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Kashida H. Outline of Japanese Guidelines for Colorectal Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection with a Short Reference to the Western Recommendations. J Anus Rectum Colon 2024; 8:1-8. [PMID: 38313746 PMCID: PMC10831978 DOI: 10.23922/jarc.2023-043] [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: 08/13/2023] [Accepted: 11/07/2023] [Indexed: 02/06/2024] Open
Abstract
The Japan Gastroenterological Endoscopy Society published the latest English versions of the guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for colorectal neoplastic lesions and colorectal cold polypectomy in 2020 and 2022, respectively. In this article, I present a comprehensive overview of these guidelines, including a comparison with the Western recommendations.
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Affiliation(s)
- Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
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2
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Xiao Q, Eckardt M, Mohamed A, Ernst H, Behrens A, Homann N, Hielscher T, Kähler G, Ebert M, Belle S, Zhan T. Onset Time and Characteristics of Postprocedural Bleeding after Endoscopic Resection of Colorectal Lesions: A Multicenter Retrospective Study. Dig Dis 2023; 42:78-86. [PMID: 37812925 DOI: 10.1159/000534109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Postprocedural bleeding is a major adverse event after endoscopic resection of colorectal lesions, but the optimal surveillance time after endoscopy is unclear. In this study, we determined onset time and characteristics of postprocedural bleeding events. METHODS We retrospectively screened patients who underwent endoscopic resection of colorectal lesions at three German hospitals between 2010 and 2019 for postprocedural bleeding events using billing codes. Only patients who required re-endoscopy were included for analysis. For identified patients, we collected demographic data, clinical courses, characteristics of colorectal lesions, and procedure-related variables. Factors associated with late-onset bleeding were determined by univariate and multivariate logistic regression analysis. RESULTS From a total of 6,820 patients with eligible billing codes, we identified 113 cases with postprocedural bleeding after endoscopic mucosal (61.9%) or snare resection (38.1%) that required re-endoscopy. The median size of the culprit lesion was 20 mm (interquartile range 14-30 mm). The median onset time of postprocedural bleeding was day 3 (interquartile range: 1-6.5 days), with 48.7% of events occurring within 48 h. Multivariate logistic regression analysis demonstrates that a continued intake of antiplatelet drugs (OR: 3.98, 95% CI: 0.89-10.12, p = 0.025) and a flat morphology of the colorectal lesion (OR: 2.98, 95% CI: 1.08-8.01, p = 0.031) were associated with an increased risk for late postprocedural bleeding (>48 h), whereas intraprocedural bleeding was associated with a decreased risk (OR: 0.12, 95% CI: 0.04-0.50, p = 0.001). CONCLUSION Significant postprocedural bleeding can occur up to 18 days after endoscopic resection of colorectal lesions, but was predominantly observed within 48 h. Continued intake of antiplatelet drugs and a flat polyp morphology are associated with risk for late postprocedural bleeding.
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Affiliation(s)
- Qiyun Xiao
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian Eckardt
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Awsan Mohamed
- Department of Medicine IV, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Helmut Ernst
- Department of Medicine IV, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Alexander Behrens
- Department of Internal Medicine II, Academic Teaching Hospital Wolfsburg, Wolfsburg, Germany
| | - Nils Homann
- Department of Internal Medicine II, Academic Teaching Hospital Wolfsburg, Wolfsburg, Germany
| | - Thomas Hielscher
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Ebert
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Cancer Center, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Belle
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tianzuo Zhan
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Cancer Center, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Tokuhara M, Shimatani M, Tominaga K, Nakahira H, Ohtsu T, Kouda K, Naganuma M. Evaluation of a new method, "non-injection resection using bipolar soft coagulation mode (NIRBS)", for colonic adenomatous lesions. Clin Endosc 2023; 56:623-632. [PMID: 37524565 PMCID: PMC10565442 DOI: 10.5946/ce.2022.200] [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: 08/03/2022] [Revised: 11/21/2022] [Accepted: 12/16/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic resection of all colorectal adenomatous lesions with a low complication rate, simplicity, and negative residuals is challenging. Hence, we developed a new method called "non-injection resection using bipolar soft coagulation mode (NIRBS)" method, adapted for colorectal lesions. In addition, we evaluated the effectiveness of this method. METHODS We performed NIRBS throughout a 12-month period for all colorectal lesions which snare resection was acceptable without cancerous lesions infiltrating deeper than the submucosal layer. RESULTS A total of 746 resected lesions were included in the study, with a 4.5 mm mean size (range, 1-35 mm). The major pathological breakdowns were as follows: 64.3% (480/746) were adenomas, and 5.0% (37/746) were intraepithelial adenocarcinomas (Tis lesions). No residuals were observed in any of the 37 Tis lesions (mean size, 15.3 mm). Adverse events included bleeding (0.4%) but no perforation. CONCLUSIONS NIRBS allowed the resection of multiple lesions with simplicity because of the non-injection and without perforating due to the minimal burn effect of the bipolar snare set in the soft coagulation mode. Therefore, NIRBS can be used to resect adenomatous lesions easily, including Tis lesions, from small to large lesions without leaving residuals.
