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Ayoub F, Kim GE, Wang W, Chen D, Siddiqui UD. Delays in definitive endoscopic resection of previously manipulated colorectal polyps as a risk factor for inferior resection outcomes. Gastrointest Endosc 2024; 100:109-115. [PMID: 38215857 DOI: 10.1016/j.gie.2024.01.014] [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] [Received: 08/20/2023] [Revised: 12/03/2023] [Accepted: 01/09/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND AND AIMS Manipulation of colorectal polyps by biopsy, incomplete resection, or tattoo placement under the lesion has been shown to cause submucosal fibrosis and associated inferior outcomes. The effect of delays between index manipulation and definitive resection on the incidence of fibrosis is unknown. METHODS Patients undergoing EMR of previously manipulated colorectal polyps ≥10 mm from 2016 to 2021 at a tertiary referral center were included. Time from index manipulation to definitive resection and the presence of fibrosis were noted. The effects of fibrosis on EMR outcomes were assessed. RESULTS Among 221 previously manipulated lesions (180 biopsy, 23 incomplete/failed resection, 1 tattoo under lesion, 17 multiple types of manipulation), 51 (23%) demonstrated fibrosis. Fibrotic lesions were found to have been resected significantly later than nonfibrotic lesions (76 vs 61 days; P = .014). In a multivariate analysis controlling for other predictors of fibrosis, each 2-week delay was associated with a 14% increase in the odds of fibrosis. Fibrotic lesions had inferior outcomes with a lower en-bloc resection rate (8% vs 24%; P = .014) and longer procedure time (71 vs 52 minutes; P < .001). Adverse event and recurrence rates were similar between groups. CONCLUSIONS Delays in definitive resection of previously manipulated polyps are associated with an increased incidence of fibrosis with time and associated inferior outcomes. Manipulation should be discouraged, and if it occurs, prompt referral and scheduling for definitive resection should be prioritized.
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Affiliation(s)
- Fares Ayoub
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Grace E Kim
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois
| | - Wenfei Wang
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois; MNGI Digestive Health, Minneapolis, Minnesota
| | - Dennis Chen
- Center for Endoscopic Research and Therapeutics, University of Chicago Medicine, Chicago, Illinois, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago Medicine, Chicago, Illinois, USA
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Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, Paspatis GA, Moss A, Libânio D, Lorenzo-Zúñiga V, Voiosu AM, Rutter MD, Pellisé M, Moons LMG, Probst A, Awadie H, Amato A, Takeuchi Y, Repici A, Rahmi G, Koecklin HU, Albéniz E, Rockenbauer LM, Waldmann E, Messmann H, Triantafyllou K, Jover R, Gralnek IM, Dekker E, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024; 56:516-545. [PMID: 38670139 DOI: 10.1055/a-2304-3219] [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: 04/28/2024]
Abstract
1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
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Affiliation(s)
- Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Gastroenterology, Evangelical Hospital, Vienna, Austria
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Mauro Risio
- Department of Pathology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy
| | - Gregorios A Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Vincente Lorenzo-Zúñiga
- Endoscopy Unit, La Fe University and Polytechnic Hospital / IISLaFe, Valencia, Spain
- Department of Medicine, Catholic University of Valencia, Valencia, Spain
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthew D Rutter
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
- Department of Gastroenterology, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Leon M G Moons
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, Ospedale A. Manzoni, Lecco, Italy
| | - Yoji Takeuchi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Gabriel Rahmi
- Hepatogastroenterology and Endoscopy Department, Hôpital européen Georges Pompidou, Paris, France
- Laboratoire de Recherches Biochirurgicales, APHP-Centre Université de Paris, Paris, France
| | - Hugo U Koecklin
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Teknon Medical Center, Barcelona, Spain
| | - Eduardo Albéniz
- Gastroenterology Department, Hospital Universitario de Navarra (HUN); Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lisa-Maria Rockenbauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Helmut Messmann
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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Khalaf K, Seleq S, Bourke MJ, Alkandari A, Bapaye A, Bechara R, Calo NC, Fedorov ED, Hassan C, Kalauz M, Kandel GP, Matsuda T, May GR, Mönkemüller K, Mosko JD, Ohno A, Pavic T, Pellisé M, Raos Z, Repici A, Rex DK, Saxena P, Schauer C, Sethi A, Sharma P, Shaukat A, Siddiqui UD, Singh R, Smith LA, Tanabe M, Teshima CW, von Renteln D, Gimpaya N, Pawlak KM, Angeli Fujiyoshi MR, Fujiyoshi Y, Lamba M, Li S, Malipatil SB, Grover SC. Establishment of standards for the referral of large nonpedunculated colorectal polyps: an international expert consensus using a modified Delphi process. Gastrointest Endosc 2024:S0016-5107(24)00090-7. [PMID: 38331224 DOI: 10.1016/j.gie.2024.02.001] [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: 09/26/2023] [Revised: 01/10/2024] [Accepted: 02/02/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND AND AIMS Resection of colorectal polyps has been shown to decrease the incidence and mortality of colorectal cancer. Large nonpedunculated colorectal polyps are often referred to expert centers for endoscopic resection, which requires relevant information to be conveyed to the therapeutic endoscopist to allow for triage and planning of resection technique. The primary objective of this study was to establish minimum expected standards for the referral of large non-pedunculated colonic polyps for potential endoscopic resection. METHODS A Delphi method was used to establish consensus on minimum expected standards for the referral of large colorectal polyps among a panel of international endoscopy experts. The expert panel was recruited through purposive sampling, and 3 rounds of surveys were conducted to achieve consensus. Quantitative and qualitative data were analyzed for each round. RESULTS A total of 24 international experts from diverse continents participated in the Delphi study, resulting in consensus on 19 statements related to the referral of large colorectal polyps. The identified factors, including patient demographic characteristics, relevant medications, lesion factors, photodocumentation, and the presence of a tattoo, were deemed important for conveying the necessary information to therapeutic endoscopists. The mean scores for the statements, which were scored on a scale of 1 to 10, ranged from 7.04 to 9.29, with high percentages of experts considering most statements as a very high priority. Subgroup analysis according to continent revealed some variations in consensus rates among experts from different regions. CONCLUSIONS The identified consensus statements can aid in improving the triage and planning of resection techniques for large colorectal polyps, ultimately contributing to the reduction of colorectal cancer incidence and mortality.
