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Santos CEOD, Malaman D, Sanmartin IDA, Leão ABHS, Bombassaro IZ, Pereira-Lima JC. COLD SNARE POLYPECTOMY: A SAFE PROCEDURE FOR REMOVING SMALL NON-PEDUNCULATED COLORECTAL LESIONS. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:470-477. [PMID: 38018552 DOI: 10.1590/s0004-2803.23042023-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/10/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Polypectomy is an important treatment option for preventing colorectal cancer. Incomplete polyp resection (IPR) is re-cognized as a risk factor for interval cancer. OBJECTIVE The primary objective was to evaluate the complete polyp resection (CPR) rate for cold snare polypectomy (CSP) in small non-pedunculated polyps and, secondarily, specimen retrieval and complication rates. METHODS We prospectively evaluated 479 polyps <10 mm removed by CSP in 276 patients by an inexperienced endoscopist. RESULTS A total of 476 polyps (99.4%) were resected en bloc. A negative margin (classified as CPR) was observed in 435 polyps (90.8%). An unclear or positive margin (classified as IPR) was observed in 43 cases (9.0%) and 1 case (0.2%), respectively, for an overall IPR rate of 9.2% (44/479). The IPR rate was 12.2% in the first half of cases and 5.9% in the second half (P=0.02). Dividing into tertiles, the IPR rate was 15.0% in the first tertile, 6.9% in the second tertile, and 5.7% in the third tertile (P=0.01). Dividing into quartiles, the IPR rate was 15.8% in the first quartile and 5.9% in the fourth quartile (P=0.03). The IPR rate was 6.3% for type 0-IIa lesions and 14.1% for type 0-Is lesions (P=0.01). For serrated and adenomatous lesions, the IPR rate was 9.2%. Specimen retrieval failed in 3.6% of cases. Immediate bleeding (>30 s) occurred in 1 case (0.2%), treated with argon plasma coagulation. No delayed bleeding or perforation occurred. CONCLUSION CSP is a safe technique that provides good results for the resection of small non-pedunculated polyps, with a short learning curve.
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Affiliation(s)
- Carlos Eduardo Oliveira Dos Santos
- Hospital Santa Casa de Caridade, Serviço de Endoscopia, Bagé, RS, Brasil
- Pontifícia Universidade Católica do Rio Grande do Sul, Departamento de Endoscopia, Porto Alegre, RS, Brasil
| | - Daniele Malaman
- Hospital Santa Casa de Caridade, Serviço de Endoscopia, Bagé, RS, Brasil
| | | | - Ari Ben-Hur Stefani Leão
- Pontifícia Universidade Católica do Rio Grande do Sul, Departamento de Endoscopia, Porto Alegre, RS, Brasil
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Anderson JC, Rex DK. Performing High-Quality, Safe, Cost-Effective, and Efficient Basic Colonoscopy in 2023: Advice From Two Experts. Am J Gastroenterol 2023; 118:1779-1786. [PMID: 37463252 DOI: 10.14309/ajg.0000000000002407] [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: 05/18/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023]
Abstract
Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, and cost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparation using a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferred method for all polyps < 10 mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations.
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Affiliation(s)
- 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
- Division of Gastroenterology, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Schiemer M, Schmidt A. [Current endoscopic resection techniques in the colorectum: possibilities, perspectives, limitations]. Dtsch Med Wochenschr 2023; 148:84-93. [PMID: 36690004 DOI: 10.1055/a-1832-4090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Since the first endoscopic polypectomies have been performed, the resection of premalignant lesions during colonoscopy has become a success story in the field of gastroenterology: Incidence and mortality of colorectal cancer have been significantly reduced with the implementation of screening programs. Most polyps in the lower gastrointestinal tract are small and easy to remove. However, larger polyps, early carcinomas and subepithelial lesions can be removed with modern endoscopic resection techniques as well. Minimally invasive endoscopic resections offer an organ-preserving alternative to surgery in a growing number of patients. In this review, we discuss the advantages and limitations of traditional and novel endoscopic resection techniques, including endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic full thickness resection.
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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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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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Muething L, Quach B, Smith DE, Gao D, Smith JA, Simril RT, Tompkins A, Espinoza J, Cowan ML, Hammad H, Wani S, Patel SG. Adoption of Optimal Small (6-9 mm) Colorectal Polyp Resection Technique Over Time. Dig Dis Sci 2023; 68:240-251. [PMID: 35624328 DOI: 10.1007/s10620-022-07554-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is the preferred resection technique for small (6-9 mm) polyps due to lower rate of incomplete resection compared to cold forceps polypectomy (CFP) and improved safety profile over hot snare polypectomy (HSP). AIMS To describe resection techniques for small (6-9 mm) polyps and determine factors associated with sub-optimal technique. METHODS This was retrospective cohort study of colonoscopies performed by gastroenterological and surgical endoscopists from 2012 to 2019 where at least one 6-9 mm polyp was removed. Patient, provider, and procedure characteristics were collected. Univariate and multivariate regression analyses were performed to determine factors associated with sub-optimal technique. RESULTS In total, 773 colonoscopies where 1,360 6-9 mm polyps removed by 21 endoscopists were included. CSP was used for 1,122 (82.5%), CFP for 61 (4.5%), and HSP for 177 (13.0%). Surgeon specialty was associated with CFP use (aOR 7.81; 95% CI 3.02-20.16). Polyp location in left colon (aOR 1.65; 95% CI 1.17-2.33) and pedunculated morphology (aOR 12.76; 95% CI 7.24-22.50) were associated with HSP. There was a significant increase in overall CSP use from 30.4% in 2012 to 96.8% in 2019. CONCLUSIONS 82.5% of all 6-9 mm polyps removed from 2012 to 2019 were removed using a cold snare with significant increase in CSP from 2012 to 2019. Differences in how optimal technique was adopted over time based on specialty highlight the need for standardized practice guidelines and quality monitoring.
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Affiliation(s)
- Larissa Muething
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Bill Quach
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Derek E Smith
- Department of Pediatrics, Cancer Center Biostatistics Core, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Dexiang Gao
- Department of Pediatrics, Cancer Center Biostatistics Core, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joshua A Smith
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert T Simril
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Amanda Tompkins
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeannine Espinoza
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Michelle L Cowan
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Hazem Hammad
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Sachin Wani
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Swati G Patel
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.
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Zhang XQ, Sang JZ, Xu L, Mao XL, Li B, Zhu WL, Yang XY, Yu CH. Endoscopic mucosal resection-precutting vs conventional endoscopic mucosal resection for sessile colorectal polyps sized 10-20 mm. World J Gastroenterol 2022; 28:6397-6409. [PMID: 36533110 PMCID: PMC9753056 DOI: 10.3748/wjg.v28.i45.6397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/14/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The optimal method to remove sessile colorectal lesions sized 10-20 mm remains uncertain. Piecemeal and incomplete resection are major limitations in current practice, such as endoscopic mucosal resection (EMR) and cold or hot snare polypectomy. Recently, EMR with circumferential precutting (EMR-P) has emerged as an effective technique, but the quality of current evidence in comparative studies of conventional EMR (CEMR) and EMR-P is limited.
AIM To investigate whether EMR-P is superior to CEMR in removing sessile colorectal polyps.
METHODS This multicenter randomized controlled trial involved seven medical institutions in China. Patients with colorectal polyps sized 10-20 mm were enrolled and randomly assigned to undergo EMR-P or CEMR. EMR-P was performed following submucosal injection, and a circumferential mucosa incision (precutting) was conducted using a snare tip. Primary outcomes included a comparison of the rates of en bloc and R0 resection, defined as one-piece resection and one-piece resection with histologically assessed clear margins, respectively.
RESULTS A total of 110 patients in the EMR-P group and 110 patients in the CEMR group were finally evaluated. In the per-protocol analysis, the proportion of en bloc resections was 94.3% [95% confidence interval (CI): 88.2%-97.4%] in the EMR-P group and 86% (95%CI: 78.2%-91.3%) in the CEMR group (P = 0.041), while subgroup analysis showed that for lesions > 15 mm, EMR-P also resulted in a higher en bloc resection rate (92.0% vs 58.8% P = 0.029). The proportion of R0 resections was 81.1% (95%CI: 72.6%-87.4%) in the EMR-P group and 76.6% (95%CI: 68.8%-84.4%) in the CEMR group (P = 0.521). The EMR-P group showed a longer median procedure time (6.4 vs 3.0 min; P < 0.001). No significant difference was found in the proportion of patients with adverse events (EMR-P: 9.1%; CEMR: 6.4%; P = 0.449).
CONCLUSION In this study, EMR-P served as an alternative to CEMR for removing nonpedunculated colorectal polyps sized 10-20 mm, particularly polyps > 15 mm in diameter, with higher R0 and en bloc resection rates and without increasing adverse events. However, EMR-P required a relatively longer procedure time than CEMR. Considering its potential benefits for en bloc and R0 resection, EMR-P may be a promising technique in colorectal polyp resection.
