 26.5 mm). RRA was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P < .001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range, 1-6) endoscopic procedures. Only 1 patient (2.3%) had immediate postprocedural bleeding. No cases of perforation or postpolypectomy syndrome were seen. CONCLUSIONS Piecemeal cold snare EMR may be a feasible, safe, and efficacious technique for small-bowel polyps >10 mm. Prospective, randomized studies are needed to assess how outcomes compare with traditional cautery-based polypectomy.
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Affiliation(s)
- Duyen T Dang
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Suraj Suresh
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - R Brooks Vance
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sumit Singla
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Siddharth Javia
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Andrew Watson
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Vinay Katukuri
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Robert Pompa
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ryan W Stidham
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - Tobias Zuchelli
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Cyrus Piraka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
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22
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Rex DK, Vemulapalli KC. Response. Gastrointest Endosc 2022; 95:1288-1289. [PMID: 35589217 DOI: 10.1016/j.gie.2022.02.040] [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: 01/20/2022] [Accepted: 02/19/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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23
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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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24
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Patient Selection, Risks, and Long-Term Outcomes Associated with Colorectal Polyp Resection. Gastrointest Endosc Clin N Am 2022; 32:351-370. [PMID: 35361340 DOI: 10.1016/j.giec.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Although the incidence rates are generally low (<1%), these can be avoided by recognizing pertinent risk factors, which can be patient, polyp, and technique/device related. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques to achieve hemostasis and manage colon perforations are reviewed.
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25
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Thiruvengadam SS, Fung BM, Barakat MT, Tabibian JH. Endoscopic Mucosal Resection: Best Practices for Gastrointestinal Endoscopists. Gastroenterol Hepatol (N Y) 2022; 18:133-144. [PMID: 35506001 PMCID: PMC9053487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Endoscopic mucosal resection (EMR) is an endoscopic technique used to remove sessile or flat lesions from the gastrointestinal tract. This article reviews EMR and focuses on large colorectal polyps, which constitute the most common indication for EMR. Various methods of polyp evaluation can help gastroenterologists determine whether EMR is feasible and whether referral to an advanced endoscopist may be necessary. Techniques for performing EMR include conventional hot-snare EMR with submucosal injection and electro-cautery snare removal of colorectal lesions, as well as alternative EMR techniques such as cold-snare EMR and underwater EMR. Key adverse events associated with EMR include bleeding, perforation, and post-polypectomy coagulation syndrome. Finally, as residual or recurrent polyp formation is possible regardless of EMR technique, this article addresses the importance of surveillance post-EMR and the patients who are at highest risk for polyp recurrence.
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Affiliation(s)
- Sushrut Sujan Thiruvengadam
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Brian M. Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
| | - Monique T. Barakat
- Divisions of Adult and Pediatric Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California
| | - James H. Tabibian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
- Division of Gastroenterology, Department of Medicine, Olive View–UCLA Medical Center, Sylmar, California
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26
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Bendall O, James J, Pawlak KM, Ishaq S, Tau JA, Suzuki N, Bollipo S, Siau K. Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients. Clin Exp Gastroenterol 2022; 14:477-492. [PMID: 34992406 PMCID: PMC8714413 DOI: 10.2147/ceg.s282699] [Citation(s) in RCA: 1] [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: 10/12/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022] Open
Abstract
Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3–1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.
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Affiliation(s)
- Oliver Bendall
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Joel James
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Katarzyna M Pawlak
- Endoscopy Unit, Department of Gastroenterology, Ministry of Interior and Administration, Szczecin, Poland
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, UK.,Medicine, Birmingham City Hospital, Birmingham, UK
| | - J Andy Tau
- Austin Gastroenterology, Austin, TX, USA
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St. Mark's Hospital, London, UK
| | - Steven Bollipo
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
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27
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Ortiz O, Rex DK, 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 R, Wallace MB, Elias PA, MacKenzie TA, Pohl H, Pellisé M. Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps. Endoscopy 2021; 53:1150-1159. [PMID: 33291159 DOI: 10.1055/a-1332-6727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIM : Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of nonpedunculated polyps larger than 20 mm reduces the incidence of severe delayed bleeding, especially in proximal polyps. This study aimed to evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. METHODS : This is a post hoc analysis of the CLIP study (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when no remaining mucosal defect was visible and clips were less than 1 cm apart. Factors associated with complete closure were evaluated in multivariable analysis. RESULTS : In total, 458 patients (age 65, 58 % men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4 %); closure was not complete for 156 (31.6 %). Factors associated with complete closure in adjusted analysis were smaller polyp size (odds ratio 1.06 for every millimeter decrease [95 % confidence interval 1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]). CONCLUSIONS : Complete clip closure was not achieved for almost one in three resected large nonpedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. This highlights the need for alternative closure options and measures to prevent bleeding.