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Affiliation(s)
- Kareem Khalaf
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Samir Seleq
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Michael J Bourke
- Westmead Hospital University of Sydney, Sydney, New South Wales, Australia
| | - Asma Alkandari
- Thanyan Alghanim Center for Gastroenterology and Hepatology, Alamiri Hospital, Kuwait City, Kuwait
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Robert Bechara
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Natalia C Calo
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Evgeniy D Fedorov
- Pirogov Russia National Research Medical University, Moscow, Russian Federation
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Mirjana Kalauz
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Gabor P Kandel
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Gary R May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Klaus Mönkemüller
- Department of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Akiko Ohno
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tajana Pavic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Maria Pellisé
- Gastroenterology Department, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Zoe Raos
- Department of Gastroenterology, Te Whatu Ora-Waitemata, Faculty of Medicine, The University of Auckland, Auckland, New Zealand
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Cameron Schauer
- Department of Gastroenterology, Te Whatu Ora-Waitemata, Faculty of Medicine, The University of Auckland, Auckland, New Zealand
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Irving Medical Center, Columbia University, New York, New York, USA
| | - Prateek Sharma
- University of Kansas School of Medicine, VA Medical Center, Kansas City, Kansas, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York City, New York, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), University of Chicago, Chicago, Illinois, USA
| | - Rajvinder Singh
- Lyell McEwin Hospital, NALHN & the University of Adelaide, Adelaide, South Australia, Australia
| | - Lesley-Ann Smith
- Department of Gastroenterology, Te Whatu Ora-Waitemata, Faculty of Medicine, The University of Auckland, Auckland, New Zealand
| | - Mayo Tanabe
- Showa University Koto Toyosu Hospital, Digestive Diseases Center, Tokyo, Japan
| | - Christopher W Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Daniel von Renteln
- Centre Hospitalier de l'Universite de Montreal (CHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Katarzyna M Pawlak
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Mary Raina Angeli Fujiyoshi
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Yusuke Fujiyoshi
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Mehul Lamba
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Suqing Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sharan B Malipatil
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Endoscopy Research Network (CanENDO), Canada; Scarborough Health Network, Toronto, Ontario, Canada.
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Kilincalp S, Mottacki N. Comments on: "Effect of pre-resection biopsy on detection of advanced dysplasia in large nonpedunculated colorectal polyps undergoing endoscopic mucosal resection". Endoscopy 2023; 55:975. [PMID: 37757798 DOI: 10.1055/a-2085-5532] [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] [Indexed: 09/29/2023]
Affiliation(s)
- Serta Kilincalp
- Department of Gastroenterology, University of Gothenburg, Gothenburg, Sweden
| | - Nima Mottacki
- Department of Gastroenterology, University of Gothenburg, Gothenburg, Sweden
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Ma MX, Bourke MJ. Reply to Kilincalp and Mottacki. Endoscopy 2023; 55:976. [PMID: 37757799 DOI: 10.1055/a-2085-5872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Department of Medicine, Midland St John of God Hospital, Perth, Western Australia, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
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6
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Tate DJ, Argenziano ME, Anderson J, Bhandari P, Boškoski I, Bugajski M, Desomer L, Heitman SJ, Kashida H, Kriazhov V, Lee RRT, Lyutakov I, Pimentel-Nunes P, Rivero-Sánchez L, Thomas-Gibson S, Thorlacius H, Bourke MJ, Tham TC, Bisschops R. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023. [PMID: 37285908 DOI: 10.1055/a-2077-0497] [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] [Indexed: 06/09/2023]
Abstract
Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
- Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
| | - John Anderson
- Cheltenham General Hospital, Gloucestershire Hospitals Foundation Trust, Cheltenham, UK
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marek Bugajski
- Department of Gastroenterology, Luxmed Oncology, Warsaw, Poland
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Vladimir Kriazhov
- Endoscopy Department, Nizhny Novgorod Regional Clinical Oncology Center, Nizhny Novgorod, Russia Federation
| | - Ralph R T Lee
- The Ottawa Hospital - Civic Campus, University of Ottawa, Ottawa, Canada
| | - Ivan Lyutakov
- University Hospital Tsaritsa Yoanna-ISUL, Medical University Sofia, Sofia, Bulgaria
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
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7
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Kolb JM. Optimizing referral practices for resection of large colorectal polyps. Endoscopy 2023; 55:274-275. [PMID: 36351440 DOI: 10.1055/a-1961-7035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer M Kolb
- Division of Gastroenterology, Hepatology and Parenteral Nutrition, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
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