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Affiliation(s)
- Xue-Qun Zhang
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jian-Zhong Sang
- Department of Gastroenterology, Renmin Hospital of Yuyao City, Yuyao 315499, Zhejiang Province, China
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo 315010, Zhejiang Province, China
| | - Xin-Li Mao
- Department of Gastroenterology, Taizhou Hospital, Taizhou 317099, Zhejiang Province, China
| | - Bo Li
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Wan-Lin Zhu
- Department of Gastroenterology, The Central Hospital of Lishui City, Lishui 323020, Zhejiang Province, China
| | - Xiao-Yun Yang
- Department of Gastroenterology, Jinhua Municipal Central Hospital, Jinhua 321099, Zhejiang Province, China
| | - Chao-Hui Yu
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Choosing the Best Resection Tool for Polyps ≤3 mm: Is Forceps an Acceptable Alternative to Cold Snare? Am J Gastroenterol 2022; 117:1244-1245. [PMID: 35926492 DOI: 10.14309/ajg.0000000000001854] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
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9
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Randomized Controlled Trial Investigating Cold Snare and Forceps Polypectomy Among Small POLYPs in Rates of Complete Resection: The TINYPOLYP Trial. Am J Gastroenterol 2022; 117:1305-1310. [PMID: 35467557 DOI: 10.14309/ajg.0000000000001799] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Optimizing complete resection during colonoscopy is important because residual neoplastic tissue may play a role in interval cancers. The US Multi-Society Task Force recommends diminutive (≤5 mm) and small (6-9 mm) polyps be removed by cold snare polypectomy (CSP). However, evidence is less clear whether CSP retains significant advantage over cold forceps polypectomy (CFP) for polyps ≤3 mm. METHODS This study is a single-center prospective noninferiority randomized clinical trial evaluating CFP and CSP for nonpedunculated polyps ≤3 mm. Patients 18 years and older undergoing colonoscopy for any indication were recruited. During each colonoscopy, polyps underwent block randomization to removal with CFP or CSP. After polypectomy, 2 biopsies were taken from the polypectomy margin. The primary noninferiority outcome was the complete resection rate, defined by absence of residual polyp in the margin biopsies. RESULTS A total of 179 patients were included. Patients had similar distribution in age, sex, race/ethnicity, as well as indication of procedure. A total of 279 polyps ≤3 mm were identified, with 138 in the CSP group and 141 in the CFP group. Mean polypectomy time was longer for CSP compared with CFP (42.3 vs 23.2 seconds, P < 0.001), although a higher proportion of polyps removed by CFP were removed in more than 1 piece compared with CSP (15.6 vs 3.6%, P < 0.001). There were positive margin biopsies in 2 cases per cohort, with a complete resection rate of 98.3% in both groups. There was no significant difference in cohorts in complete resection rates (difference in complete resection rates was 0.057%, 95% confidence interval: -4.30% to 4.53%), demonstrating noninferiority of CFP compared with CSP. DISCUSSION Use of CFP was noninferior to CSP in the complete resection of nonpedunculated polyps ≤3 mm. CSP required significantly more time to perform compared with CFP. CFP should be considered an acceptable alternative to CSP for removal of polyps ≤3 mm.
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Fudman DI, Singal AG, Cooper MG, Lee M, Murphy CC. Prevalence of Forceps Polypectomy of Nondiminutive Polyps Is Substantial But Modifiable. Clin Gastroenterol Hepatol 2022; 20:1508-1515. [PMID: 34839039 PMCID: PMC9133266 DOI: 10.1016/j.cgh.2021.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The use of forceps for removal of nondiminutive polyps is associated with incomplete resection compared with snare polypectomy. However, few studies have characterized the frequency of forceps polypectomy for nondiminutive polyps or identified strategies to improve this practice. To address this gap, we estimated the prevalence and predictors of forceps polypectomy in clinical practice and examined the effectiveness of a multicomponent intervention to reduce inappropriate forceps polypectomy. METHODS We retrospectively reviewed all colonoscopies with polypectomies performed at 2 U.S. health systems between October 1, 2017, and September 30, 2019. We used a mixed-effects logistic regression model to examine the effect of a multicomponent intervention, including provider education and a financial incentive, to reduce inappropriate forceps polypectomy, defined as use of forceps polypectomy for polyps ≥5 mm. RESULTS A total of 9968 colonoscopies with 25,534 polypectomies were performed by 42 gastroenterologists during the study period. Overall, 8.5% (n = 2176) of polyps were removed with inappropriate forceps polypectomy. Inappropriate forceps polypectomy significantly decreased after the intervention (odds ratio [OR], 0.34, 95% confidence interval [CI], 0.30-0.39), from 11.4% (n = 1539) to 5.3% (n = 637). Predictors of inappropriate forceps polypectomy included inadequate bowel prep (OR, 1.25; 95% CI, 1.06-1.47), polyps in the right colon (vs left: OR, 1.29; 95% CI, 1.09-1.51), and number of polyps removed (OR, 0.96; 95% CI, 0.94-0.97). Inappropriate forceps polypectomy also varied by gastroenterologist (median OR, 3.43). In a post hoc analysis, the proportion of polyps >2 mm removed with forceps decreased from 50.0% before the intervention to 43.0% after it (OR, 0.62; 95% CI, 0.58-0.68). CONCLUSIONS Inappropriate forceps polypectomy is common but modifiable. The proportion of nondiminutive polyps removed with forceps polypectomy should be considered as a quality measure.
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Affiliation(s)
- David I. Fudman
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center,Department of Population and Data Sciences, University of Texas Southwestern Medical Center
| | - Mark G. Cooper
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center
| | - MinJae Lee
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center
| | - Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth)
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11
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Fatima H, Rex DK, Imperiale T. A Pilot Randomized Trial of Polypectomy Techniques for 4 to 6 mm Colonic Polyps. J Clin Gastroenterol 2022; 56:426-432. [PMID: 34115660 DOI: 10.1097/mcg.0000000000001571] [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: 02/16/2021] [Accepted: 04/22/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND GOALS There is variation in polypectomy techniques for resection of small polyps. Aim was to compare techniques for 4 to 6 mm polyps for recurrent adenoma, efficiency, and adverse events and to establish methodological factors for definitive trial. MATERIALS AND METHODS The study was a randomized controlled trial. Outpatients with ≥1, 4 to 6 mm polyps were randomized to cold forceps (CF), cold snare (CS), and hot snare (HS). Polypectomy site was marked with SPOT to assess for recurrence at the original polypectomy site during surveillance colonoscopy. To assess feasibility of a definitive trial we measured (1) rates of patient refusal, participation, ineligibility; (2) retention; (3) recurrent neoplasia; and (4) sample size for a definitive trial. RESULTS Three hundred fifty-three patients were randomized to 1 of the 3 polypectomy techniques, of whom 260 (73.6%) completed the initial colonoscopy (mean age 57 y, 50.4% women), with 91, 87, and 82 patients randomized to CF, CS, and HS polypectomy, respectively. Mean time for polyp resection for CF, CS, and HS were 198.8, 58.5, and 96.8 seconds, respectively, with CS and HS requiring less time than CF (P<0.001). One hundred sixty-four (63.1%) completed surveillance colonoscopy. Polyp recurrences were 9 (14.5%) with CF, 5 (9.6%) with CS, and 0 (0%) with HS. Although the recurrence relative risks with CF and CS polypectomy were 1.84 and 1.65 as compared with HS, respectively, neither was statistically significant. CONCLUSIONS CS and HS polypectomy require less time than CF. HS polypectomy may have a lower risk for recurrent neoplasia. High attrition rate is a challenge in conducting randomized controlled trial with polyp recurrence as endpoint.
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Affiliation(s)
- Hala Fatima
- Department of Internal Medicine/Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN
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Becker L, Janssen N, Layland SL, Mürdter TE, Nies AT, Schenke-Layland K, Marzi J. Raman Imaging and Fluorescence Lifetime Imaging Microscopy for Diagnosis of Cancer State and Metabolic Monitoring. Cancers (Basel) 2021; 13:cancers13225682. [PMID: 34830837 PMCID: PMC8616063 DOI: 10.3390/cancers13225682] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 02/08/2023] Open
Abstract
Hurdles for effective tumor therapy are delayed detection and limited effectiveness of systemic drug therapies by patient-specific multidrug resistance. Non-invasive bioimaging tools such as fluorescence lifetime imaging microscopy (FLIM) and Raman-microspectroscopy have evolved over the last decade, providing the potential to be translated into clinics for early-stage disease detection, in vitro drug screening, and drug efficacy studies in personalized medicine. Accessing tissue- and cell-specific spectral signatures, Raman microspectroscopy has emerged as a diagnostic tool to identify precancerous lesions, cancer stages, or cell malignancy. In vivo Raman measurements have been enabled by recent technological advances in Raman endoscopy and signal-enhancing setups such as coherent anti-stokes Raman spectroscopy or surface-enhanced Raman spectroscopy. FLIM enables in situ investigations of metabolic processes such as glycolysis, oxidative stress, or mitochondrial activity by using the autofluorescence of co-enzymes NADH and FAD, which are associated with intrinsic proteins as a direct measure of tumor metabolism, cell death stages and drug efficacy. The combination of non-invasive and molecular-sensitive in situ techniques and advanced 3D tumor models such as patient-derived organoids or microtumors allows the recapitulation of tumor physiology and metabolism in vitro and facilitates the screening for patient-individualized drug treatment options.