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Affiliation(s)
- Oswaldo Ortiz
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Douglas Pleskow
- Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Firas H Al-Kawas
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Sibley Memorial Hospital, Washington, DC, USA
| | - Stuart R Gordon
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA.,Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John M Levenick
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Harry R Aslanian
- Section of Digestive Diseases, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Fadi Antaki
- Division of Gastroenterology, John D. Dingell Veterans Affairs Medical Center and Wayne State University, Detroit, Michigan, USA
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Medical Center (CHUM) and Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey A Gill
- Division of Gastroenterology, James A. Haley VA, University of South Florida, Tampa, Florida, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Pooja A Elias
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Todd A MacKenzie
- The Dartmouth Institute, Department for Biomedical Data Science, Lebanon, New Hampshire, USA
| | - Heiko Pohl
- Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Section of Gastroenterology and Hepatology, VA White River Junction, Vermont, USA
| | - Maria Pellisé
- Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universitat de Barcelona, Barcelona, Spain
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28
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van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, Bar-Yishay I, Schoeman S, Tate DJ, Byth K, Hewett DG, Pellisé M, Hourigan LF, Moss A, Tutticci N, Bourke MJ. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70:1691-1697. [PMID: 33172927 DOI: 10.1136/gutjnl-2020-321753] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known. DESIGN Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods. RESULTS A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively. CONCLUSIONS In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.
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Affiliation(s)
- W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kaushali Britto
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David James Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
| | - Karen Byth
- Biostatistics, Sydney University, Sydney, New South Wales, Australia
| | - David G Hewett
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - María Pellisé
- Gastroenterology, Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Luke F Hourigan
- Department of gastroenterology and hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,Department of gastroenterology and hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Tutticci
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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29
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Rex DK, Risio M, Hassan C. Prioritizing an oncologic approach to endoscopic resection of pedunculated colorectal polyps. Gastrointest Endosc 2021; 94:155-159. [PMID: 33931206 DOI: 10.1016/j.gie.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/05/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mauro Risio
- Institute for Cancer Research and Treatment, Candiolo (Torino), Italy
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30
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Triaging advanced GI endoscopy procedures during the COVID-19 pandemic: consensus recommendations using the Delphi method. Gastrointest Endosc 2020; 92:535-542. [PMID: 32425235 PMCID: PMC7229945 DOI: 10.1016/j.gie.2020.05.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is a lack of consensus on which GI endoscopic procedures should be performed during the COVID-19 pandemic, and which procedures could be safely deferred without having a significant impact on outcomes. METHODS We selected a panel of 14 expert endoscopists. We identified 41 common indications for advanced endoscopic procedures from the ASGE Appropriate Use of GI Endoscopy guidelines. Using a modified Delphi method, we first achieved consensus on the patient-important outcome for each procedural indication. Panelists prioritized consensus patient-important outcome when categorizing each indication into one of the following 3 procedural time periods: (1) time-sensitive emergent (schedule within 1 week), (2) time-sensitive urgent (schedule within 1 to 8 weeks), and (3) non-time sensitive (defer for >8 weeks and then reassess the timing). Three anonymous rounds of voting were allowed before attempts at consensus were abandoned. RESULTS All 14 invited experts agreed to participate in the study. The prespecified consensus threshold of 51% was achieved for assigning patient-important outcome(s) to each advanced endoscopy indication. The prespecified consensus threshold of 66.7% was achieved for 40 of 41 advanced endoscopy indications in stratifying them into 1 of 3 procedural time periods. For 12 of 41 indications, 100% consensus was achieved; for 20 of 41 indications, 75% to 99% consensus was achieved. CONCLUSIONS By using a Modified Delphi method that prioritized patient-important outcomes, we developed consensus recommendations on procedural timing for common indications for advanced endoscopy. These recommendations and the structured decision framework provided by our study can inform decision making as endoscopy services are reopened.
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31
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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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