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Affiliation(s)
- Lucas Becker
- Department for Medical Technologies and Regenerative Medicine, Institute of Biomedical Engineering, University of Tübingen, 72076 Tübingen, Germany
- Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tübingen, 72076 Tübingen, Germany
| | - Nicole Janssen
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, University of Tübingen, 72076 Tübingen, Germany
| | - Shannon L Layland
- Department for Medical Technologies and Regenerative Medicine, Institute of Biomedical Engineering, University of Tübingen, 72076 Tübingen, Germany
| | - Thomas E Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, University of Tübingen, 72076 Tübingen, Germany
| | - Anne T Nies
- Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tübingen, 72076 Tübingen, Germany
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, University of Tübingen, 72076 Tübingen, Germany
| | - Katja Schenke-Layland
- Department for Medical Technologies and Regenerative Medicine, Institute of Biomedical Engineering, University of Tübingen, 72076 Tübingen, Germany
- Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tübingen, 72076 Tübingen, Germany
- NMI Natural and Medical Sciences Institute at the University of Tübingen, 72770 Reutlingen, Germany
- Cardiovascular Research Laboratories, Department of Medicine/Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA 90073, USA
| | - Julia Marzi
- Department for Medical Technologies and Regenerative Medicine, Institute of Biomedical Engineering, University of Tübingen, 72076 Tübingen, Germany
- Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tübingen, 72076 Tübingen, Germany
- NMI Natural and Medical Sciences Institute at the University of Tübingen, 72770 Reutlingen, Germany
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13
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Toward safer and more efficacious colonoscopy polypectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Yamasaki Y, Harada K, Yamamoto S, Yasutomi E, Hirai M, Ohmori M, Oka S, Inokuchi T, Kinugasa H, Sugihara Y, Takahara M, Hiraoka S, Tanaka T, Mitsuhashi T, Okada H. Evaluation of complete cold forceps polypectomy resection rate for 3- to 5-mm colorectal polyps. Dig Endosc 2021; 33:948-954. [PMID: 33211353 DOI: 10.1111/den.13895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIMS The propriety of cold forceps polypectomy (CFP) using jumbo biopsy forceps for diminutive polyps remains controversial. We conducted a prospective study to evaluate the complete CFP resection rate of 3-5-mm polyps using additional endoscopic mucosal resection (EMR) specimens following CFP. PATIENTS AND METHODS Patients with 3-5-mm protruded or flat elevated colorectal polyps diagnosed endoscopically as adenomas or serrated lesions were prospectively enrolled. CFP using jumbo biopsy forceps was used to remove the eligible polyps and repeated until the absence of residuals were confirmed via image-enhanced endoscopy or chromoendoscopy. After CFP, saline was injected at the defect, and the marginal specimen of the defect was resected using EMR to histologically evaluate the residue. The primary outcome was the complete CFP resection rate, which was defined as no residue at the EMR site. Other outcomes were the number of CFP bites and the complete resection rate by lesion size. RESULTS Eighty patients with 120 polyps were enrolled. The mean polyp size was 4.1 ± 0.7 mm. The overall complete resection rate was 96.7% (95% confidence interval [CI], 91.7-98.7), and the rates for 3-, 4- and 5-mm polyps were 100% (95% CI, 86.7-100), 96.0% (95% CI, 86.5-98.9) and 95.5% (95% CI, 85.1-98.8), respectively. The one-bite CFP rates were 92%, 60% and 31% for the 3-, 4- and 5-mm polyps, respectively. CONCLUSIONS The complete CFP resection rate for 3-5-mm polyps was acceptable, although the one-bite clearance rate decreased as the polyp size increased (UMIN000028841).
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Affiliation(s)
- Yasushi Yamasaki
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Keita Harada
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Shumpei Yamamoto
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Eriko Yasutomi
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Mami Hirai
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Masayasu Ohmori
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Shohei Oka
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Toshihiro Inokuchi
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Hideaki Kinugasa
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Yuusaku Sugihara
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Masahiro Takahara
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Sakiko Hiraoka
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiharu Mitsuhashi
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
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Keswani RN, Crockett SD, Calderwood AH. AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review. Gastroenterology 2021; 161:701-711. [PMID: 34334168 DOI: 10.1053/j.gastro.2021.05.041] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 12/23/2022]
Abstract
The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.
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Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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16
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Yang DH, Luvsandagva B, Tran QT, Fauzi A, Piyachaturawat P, Soe T, Wong Z, Byeon JS. Colonoscopic Polypectomy Preferences of Asian Endoscopists: Results of a Survey-Based Study. Gut Liver 2021; 15:391-400. [PMID: 32839364 PMCID: PMC8129667 DOI: 10.5009/gnl20140] [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: 05/02/2020] [Revised: 06/14/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022] Open
Abstract
Background/Aims The clinical practice pattern of polypectomy is not well-investigated in Asian countries. We aimed to survey Asian endoscopists about their preferred polypectomy techniques for given conditions and images of polyps. Methods A survey was performed using questionnaires composed of two parts a scenario-based questionnaire using scenarios of polyps, which were adopted from the European Society of Gastrointestinal Endoscopy guidelines, and an image-based questionnaire using provided endoscopic images of polyps. Results A total of 154 endoscopists participated in this survey. The most preferred resection techniques for diminutive (≤5 mm), small (6–9 mm), and benign-looking intermediate (10–19 mm) nonpedunculated polyps were cold forceps polypectomy, hot snare polypectomy, and endoscopic mucosal resection (EMR), respectively, in both the scenario- and image-based questionnaires. For benign-looking large (≥20 mm) nonpedunculated polyps, EMR and endoscopic submucosal dissection (ESD) were preferred in the scenario- and image-based surveys, respectively. In case of malignant nonpedunculated polyps, EMR and ESD were preferred for intermediate-sized and large lesions, respectively, according to the scenario-based survey. However, ESD was preferred in both intermediate-sized and large malignant nonpedunculated polyps according to the image-based survey. Trainee endoscopists, endoscopists working in referral centers, and endoscopists in the colorectal cancer–prevalent countries were independently associated with preference of cold snare polypectomy for removing small polyps. Conclusions The polypectomy practice patterns of Asian endoscopists vary, and cold snare polypectomy was not the most preferred resection method for polyps <10 mm in size, in contrast to recent guidelines. (Gut Liver 2021;15-400)
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Affiliation(s)
- Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bayasgalan Luvsandagva
- Department of Endoscopy, Ulaanbaatar Songdo Hospital, Ulaanbaatar, Mongolia.,Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quang Trung Tran
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue, Vietnam.,Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Achmad Fauzi
- Division of Gastroenterology, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Panida Piyachaturawat
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thida Soe
- Department of Gastroenterology, University of Medicine 1 Yangon, Yangon, Myanmar
| | - Zhiqin Wong
- Gastroentorology Unit, Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chandrasekhara V, Kumta NA, Abu Dayyeh BK, Bhutani MS, Jirapinyo P, Krishnan K, Maple JT, Melson J, Pannala R, Parsi MA, Sethi A, Trikudanathan G, Trindade AJ, Lichtenstein DR. Endoscopic polypectomy devices. VideoGIE 2021; 6:283-293. [PMID: 34278088 PMCID: PMC8267590 DOI: 10.1016/j.vgie.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.
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Affiliation(s)
- Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Amrita Sethi
- Department of Digestive and Liver Diseases, Columbia University Medical Center/New York-Presbyterian, New York, New York
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Stier MW, Chapman CG, Shamah S, Donboli K, Yassan L, Waxman I, Siddiqui UD. Endoscopic resection is more effective than biopsy or EUS to detect residual rectal neuroendocrine tumor. Endosc Int Open 2021; 9:E4-E8. [PMID: 33403229 PMCID: PMC7775810 DOI: 10.1055/a-1300-1017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Rectal neuroendocrine tumors (NETs) are often discovered incidentally and may be misidentified as adenomatous polyps. This can result in a partial resection at the index procedure, and lesions are often referred for staging or evaluation for residual disease at the resection site. The aim of this study was to identify the ideal method to confirm complete excision of small rectal NETs. Patients and methods Data from patients with a previously resected rectal NET referred for follow-up endoscopy or endoscopic ultrasound (EUS) were retrospectively reviewed. Univariate analysis was performed on categorical data using the Chi-squared test. Results Forty-nine patients with rectal NETs were identified by pathology specimens. Of those, 39 underwent follow-up endoscopy or EUS and were included. Baseline characteristics included gender (71 % F, 29 % M), age (57.2 ± 13.4 yrs) lesion size (7.3 ± 4.2 mm) and location. The prior resection site was identified in 37/39 patients who underwent tissue sampling. Residual NET was found histologically in 14/37 lesions. All residual disease was found during salvage endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) and 43 % had a normal-appearing scar. Every patient undergoing EUS had an unremarkable exam. Initial cold biopsy polypectomy ( P = 0.006), visible lesions ( P = 0.001) and EMR/ESD of the prior resection site ( P = 0.01) correlated with residual NET. Conclusions Localized rectal NETs may be incompletely removed with standard polypectomy. If an advanced resection is not performed initially, repeat endoscopy with salvage EMR or ESD of the scar should be considered. For small rectal NETs, biopsy may miss residual disease when there is no visible lesion and EUS appears to have no benefit.
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Affiliation(s)
- Matthew W. Stier
- University of Chicago Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Christopher G. Chapman
- University of Chicago Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Steven Shamah
- University of Chicago Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Kianoush Donboli
- University of Chicago Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Lindsay Yassan
- Department of Pathology, the University of Chicago Medicine, Chicago, Illinois, United States
| | - Irving Waxman
- University of Chicago Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Uzma D. Siddiqui
- University of Chicago Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
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Rutter MD, Jover R. Personalizing Polypectomy Techniques Based on Polyp Characteristics. Clin Gastroenterol Hepatol 2020; 18:2859-2867. [PMID: 31563558 DOI: 10.1016/j.cgh.2019.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/20/2019] [Indexed: 12/18/2022]
Abstract
Polypectomy is an essential skill for all endoscopists performing lower gastrointestinal endoscopy. Different polypectomy tools and techniques have evolved and it is important that endoscopists are familiar with these so they can select the most appropriate technique for each polyp. This narrative review updates the different concepts in tailoring polypectomy technique to the characteristics of polyps. Effective polypectomy requires different components, including the following: careful evaluation of the polyp; decision making about optimal polyp management; actual polypectomy, which includes careful positioning of the endoscope and polyp; and postpolypectomy evaluation of the results (for completeness of resection and prophylaxis of complications).
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Affiliation(s)
- Matthew D Rutter
- University Hospital of North Tees, Stockton on Tees, United Kingdom; Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Rodrigo Jover
- Servicio de Medina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain.
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20
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Caliţa M, Florescu DN, Streba CT, Stănculescu AD, Florescu MM, Popa P, Gheonea DI, Oancea CN, Săftoiu A. The quality of colorectal polypectomy. Is it enough to have just a visual assessment of the site? ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2020; 61:1301-1307. [PMID: 34171078 PMCID: PMC8343597 DOI: 10.47162/rjme.61.4.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Performing a colonoscopy allows the examination of the entire colon and the assessment of polyps. PATIENTS, MATERIALS AND METHODS We performed a retrospective analysis of prospectively collected data from January 2018 until February 2020 (two years), in which we enrolled a number of 210 patients performing colonoscopy in the Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Romania. We performed 326 polypectomies. RESULTS We classified the polyps into diminutive (n=169), small (n=103) and large polyps (n=54). Regarding the polypectomy technique, our results indicated that 40 out of 48 (83.3%) polypectomies with the biopsy forceps were complete, as well as 27 out of 31 (87.1%) cold snare polypectomies and 12 out of 14 (85.7%) hot snare polypectomies. The differences were not statistically significant (p=0.116). Regarding the number of incomplete polypectomies, our data suggests that the high expertise endoscopist had two incomplete resections (5.1% of total), the medium expertise endoscopist 1 had also two incomplete resections (11.1% of total), the medium expertise endoscopist 2 had three incomplete resections (15% of total), the limited expertise endoscopist 1 had three incomplete resections (27.27% of total) and the limited expertise endoscopist 2 had four incomplete resections (30.76% of total). Analyzing the data, the differences were statistically significant (p=0.006). CONCLUSIONS Our study is able to suggest that high-definition white-light endoscopy (HD-WLE) macroscopic visualization of the polyp resection site is not enough to assess complete polyp resection and follow-up colonoscopy should be performed for cases with incomplete margins of resection.
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Affiliation(s)
- Mihaela Caliţa
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Romania;
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Zhang Z, Xia Y, Cui H, Yuan X, Wang C, Xie J, Tong Y, Wang W, Xu L. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial : (UEMR vs. CEMR for small size non-pedunculated colorectal polyps). BMC Gastroenterol 2020; 20:311. [PMID: 32967616 PMCID: PMC7510164 DOI: 10.1186/s12876-020-01457-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a recently developed technique and can be performed during water-aided or ordinary colonoscopy for the treatment of colorectal polyps. The objective of this clinical trial was to evaluate the efficacy and safety of UEMR in comparison with conventional endoscopic mucosal resection (CEMR) of small non-pedunculated colorectal polyps. METHODS Patients with small size, non-pedunculated colorectal polyps (4-9 mm in size) who underwent colonoscopic polypectomy were enrolled in this multicenter randomized controlled clinical trial. The patients were randomly allocated to two groups, an UEMR group and a CEMR group. Efficacy and safety were compared between groups. RESULTS In the intention-to-treat (ITT) analysis, the complete resection rate was 83.1% (59/71) in the UEMR group and 87.3% (62/71) in the CEMR group. The en-bloc resection rate was 94.4% (67/71) in the UEMR group and 91.5% (65/71) in the CEMR group (difference 2.9%; 90% CI - 4.2 to 9.9%), showed noninferiority (noninferiority margin - 5.7% < - 4.2%). No significant difference in procedure time (81 s vs. 72 s, P = 0.183) was observed. Early bleeding was observed in 1.4% of patients in the CEMR group (1/71) and 1.4% of patients in the UEMR group (1/71). None of the patients in the UEMR group complained of postprocedural bloody stool, whereas two patients in the CEMR group (2/64) reported this adverse event. CONCLUSION Our results indicate that UEMR is safer and just as effective as CEMR in En-bloc resection for the treatment of small colorectal polyps as such, UEMR is recommended as an alternative approach to excising small and non-pedunculated colorectal adenomatous polyps. TRIAL REGISTRATION Clinical Trials.gov, NCT03833492 . Retrospectively registered on February 7, 2019.
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Affiliation(s)
- Zhixin Zhang
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Yonghong Xia
- Department of Gastroenterology, Ninghai Second Hospital, Ningbo, 315600, China
| | - Hongyao Cui
- Department of Gastroenterology, Haishu Second Hospital, Ningbo, 315000, China
| | - Xin Yuan
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Chunnian Wang
- Ningbo Clinical and Pathological Diagnosis Center, Ningbo, 315021, China
| | - Jiarong Xie
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Yarong Tong
- Department of Gastroenterology, Ninghai Second Hospital, Ningbo, 315600, China
| | - Weihong Wang
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China.
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China.
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Willems P, Orkut S, Ditisheim S, Pohl H, Barkun A, Djinbachian R, Bouin M, von Renteln D. An international polypectomy practice survey. Scand J Gastroenterol 2020; 55:497-502. [PMID: 32267187 DOI: 10.1080/00365521.2020.1749297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and study aims: In recent years, cold snare polypectomy (CSP) has been recommended as the preferred approach for removal of small and diminutive colorectal polyps. We conducted an international survey among endoscopists to understand the uptake of CSP and changes in polypectomy practice during recent years.Patients and methods: Endoscopists were invited through gastroenterology, colorectal surgery and endoscopy societies to participate in an online survey. The primary outcome was to identify the predominant polypectomy approach used to remove 4‒10 mm colorectal polyps. Secondary outcomes included the uptake of CSP in the past 5 years, current polypectomy practice patterns for 1‒20 mm polyps, practice changes in recent years, and perceived benefits/concerns related to different polypectomy techniques.Results: The survey was distributed internationally by nine societies and completed by 808 endoscopists (response rate 3.7%). CSP was the predominant polypectomy technique for 4‒5 mm polyps (67.0%, 95% CI, 63.7-70.2%) and 6‒10 mm polyps (55.2%, 95% CI, 51.8-58.6%). For 1‒3 mm polyps, cold forceps remained the predominant technique (78.4%, 95% CI, 75.6-81.3%), whereas hot snare polypectomy (HSP) remained the predominant technique for 10‒20 mm polyps (92.5%, 95% CI, 90.7-94.3%). 87.5% (95% CI, 85.2-89.8%) of endoscopists reported an increase in CSP use during the past 5 years.Conclusions: This survey found a substantial increase in CSP use during recent years. CSP has become the predominant polypectomy approach for 4‒10 mm colorectal polyps, while HSP remained the predominant approach for larger (10‒20 mm) polyps. Clinical practice patterns are well aligned with recently issued guideline recommendations.
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Affiliation(s)
- Philippe Willems
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sinan Orkut
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Saskia Ditisheim
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Hartford, VT, USA.,Dartmouth, Geisel School of Medicine, Hanover, NH, USA
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Mickael Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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Kadle N, Westerveld DR, Banerjee D, Jacobs C, Gesiotto F, Moon N, Forde JJ, Conti M, Hatamleh D, Taylor R, Brar T, Riverso M, Jawaid S, Perbtani YB, Zhang Y, Draganov PV, Beyth R, Yang D. Discrepancy between self-reported and actual colonoscopy polypectomy practices for the removal of small polyps. Gastrointest Endosc 2020; 91:655-662.e2. [PMID: 31669181 DOI: 10.1016/j.gie.2019.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Cold snare polypectomy (CSP) is associated with higher rates of complete resection compared with cold biopsy forceps (CBF) for the removal of small polyps (4-9 mm). This study aimed to evaluate self-reported polypectomy preferences and actual practice patterns among endoscopists at an academic center and to identify factors associated with the use of CSP for small polyps. METHODS In phase A, endoscopists completed a survey evaluating preferences for polypectomy techniques. In phase B, we performed a retrospective analysis of all consecutive colonoscopies with polypectomy (January 2016 to September 2018). Uni- and multivariate analysis were performed to identify factors associated with CSP for small polyps. RESULTS Nineteen of 26 (73%) endoscopists completed the survey (phase A); 3 (15.8%) were interventional endoscopists. Most respondents indicated that they use CSP (89.5%) for small polyps and identified no reasons for choosing CBF over CSP (73.7%). In phase B, we identified 1118 colonoscopies with 2625 polypectomies for polyps ≤9 mm. Most diminutive polyps (≤3 mm) were removed with CBF (819 of 912; 90%). CBF (46.2%) was also preferentially used for removal of small polyps (n = 1713), followed by hot snare polypectomy (27.2%), and CSP (26.6%). On multivariate analysis, interventional endoscopists were associated with a higher likelihood of using CSP for small polyps (odds ratio, 1.38; 95% confidence interval, 1.07-1.79; P = .01). CONCLUSIONS Significant discrepancy exists between self-reported preferences and actual polypectomy practices. CBF is still preferentially used over CSP for the removal of polyps sized 4-9 mm; further strategies are needed to monitor and implement adequate polypectomy techniques.
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Affiliation(s)
- Nikhil Kadle
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Donevan R Westerveld
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Debdeep Banerjee
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Chelsea Jacobs
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Francesca Gesiotto
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Nabeel Moon
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Justin J Forde
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Mathew Conti
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Diana Hatamleh
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Robert Taylor
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Tony Brar
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Michael Riverso
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Salmaan Jawaid
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Yang Zhang
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Rebecca Beyth
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:486-519. [PMID: 32067745 DOI: 10.1016/j.gie.2020.01.029] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:435-464. [PMID: 32058340 DOI: 10.14309/ajg.0000000000000555] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1095-1129. [PMID: 32122632 DOI: 10.1053/j.gastro.2019.12.018] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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O’Morain NR, Syafiq MI, Shahin A, Ryan B, Crowther S, McNamara D. Dye-based chromoendoscopy following polypectomy reduces incomplete polyp resection. Endosc Int Open 2020; 8:E13-E19. [PMID: 31921979 PMCID: PMC6949170 DOI: 10.1055/a-1024-3759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 07/29/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims The completeness of a polyp resection is an important determinant of quality in colonoscopy, and may reduce incidence of interval cancers. Incomplete resection rates (IRR) vary widely and range from 6.5 % to 22.7 %. Residual disease is more likely with larger polyps, for sessile serrated adenomas, and with more proximal lesions. Chromoendoscopy is increasingly employed in lesion detection. The aims of this study were to assess local IRR, and to determine whether chromoendoscopy could correctly identify residual disease post polypectomy. Patients and methods This was a prospective study examining post polypectomy sites. Chromoendoscopy (0.13 % indigo carmine) was applied to resection bases to identify residual disease. Targeted base biopsies were taken from identified residual disease (positive group) or random base biopsies were taken when a clear base was visualised (negative group). Overall rates of incomplete resection were documented. Reported rates post chromoendoscopy and actual histological rates were documented and compared. Results A total of 102 polyps were identified for inclusion, of which 15 % (n = 16) were excluded. Resection quality was evaluated in 86 polyps of 61 patients (female n = 33 54 %; mean Age 62.3 years). Polyps were mainly removed by cold snare (n = 71, 82.5 %). Most polyps (n = 58, 67 %) measured between 5 to 10 mm. Polyps were largely located in the right colon (n = 57, 66 %). Overall histological residual disease occurred in 17 /86 (19.6 %). Chromoendoscopy correctly identified residual disease in 13 of 17 bases (76.5 %). Only four of /86 (4.6 %) of polyp bases were missclassified post-chromoendoscopy (odds ratio 0.284 (95 % CI 0.0857-0.9409), P = 0.03). Conclusion Indigo carmine chromoendoscopy improves early detection of residual disease post polypectomy, reducing incomplete resection rates.
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Affiliation(s)
- Neil R. O’Morain
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
| | - Mohd I. Syafiq
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
| | - Ammar Shahin
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin
| | - Barbara Ryan
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
| | - Stephen Crowther
- Department of Histopathology, Tallaght University Hospital, Trinity College Dublin, Ireland
| | - Deirdre McNamara
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
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Duloy AM, Keswani RN. Assessing the Quality of Polypectomy and Teaching Polypectomy. Gastrointest Endosc Clin N Am 2019; 29:587-601. [PMID: 31445684 DOI: 10.1016/j.giec.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ineffective polypectomy technique may lead to incomplete polyp resection, high complication rates, interval colorectal cancer, and costly referral to surgery. Despite its central importance to endoscopy, training in polypectomy is not standardized nor has the most effective training approach been defined. Polypectomy competence is rarely reported and quality metrics for this skill are lacking. Use of tools and measurements to assess polypectomy outcomes is low. There is a need for standardization of training and remediation in polypectomy; defining standards of competent polypectomy and how it is feasibly measured; and integration of polypectomy quality metrics into training programs and the accreditation process.
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Affiliation(s)
- Anna M Duloy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635, Aurora CT, Aurora, CO 80045, USA
| | - Rajesh N Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North Street Clair, Suite 1400, Chicago, IL 60611, USA.
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Lee Krinsky M. The art of diminutive polypectomy and the tools we use: Is there a best practice? Gastrointest Endosc 2019; 90:112-115. [PMID: 31228974 DOI: 10.1016/j.gie.2019.03.009] [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: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Mary Lee Krinsky
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California, USA
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Huh CW, Kim JS, Choi HH, Maeng IS, Jun SY, Kim BW. Jumbo biopsy forceps versus cold snares for removing diminutive colorectal polyps: a prospective randomized controlled trial. Gastrointest Endosc 2019; 90:105-111. [PMID: 30684600 DOI: 10.1016/j.gie.2019.01.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Cold snare polypectomy (CSP) and jumbo forceps polypectomy (JFP) have been shown to be effective for removing diminutive colorectal polyps (DCPs) (≤5 mm). However, no study has compared complete resection rates between CSP and JFP for DCPs. The aim of this study was to compare the efficacy and safety of JFP with CSP for the removal of DCPs. METHODS This was a prospective randomized controlled trial from 2 tertiary-care referral centers. A total of 1003 patients were screened, and 169 patients with 196 DCPs were enrolled. The main outcome was complete polyp resection rate. RESULTS Of 196 diminutive polyps, 177 (90.3%) were adenomatous polyps. The overall complete resection rate was 92.1% (163/177). The complete resection rate was not significantly different between JFP and CSP groups (92.0% vs 92.2%; P = .947). JFP achieved complete resection rates comparable with CSP for polyps >3 mm (90.3% vs 89.8%; P = .928). Polypectomy procedure time, tissue retrieval rate, and rate of postpolypectomy adverse events were not significantly different between the 2 groups. CONCLUSIONS Both JFP and CSP achieved complete resection rates of >90% for DCPs. Thus, JFP may be considered for polypectomy of DCPs. (International clinical trial registry number: KCT0002805.).
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Affiliation(s)
- Cheal Wung Huh
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - I So Maeng
- Department of Pathology, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun-Young Jun
- Department of Pathology, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Desai S, Gupta S, Copur-Dahi N, Krinsky ML. A prospective randomized study comparing jumbo biopsy forceps to cold snare for the resection of diminutive colorectal polyps. Surg Endosc 2019; 34:1206-1213. [DOI: 10.1007/s00464-019-06874-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
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32
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Duloy AM, Kaltenbach TR, Wood M, Gregory DL, Keswani RN. Colon polypectomy report card improves polypectomy competency: results of a prospective quality improvement study (with video). Gastrointest Endosc 2019; 89:1212-1221. [PMID: 30825535 DOI: 10.1016/j.gie.2019.02.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 02/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Polypectomy competency varies significantly among providers. Poor polypectomy technique may lead to interval cancer and/or adverse events. Our aim was to determine the effect of a polypectomy skills report card on subsequent polypectomy performance. METHODS We conducted a 3-phase, prospective, single-blinded study. In phase 1 ("baseline"), we graded 10 polypectomies per endoscopist using the Direct Observation of Polypectomy Skills (DOPyS) tool (scores 1-4); mean overall scores ≥3 are competent. In phase 2 ("pre-report card"), we selected 10 additional polypectomies per endoscopist. We subsequently gave endoscopists a report card with baseline scores and instructional videos demonstrating optimal polypectomy technique. In phase 3 ("post-report card"), 10 additional polypectomies per endoscopist were selected. Raters, blinded to study phase, graded 10 pre- and 10 post-report card polypectomies per endoscopist. We compared mean DOPyS scores and rate of competent polypectomy in the pre- and post-report card phases. RESULTS We graded 110 pre- and 110 post-report card polypectomies performed by 11 endoscopists. The mean DOPyS score increased between the pre- and post-report card phases (2.7 ± .9 vs 3.0 ± .8, P = .01); this improvement was seen for diminutive (P < .0001) but not for small-to-large polyps. Rate of competent polypectomy significantly improved from the pre- to post-report card phase (56% vs 69%, P = .04); this improvement was seen for diminutive (57% vs 81%, P = .001) but not for small-to-large polyps (55% vs 36%, P = .2). CONCLUSIONS Report cards with educational videos effectively improved polypectomy technique, primarily because of improvements in resecting diminutive polyps. The improved competency and decreased piecemeal resection may reduce the risk of polyp recurrence. Further education is needed to improve larger polyp resection.
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Affiliation(s)
- Anna M Duloy
- Department of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, USA
| | - Tonya R Kaltenbach
- Department of Gastroenterology, University of California, San Francisco, San Francisco, California, USA
| | - Mariah Wood
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Dyanna L Gregory
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Rajesh N Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
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Jegadeesan R, Aziz M, Desai M, Sundararajan T, Gorrepati VS, Chandrasekar VT, Jayaraj M, Singh P, Saeed A, Rai T, Choudhary A, Repici A, Hassan C, Fuccio L, Sharma P. Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies. Endosc Int Open 2019; 7:E708-E716. [PMID: 31073538 PMCID: PMC6506415 DOI: 10.1055/a-0808-3680] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/03/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction In recent years, cold snare polypectomy (CSP) has increasingly been used over hot snare polypectomy (HSP) for the removal of colorectal polyps (4 - 10 mm in size). However, the optimal technique (CSP vs. HSP), in terms of complete polyp resection and complications, is uncertain. Our aim was to compare incomplete resection rate (IRR) of polyps and complications using CSP vs. HSP. Methods Randomized controlled studies (RCTs) comparing CSP and HSP for removal of 4 - 10 mm colorectal polyps were considered. Studies were included in the analysis if they obtained biopsy specimens from the resection margin to confirm the absence of residual tissue and reported complications. IRR and complication rate were the outcome measures. Pooled rates were reported as Odds Ratios (OR) or risk difference with 95 % Confidence Interval (CI). Results In total, three RCTs were included in the final analysis. A total of 1051 patients with 1485 polyps were randomized to either HSP group (n = 741 polyps) or CSP group (n = 744 polyps). The overall IRR did not differ between the two groups (HSP vs. CSP: 2.4 % vs. 4.7 %; OR 0.51, 95 %CI 0.13 - 1.99, P = 0.33, I 2 = 73 %). The HSP group had a lower rate of overall complications compared to the CSP group (3.7 % vs. 6.6 %; OR 0.53, 95 % CI 0.3 - 0.94, P = 0.03, I 2 = 0 %). Polyp retrieval rates were not different between the two groups (99 % vs. 98.1 %). Conclusion Our results suggest that HSP and CSP techniques can be effectively used for the complete removal of 4 - 10 mm colorectal polyps; however, HSP has a lower incidence of overall complications.
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Affiliation(s)
- Ramprasad Jegadeesan
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Muhammad Aziz
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Madhav Desai
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Tharani Sundararajan
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | | | - Viveksandeep Thogulva Chandrasekar
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Mahendran Jayaraj
- Division of Gastroenterology, University of Nevada, Las Vegas, NV, USA
| | - Pratiksha Singh
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Ahmed Saeed
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Tarun Rai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Abhishek Choudhary
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
| | - Alessandro Repici
- Division of Gastroenterology, Humanitas Research Hospital & Humanitas University, Milan, Italy
| | - Cesare Hassan
- Nuovo Regina Margherita Hospital, Digestive Endoscopy Unit, Rome, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, KS, USA
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Risk of metachronous advanced lesions after resection of diminutive and small, non-advanced adenomas. Clin Res Hepatol Gastroenterol 2019; 43:201-207. [PMID: 30266580 DOI: 10.1016/j.clinre.2018.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/11/2018] [Accepted: 03/01/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Current post-polypectomy surveillance interval guidelines do not discriminate between 1-2 diminutive (1-5mm) and small (6-9mm) non-advanced adenomas. This study compared the risk for metachronous advanced lesions in these groups. METHODS Patients with 1-2 diminutive, non-advanced adenomas and no further advanced lesions, and patients with no polyps at baseline colonoscopy were retrospectively analyzed to determine the rate of metachronous advanced lesions. These were defined as the combined rate of colon cancer, advanced adenoma and ≥ 3 non-advanced adenomas at surveillance colonoscopy. Polyp size was measured either subjectively by the endoscopist or by pathology-based measurements. RESULTS Among patients with diminutive (n = 395) and small polyps (n = 110), advanced lesions were found in 68 patients (17.2%) and 16 patients (14.5%), respectively (P = 0.53), during a mean follow-up of 4.3 ± 0.9 years. In contrast, advanced lesions were observed in 33 patients (6.6%) in the no polyp group (n = 505), significantly lower than diminutive (P = 0.000) and small polyp groups (P = 0.002), despite a mean follow-up duration of 6.1 ± 1.9 years. The rate of metachronous advanced lesions was also similar between patients with 1-3mm polyps (16%) versus 7-9mm polyps (15.8%). CONCLUSIONS Our findings suggest that among patients who underwent polypectomy of up to 2 non-advanced adenomas, those with diminutive and small polyps have the same risk of metachronous advanced lesions; thus, supporting uniform recommendations for surveillance colonoscopy for these lesions.
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Verma AM, Chilton AP. National survey of UK endoscopists showing variation in diathermy practice for colonic polypectomy. Frontline Gastroenterol 2019; 10:120-127. [PMID: 31205651 PMCID: PMC6540286 DOI: 10.1136/flgastro-2018-101059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/12/2018] [Accepted: 09/16/2018] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Diathermy practice in colonic polypectomy has a poor evidence base. We surveyed endoscopists across the UK to gain an insight in current diathermy practice. METHODS An eight-question survey was designed to be compact, easy to complete, while still capturing the relevant data. This national survey was circulated by the endoscopy committees of the British Society of Gastroenterology and Association of Coloproctology of Great Britain and Ireland. RESULTS The survey was open between February and October 2016. Analysis showed: (1) 250/348 (71.8%) completed the full survey, 159 gastroenterologists (63.6%), 36 surgeons (14.4%), 34 gastroenterology trainees (13.6%), 21 others (8.4%); (2) predominant use of coagulation current for small pedunculated polypectomy, high rates of cold snare polypectomy for small sessile polyps (right 43.2% > left 34.4%); (3) a combination of coagulation and cutting current, or Endo Cut, was most popular for larger polypectomy; (4) low use of Endo Cut mode irrespective of size/location of polyp (17.2%-32.0%); (5) 204/250 (81.6%) used reduced current settings for right colon polypectomy; and (6) 208/250 (83.2%) were confident on knowledge and use of diathermy. CONCLUSION This national survey exposes a wide variation in practice suggesting that colonoscopists employ diathermy modalities that they are comfortable with. As many complications are as direct result of thermal injury and polypectomy is the most frequent therapeutic intervention, appropriate training and formal guidance is lacking.
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Affiliation(s)
- Ajay M Verma
- Department of Gastroenterology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Andrew P Chilton
- Department of Gastroenterology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
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Analysis of predictive factors for R0 resection and immediate bleeding of cold snare polypectomy in colonoscopy. PLoS One 2019; 14:e0213281. [PMID: 30822318 PMCID: PMC6396914 DOI: 10.1371/journal.pone.0213281] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/18/2019] [Indexed: 02/07/2023] Open
Abstract
Background Factors associated with efficacy and safety of cold snare polypectomy (CSP) are not well established. The aim is to elucidate the predictors of R0 resection and immediate bleeding of CSP. Methods We retrospectively reviewed a database of patients who underwent CSP for subcentimetric polyps at the University of Tokyo Hospital in Japan. Using the data regarding the characteristics of patients and polyps, such as location, size, and macroscopic appearance; use of narrow band imaging with magnification (NBI-M); and endoscopists’ experience, we revealed the predictive factors associated with R0 resection and immediate post-CSP bleeding by univariate and multivariate analyses. Results In total, 399 polyps, in 200 patients without antithrombotics, were removed. Failure of tissue retrieval was noted in 4% of resected lesions. There was no intramucosal carcinoma observed. The overall rate of R0 resection was 46%. Multivariate analysis elucidated that the observation of the polyp with NBI-M was an independent predictor associated with R0 resection (odds ratio [OR] 1.90; p = 0.024). Although immediate post-CSP bleeding occurred in 19 polyps (4.8%), no delayed bleeding or perforation was observed. Multivariate analysis revealed protruded lesion as an independent risk factor for immediate bleeding (OR 3.54; p = 0.018). Conclusions A higher rate of R0 resection with CSP can be achieved by performing colonoscopy with NBI-M, than with white-light imaging. Macroscopic protruding appearance of a polyp is a risk factor for immediate bleeding.
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Management and risk factors for incomplete resection associated with jumbo forceps polypectomy for diminutive colorectal polyps: a single-institution retrospective study. Surg Endosc 2018; 33:2274-2283. [PMID: 30506284 DOI: 10.1007/s00464-018-6520-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cold forceps polypectomy is simple and widely used in clinical practice. However, there are concerns about the risk of incomplete resection using this technique. In recent years, it has been reported that polypectomy with jumbo forceps (JF) is an effective treatment modality for diminutive polyps (DPs) because JF are able to remove large tissue samples with the combined advantage of a higher complete histological resection rate for DPs than standard forceps. To our knowledge, no studies have evaluated the risk factors for incomplete resection when polypectomy with JF is performed for DPs. METHODS From among 1129 DPs resected using JF at Hiroshima City Asa Citizens Hospital between November 2015 and December 2016, we retrospectively evaluated the clinical outcomes of 999 tumors with known histopathology and investigated the relationship between incomplete resection and clinicopathological factors. RESULTS Most lesions [985 (87%)] were low-grade dysplasia and 14 (1%) were high-grade dysplasia. The en bloc resection rate was 92% (918/999) and the histological en bloc resection rate was 78% (777/999). Multivariate analysis showed that the significant independent predictors of incomplete resection were tumor size ≥ 4 mm [odds ratio (OR) 3.8; 95% confidence interval (CI) 2.65-5.37; p < 0.01], non-tangential direction of forceps in relation to the tumor (OR 1.73; 95% CI 1.21-2.45; p < 0.01), and lack of muscularis mucosae in the pathological specimen (OR 15.7; 95% CI 9.16-27.7; p < 0.01). CONCLUSIONS This study identified significant independent predictors of incomplete resection of DPs which may be helpful when planning polypectomy with JF.
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O’Morain N, McNamara D. Complete polypectomy and early detection and management of residual disease to reduce the risk of interval colorectal cancers. Acta Oncol 2018; 58:S4-S9. [PMID: 30457019 DOI: 10.1080/0284186x.2018.1535715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Advances in colorectal polyp detection and resection methods aim to reduce interval cancer rates. Complete polypectomy is essential to reduce the risk of early recurrence and the development of interval cancers. To achieve this, polyps must first be correctly identified and then completely excised. This article reviews current adenoma detection methods in use and the management of residual disease.
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Affiliation(s)
- Neil O’Morain
- Department of Gastroenterology Adelaide and Meath Hospital, Dublin, Ireland
| | - Deirdre McNamara
- Department of Gastroenterology Adelaide and Meath Hospital, Dublin, Ireland
- School of Medicine, Trinity Academic Gastroenterology Group, Trinity College Dublin, Ireland
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Chien NH, Ni MH, Huang SH, Lee CL, Lee HC, Hu JT, Lai YC, Hung CS, Chiang CK, Shen MH, Tu TC, Chen HY, Huang TC. Cold snare polypectomy vs cold forceps biopsy in endoscopic treatment of colonic small and diminutive polyps-Effectiveness and safety in the real world. ADVANCES IN DIGESTIVE MEDICINE 2018. [DOI: 10.1002/aid2.13093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nai-Hsuan Chien
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- Department of Gastroenterology; Sijhih Cathay General Hospital; New Taipei City Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Min-Hsiang Ni
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
| | - Shih-Hung Huang
- Department of Pathology; Cathay General Hospital; Taipei Taiwan
| | - Chia-Long Lee
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- School of Medicine, College of Medicine; Taipei Medical University; Taipei Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Hsin-Chung Lee
- Department of Colorectal Surgery; Cathay General Hospital; Taipei Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Jui-Ting Hu
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Yung-Chih Lai
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
| | - Chih-Sheng Hung
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Chi-Kun Chiang
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
| | - Ming-Hung Shen
- Department of Colorectal Surgery; Cathay General Hospital; Taipei Taiwan
| | - Tien-Chien Tu
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- School of Medicine, College of Medicine; Taipei Medical University; Taipei Taiwan
| | - Hsin-Yu Chen
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Ting-Chun Huang
- Department of Digestive Medicine; Cathay General Hospital; Taipei Taiwan
- School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
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Pedersen IB, Løberg M, Hoff G, Kalager M, Bretthauer M, Holme Ø. Polypectomy techniques among gastroenterologists in Norway - a nationwide survey. Endosc Int Open 2018; 6:E812-E820. [PMID: 29977999 PMCID: PMC6031440 DOI: 10.1055/a-0607-0727] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/19/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Incomplete polyp removal has been estimated to cause 27 % of all colorectal cancers detected soon after colonoscopy. There is limited information regarding polypectomy techniques among endoscopists. The article is a nationwide survey of polypectomy techniques among Norwegian endoscopists. MATERIALS AND METHODS We invited all board-certified gastroenterologists in Norway to complete a web-based questionnaire about their polypectomy technique. Inadequate polypectomy techniques were defined as using biopsy forceps for polyps larger than 3 mm in diameter, using hot biopsy forceps for polypectomy, and using the same electrocautery output irrespective of polyp size and morphology. RESULTS Twenty-six of 30 Norwegian gastroenterology departments participated in the study. A total of 119 endoscopists received the survey, and 70 (59 %) responded. Mean duration of endoscopy practice was 11.5 years, and 95 % had performed more than 1,000 colonoscopies during their career. Twenty-eight endoscopists (40 %) used one or more inadequate polypectomy techniques: 10 (14.3 %) used biopsy forceps for removal of polyps larger than 3 mm in diameter, five (7.1 %) used hot biopsy for polypectomy, and 17 (24 %) used the same electrocautery output for all polypectomies. Five (7 %) endoscopists reported that they did not remove polyps smaller than 4 mm. CONCLUSION A substantial number of Norwegian endoscopists use inadequate polypectomy techniques. Improved training and certification of endoscopists is warranted.
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Affiliation(s)
- Ina B. Pedersen
- Department of Medicine, Sørlandet Hospital Kristiansand, Kristiansand, Norway,Institute of Health and Society, Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway,Corresponding author Ina B. Pedersen Sørlandet HospitalPost box 416, N-4604KristiansandNorway+47 370 83551
| | - Magnus Løberg
- Institute of Health and Society, Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway,Department of Transplantation Medicine and K. G. Jebsen Colorectal Cancer Research Center, Oslo University Hospital, Oslo, Norway
| | - Geir Hoff
- Institute of Health and Society, Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway,Department of Transplantation Medicine and K. G. Jebsen Colorectal Cancer Research Center, Oslo University Hospital, Oslo, Norway,Department of research, Telemark Hospital, Skien, Norway,Cancer Registry of Norway, Oslo, Norway
| | - Mette Kalager
- Institute of Health and Society, Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway,Department of Transplantation Medicine and K. G. Jebsen Colorectal Cancer Research Center, Oslo University Hospital, Oslo, Norway
| | - Michael Bretthauer
- Institute of Health and Society, Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway,Department of Transplantation Medicine and K. G. Jebsen Colorectal Cancer Research Center, Oslo University Hospital, Oslo, Norway,Frontier Science, Boston, Massachusetts, United States
| | - Øyvind Holme
- Department of Medicine, Sørlandet Hospital Kristiansand, Kristiansand, Norway,Institute of Health and Society, Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
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Duloy AM, Kaltenbach TR, Keswani RN. Assessing colon polypectomy competency and its association with established quality metrics. Gastrointest Endosc 2018; 87:635-644. [PMID: 28882577 DOI: 10.1016/j.gie.2017.08.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/20/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Inadequate polypectomy leads to incomplete resection, interval colorectal cancer, and adverse events. However, polypectomy competency is rarely reported, and quality metrics are lacking. The primary aims of this study were to assess polypectomy competency among a cohort of gastroenterologists and to measure the correlation between polypectomy competency and established colonoscopy quality metrics (adenoma detection rate and withdrawal time). METHODS We conducted a prospective observational study to assess polypectomy competency among 13 high-volume screening colonoscopists at an academic medical center. Over 6 weeks, we made video recordings of ≥28 colonoscopies per colonoscopist and randomly selected 10 polypectomies per colonoscopist for evaluation. Two raters graded the polypectomies by using the Direct Observation of Polypectomy Skills, a polypectomy competency assessment tool, which assesses individual polypectomy skills and overall competency. RESULTS We evaluated 130 polypectomies. A total of 83 polypectomies (64%) were rated as competent, which was more likely for diminutive (70%) than small and/or large polyps (50%, P = .03). Overall Direct Observation of Polypectomy Skills competency scores varied significantly among colonoscopists (P = .001), with overall polypectomy competency rates ranging between 30% and 90%. Individual skills scores, such as accurately directing the snare over the lesion (P = .02) and trapping an appropriate amount of tissue within the snare (P = .001) varied significantly between colonoscopists. Polypectomy competency rates did not significantly correlate with the adenoma detection rate (r = 0.4; P = .2) or withdrawal time (r = 0.2; P = .5). CONCLUSIONS Polypectomy competency varies significantly among colonoscopists and does not sufficiently correlate with established quality metrics. Given the clinical implications of suboptimal polypectomy, efforts to educate colonoscopists in polypectomy techniques and develop a metric of polypectomy quality are needed.
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Affiliation(s)
- Anna M Duloy
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Tonya R Kaltenbach
- Department of Gastroenterology, University of California, San Francisco and Department of Veterans Affairs, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Rajesh N Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
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Abstract
BACKGROUND AND AIMS Small colorectal polyps are encountered frequently and may be incompletely removed during colonoscopy. The optimal technique for removal of small colorectal polyps is uncertain. The aim of this study was to compare the incomplete resection rate (IRR) by using EMR or cold snare polypectomy (CSP) for the removal of small adenomatous polyps. METHODS This was a prospective randomized controlled study from a tertiary-care referral center. A total of 358 patients who satisfied the inclusion criteria (polyp sized 6-9 mm) were randomized to the EMR (n =179) and CSP (n =179) groups, and their polyps were treated with conventional EMR or CSP, respectively. After polypectomy, an additional 5 forceps biopsies were performed at the base and margins of polypectomy sites to assess the presence of residual polyp tissue. The EMR and CSP samples were compared to assess the IRR. RESULTS Among a total of 525 polyps, 415 (79.0%) were adenomatous polyps, and 41 (16.4%) were advanced adenomas. The overall IRR for adenomatous polyps was significantly higher in the CSP group compared with the EMR group (18/212, 8.5% vs 3/203, 1.5%; P = .001). Logistic regression analysis revealed that the CSP procedure was a stronger risk factor for the IRR (odds ratio [OR] 6.924; 95% confidence interval [CI], 2.098-24.393; P = .003). In addition, piecemeal resection was the most important risk factor for the IRR (OR 28.696; 95% CI, 3.620-227.497; P = .001). The mean procedure time for polypectomy was not significantly different between the EMR and CSP groups (5.5 ± 2.7 vs 4.7 ± 3.4 minutes; P = .410). None of these patients presented with delayed bleeding. There were no severe adverse events related to the biopsies. CONCLUSIONS EMR was significantly superior to CSP for achieving complete endoscopic resection of small colorectal polyps. Patients with piecemeal resection of polyps had a higher risk for incomplete resection. (Clinical trial registration number: Hongwei-1102-12.).
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Affiliation(s)
- Qisheng Zhang
- Digestive Endoscopy Center, Department of Gastroenterology and Hepatology, Branch of Shanghai First People's Hospital, Jiaotong University, Shanghai, China
| | - Peng Gao
- Digestive Endoscopy Center, Department of Gastroenterology and Hepatology, Branch of Shanghai First People's Hospital, Jiaotong University, Shanghai, China
| | - Bin Han
- Digestive Endoscopy Center, Department of Gastroenterology and Hepatology, Branch of Shanghai First People's Hospital, Jiaotong University, Shanghai, China
| | - Jianhua Xu
- Digestive Endoscopy Center, Department of Gastroenterology and Hepatology, Branch of Shanghai First People's Hospital, Jiaotong University, Shanghai, China
| | - Yucui Shen
- Digestive Endoscopy Center, Department of Gastroenterology and Hepatology, Branch of Shanghai First People's Hospital, Jiaotong University, Shanghai, China
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Zhang Q, Gao P, Han B, Xu J, Shen Y. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc 2018; 87:733-740. [DOI: https:/doi.org/10.1016/j.gie.2017.06.010] [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: 09/05/2023]
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O’Connor SA, Brooklyn TN, Dunckley PD, Valori RM, Carr R, Foy C, Somarathna T, Adamczyk LA, Shepherd NA, Anderson JT. High complete resection rate for pre-lift and cold biopsy of diminutive colorectal polyps. Endosc Int Open 2018; 6:E173-E178. [PMID: 29399614 PMCID: PMC5794434 DOI: 10.1055/s-0043-121874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 09/08/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The majority of polyps removed at colonoscopy are diminutive (≤ 5 mm) to small (< 10 mm) and there are few guidelines for the best way for these polyps to be removed. We aimed to assess the feasibility and effectiveness of cold biopsy forceps polypectomy with pre-lift (CBPP) for polyps ≤ 7 mm. Our aims were to assess completeness of histological resection of this technique, to identify factors contributing to this and assess secondary considerations such as timing, retrieval and complication rates. PATIENTS AND METHODS We conducted a prospective cohort study on consecutive patients receiving a colonoscopy at Cheltenham General Hospital, as part of the National Bowel Cancer Screening Program (BCSP) in England. The study included only polyps that were judged as ≤ 7 mm by the colonoscopist. A small sub-mucosal pre-lift injection was administered prior to removal of the polyp using cold biopsy forceps. One or more biopsies were taken until the polyp was confidently assessed visually as being completely removed by the colonoscopist. The entire polypectomy site was then removed en bloc by endomucosal resection (EMR) with a margin of at least 1 to 2 mm around defect. This was sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval, number of bites required for visual resection and complications were recorded at the time of the procedure. RESULTS Sixty-four patients were recruited and consented. Of them, 42 patients had a total of 60 polyps resected. Three patients had inflammatory polyps and were excluded from the study, leaving 57/60 polyps for final analysis. Seventeen were hyperplastic and 40 adenomatous polyps. Retrieval was complete for all 57 polyps and there were no complications both during or post- polypectomy. The complete resection rate (CRR) was 86 %. The technique was more effective in smaller polyps with 91.7 % of diminutive polyps (≤ 5 mm) completely excised. CONCLUSIONS CBPP is a safe and highly effective technique for polyps < 5 mm with a high complete resection and retrieval rate. The time taken for the procedure is significantly greater than cold forceps alone, or cold snare as seen in other studies.
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Affiliation(s)
- Sam A. O’Connor
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, Queensland, Australia,Department of Gastroenterology, Cheltenham General Hospital, Sandford Road, Cheltenham, UK,Corresponding author Dr Sam A. O’Connor MBBS (Hon), FRACP Princess Alexandra Hospital199 Ipswich RdWoolloongabba QLDAustralia 4102
| | - Trevor N. Brooklyn
- Department of Gastroenterology, Cheltenham General Hospital, Sandford Road, Cheltenham, UK
| | - Paul D. Dunckley
- Department of Gastroenterology, Gloucestershire Royal Hospital, Great Western Rd, Gloucester, UK
| | - Roland M. Valori
- Department of Gastroenterology, Gloucestershire Royal Hospital, Great Western Rd, Gloucester, UK
| | - Ruth Carr
- Department of Gastroenterology, Cheltenham General Hospital, Sandford Road, Cheltenham, UK
| | - Chris Foy
- Research and Development Unit, Gloucestershire NHS Hospitals Trust, Gloucester, UK
| | - Thusitha Somarathna
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Sandford Road, Cheltenham, UK
| | - Lukasz A. Adamczyk
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Sandford Road, Cheltenham, UK
| | - Neil A. Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Sandford Road, Cheltenham, UK
| | - John T. Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Sandford Road, Cheltenham, UK
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Dwyer JP, Tan JYC, Urquhart P, Secomb R, Bunn C, Reynolds J, La Nauze R, Kemp W, Roberts S, Brown G. A prospective comparison of cold snare polypectomy using traditional or dedicated cold snares for the resection of small sessile colorectal polyps. Endosc Int Open 2017; 5:E1062-E1068. [PMID: 29250580 PMCID: PMC5659868 DOI: 10.1055/s-0043-113564] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 05/22/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The evidence for efficacy and safety of cold snare polypectomy is limited. The aim of this study was to assess the completeness of resection and safety of cold snare polypectomy, using either traditional or dedicated cold snares. PATIENTS AND METHODS This was a prospective, non-randomized study performed at a single tertiary hospital. Adult patients with at least one colorectal polyp (size ≤ 10 mm) removed by cold snare were included. In the first phase, all patients had polyps removed by traditional snare without diathermy. In the second phase, all patients had polyps removed by dedicated cold snare. Complete endoscopic resection was determined from histological examination of quadrantic polypectomy margin biopsies. Immediate or delayed bleeding within 2 weeks was recorded. RESULTS In total, 181 patients with 299 eligible polyps (n = 93 (173 polyps) traditional snare group, n = 88 (126 polyps) dedicated cold snare group) were included. Patient demographics and procedure indications were similar between groups. Mean polyp size was 6 mm in both groups ( P = 0.25). Complete polyp resection was 165 /173 (95.4 %; 95 %CI 90.5 - 97.6 %) in the traditional snare group and 124/126 (98.4 %; 95 %CI 93.7 - 99.6 %) in the dedicated cold snare group ( P = 0.16). Serrated polyps, compared with adenomatous polyps, had a higher rate of incomplete resection (7 % vs. 2 %, P = 0.03). There was no statistically significant difference in the rate of immediate bleeding (3 % vs. 1 %, P = 0.41) and there were no delayed hemorrhages or perforations. CONCLUSIONS Cold snare polypectomy is effective and safe for the complete endoscopic resection of small (≤ 10 mm) colorectal polyps with either traditional or dedicated cold snares.
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Affiliation(s)
- Jeremy P. Dwyer
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Jonathan Y. C. Tan
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Paul Urquhart
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Robyn Secomb
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Catherine Bunn
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - John Reynolds
- Biostatistics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia 3004
| | - Richard La Nauze
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Stuart Roberts
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004
| | - Gregor Brown
- Department of Gastroenterology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia 3004,Corresponding author Associate Professor Gregor Brown Head of EndoscopyAlfred Hospital55 Commercial RdMelbourneVIC 3004Australia+61-3-90762757
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Shimodate Y, Mizuno M, Takezawa R, Kobayashi M, Yamazaki T, Doi A, Nishimura N, Mouri H, Matsueda K, Yamamoto H. Safety of cold polypectomy for small colorectal neoplastic lesions: a prospective cohort study in Japan. Int J Colorectal Dis 2017; 32:1261-1266. [PMID: 28730368 DOI: 10.1007/s00384-017-2856-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cold polypectomy has been widely accepted for removal of small colorectal polyps. However, no large-scale prospective study exists as for its safety in Japan. We investigated this issue in this single-center, prospective cohort study in a total of 1198 colorectal polyps resected with cold polypectomy. PATIENTS AND METHODS Four hundred and seventy-four patients who underwent cold polypectomy for colorectal neoplastic lesions less than 10-mm diameter between September 2014 and October 2016 were enrolled. Primary outcome was the incidence of delayed bleeding within 2 weeks after the procedure. Secondary outcomes were the rate of immediate bleeding, perforation, endoscopic en bloc resection, and advanced histology. RESULTS Cold polypectomy was performed on 1198 polyps in the 474 patients. No delayed bleeding or colonic perforation was observed. Immediate bleeding during the procedure, requiring endoscopic hemostasis, occurred in 97 lesions (8.1%), and all of them were successfully managed endoscopically. The endoscopic en bloc resection rate was 97.2%. Twenty-eight lesions (2.3%) were histologically diagnosed as advanced neoplasia; among them, three lesions were well-differentiated adenocarcinomas, and in two of them, a negative margin was not histologically confirmed. CONCLUSIONS Cold polypectomy for small colorectal polyps is a safe technique without significant complication, but careful endoscopic diagnosis at cold polypectomy is necessary to identify advanced neoplasia. The reliability of cold polypectomy in excision of polyps with high-grade neoplasia should be established before the procedure becomes standard in the excision of small colorectal polyps. CLINICAL TRIAL REGISTRATION NUMBER UMIN000014812.
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Affiliation(s)
- Yuichi Shimodate
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan.
| | - Motowo Mizuno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Rio Takezawa
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Mami Kobayashi
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Tatsuhiro Yamazaki
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Akira Doi
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Naoyuki Nishimura
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Hirokazu Mouri
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Kazuhiro Matsueda
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Hiroshi Yamamoto
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
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Comparative efficacy of cold polypectomy techniques for diminutive colorectal polyps: a systematic review and network meta-analysis. Surg Endosc 2017; 32:1149-1159. [PMID: 28812188 DOI: 10.1007/s00464-017-5786-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although cold polypectomy techniques are preferred over polypectomy with electrocautery in the management of diminutive polyps, comprehensive comparisons among various cold polypectomy techniques have not yet been fully performed. METHODS We searched for all relevant randomized controlled trials published up until October 2016 examining the efficacy of cold polypectomy techniques for diminutive polyps. Cold polypectomy techniques were classified as cold forceps polypectomy (CFP), jumbo forceps polypectomy (JFP), traditional cold snare polypectomy (CSP), and dedicated CSP, according to the type of device. A network meta-analysis was performed to calculate the direct and indirect estimates of efficacy among the cold polypectomy techniques. RESULTS Seven studies with 703 patients and 968 polyps were included in the meta-analysis. Regarding comparative efficacy for complete histological eradication, there was no inconsistency in the network (Cochran's Q test, df = 4, P = 0.22; I 2 = 30%). In terms of complete histological eradication, both dedicated and traditional CSP were superior to CFP (odds ratio [OR] [95% confidence interval [CI]] 4.31 [1.92-9.66] and 2.45 [1.30-4.63], respectively); dedicated CSP was superior to traditional CSP (OR [95% CI] 1.76 [1.07-2.89]); and there was no difference between JFP versus CFP (OR [95% CI] 1.36 [0.40-4.61]). Regarding tissue retrieval rate, there was no difference between dedicated versus traditional CSP (OR [95% CI] 1.03 [0.44-2.38]). The procedure time for CSP was comparable to that of CFP. CONCLUSIONS Dedicated CSP was shown to be superior to other cold polypectomy techniques in terms of complete histological eradication. Cold polypectomy using a dedicated snare can be recommended for the removal of diminutive colorectal polyps.
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Moss A, Nalankilli K. Standardisation of polypectomy technique. Best Pract Res Clin Gastroenterol 2017; 31:447-453. [PMID: 28842055 DOI: 10.1016/j.bpg.2017.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/28/2017] [Indexed: 02/07/2023]
Abstract
There are several approaches to polypectomy for sessile polyps <20 mm and for pedunculated polyps. Recent evidence is leading towards standardisation of polypectomy technique. Key recent polypectomy developments include: 1. Use of cold snare polypectomy (CSP) for sessile polyps <10 mm; 2. Use of hot snare polypectomy (HSP) following submucosal injection for sessile polyps sized 10-19 mm; 3. Piecemeal cold snare polypectomy (PCSP), with or without prior submucosal injection, for select sessile polyps sized 10-19 mm, where the potential risk for an adverse event is increased (e.g. polyps in the caecum or ascending colon, or patients with increased risk of post-polypectomy bleeding), and where the risk of submucosal invasion is low; 4. Avoidance of hot biopsy forceps (HBF); 5. Limiting the use of cold biopsy forceps (CBF) to the smallest of diminutive polyps, where CSP is not feasible; 6. Mechanical haemostasis prior to polypectomy for large pedunculated polyps with head ≥20 mm or stalk ≥10 mm.
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Affiliation(s)
- Alan Moss
- Gastroenterology Department, Western Health, Melbourne, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia.
| | - Kumanan Nalankilli
- Gastroenterology Department, Western Health, Melbourne, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia
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49
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Lee J. Resection of Diminutive and Small Colorectal Polyps: What Is the Optimal Technique? Clin Endosc 2016; 49:355-8. [PMID: 27450226 PMCID: PMC4977737 DOI: 10.5946/ce.2016.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 02/06/2023] Open
Abstract
Colorectal polyps are classified as neoplastic or non-neoplastic on the basis of malignant potential. All neoplastic polyps should be completely removed because both the incidence of colorectal cancer and the mortality of colorectal cancer patients have been found to be strongly correlated with incomplete polypectomy. The majority of colorectal polyps discovered on diagnostic colonoscopy are diminutive and small polyps; therefore, complete resection of these polyps is very important. However, there is no consensus on a method to remove diminutive and small polyps, and various techniques have been adopted based on physician preference. The aim of this article was to review the diverse techniques used to remove diminutive and small polyps and to suggest which technique will be the most effective.
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Affiliation(s)
- Jun Lee
- Department of Internal Medicine, Chosun University School of Medicine, Gwangju, Korea
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50
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Treatment outcomes and recurrence following standard cold forceps polypectomy for diminutive polyps. Surg Endosc 2016; 31:159-169. [DOI: 10.1007/s00464-016-4947-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 04/15/2016] [Indexed: 02/07/2023]
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