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Affiliation(s)
- Mitsuo Tokuhara
- Department of Gastroenterology, Japan Community Healthcare Organization Hoshigaoka Medical Center, Osaka, Japan
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Masaaki Shimatani
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Kazunari Tominaga
- Department of Gastroenterology, Japan Community Healthcare Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Hiroko Nakahira
- Department of Gastroenterology, Japan Community Healthcare Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Takuya Ohtsu
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Katsuyasu Kouda
- Department of Hygiene and Public Health, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Makoto Naganuma
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
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4
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Bi D, Zhang LY, Alqaisieh M, Shrigiriwar A, Farha J, Mahmoud T, Akiki K, Almario JA, Shah-Khan SM, Gordon SR, Adler JM, Radetic M, Draganov PV, David YN, Shinn B, Mohammed Z, Schlachterman A, Yuen S, Al-Taee A, Yunseok N, Trasolini R, Bejjani M, Ghandour B, Ramberan H, Canakis A, Ngamruengphong S, Storm AC, Singh S, Pohl H, Bucobo JC, Buscaglia JM, D'Souza LS, Qumseya B, Kumta NA, Kumar A, Haber GB, Aihara H, Sawhney M, Kim R, Berzin TM, Khashab MA. Novel through-the-scope suture closure of colonic EMR defects (with video). Gastrointest Endosc 2023; 98:122-129. [PMID: 36889364 DOI: 10.1016/j.gie.2023.02.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND AND AIMS Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS. METHODS A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding. RESULTS A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate). CONCLUSION TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.
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Affiliation(s)
- Danse Bi
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | | | | | - Jad Farha
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Tala Mahmoud
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Karl Akiki
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | | | | | - Stuart R Gordon
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jeffrey M Adler
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mark Radetic
- University of Florida, Gainesville, Florida, USA
| | | | | | - Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Zahraa Mohammed
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Sofia Yuen
- NYU Langone Health, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | | | - Heiko Pohl
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | | | | | | | - Anand Kumar
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Mandeep Sawhney
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raymond Kim
- University of Maryland, Baltimore, Maryland, USA
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023; 35:216-231. [PMID: 35778927 DOI: 10.1111/den.14397] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/30/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.
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Affiliation(s)
- Hideki Kobara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Naoya Tada
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shintaro Fujihara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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6
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Jiang W, Cen L, Dong C, Zhu S, Shen Z, Li D. Prophylactic Clipping to Prevent Delayed Bleeding and Perforation After Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2022; 56:643-653. [PMID: 35648969 DOI: 10.1097/mcg.0000000000001721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS To help prevent delayed adverse events after endoscopic surgery, endoscopists often place clips at the site. This meta-analysis aimed to assess the efficacy and safety of prophylactic clipping in the prevention of delayed bleeding and perforation after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR). METHODS Multiple databases were searched from the inception dates to April 2021. And we included all relevant studies. Pooled odds ratio comparing the prophylactic clipped group versus nonprophylactic clipped group were calculated using the random effects model. RESULTS Twenty-seven articles fulfilled the inclusion criteria, with a total size of 8693 participants. There was statistically significant difference in prophylactic clipping versus no prophylactic clipping for delayed bleeding and perforation found in all studies (odds ratio: 0.35, 95% confidence interval: 0.25-0.49, P <0.01; odds ratio: 0.42, 95% confidence interval: 0.21-0.83, P <0.05; respectively). Besides, statistically significant difference was also found in subgroup analyses based on patients with lesions larger than 20 mm. Prophylactic clipping was more protective for duodenal delayed adverse events than colorectum. The use of clip closure was more protective to ESD-related delayed adverse events than EMR. CONCLUSIONS Prophylactic clipping after ESD and EMR was beneficial in preventing delayed bleeding and perforation.
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Affiliation(s)
- Wenxi Jiang
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Li Cen
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Caijuan Dong
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Shefeng Zhu
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Zhe Shen
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Dong Li
- Department of Gastroenterology, The First People's Hospital of Wenling, Taizhou, China
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Kakiuchi T, Takedomi H, Akutagawa T, Tsuruoka N, Sakata Y, Matsuo M. Gastrointestinal bleeding after endoscopic mucosal resection in a case of Peutz-Jeghers syndrome with hypofibrinogenemia: A case report. Front Pediatr 2022; 10:961501. [PMID: 36275070 PMCID: PMC9581254 DOI: 10.3389/fped.2022.961501] [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: 06/04/2022] [Accepted: 09/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUD Peutz-Jegers syndrome (PJS) is an autosomal dominant hereditary disorder characterized by hamartomatous polyposis of the entire gastrointestinal tract. Fibrinogen (Fbg) is synthesized by the liver, and hypofibrinogenemia is often asymptomatic and manifests with bleeding after trauma or invasive surgical procedures. Here, we present a case of a pediatric patient with PJS and hypofibrinogenemia who manifested with gastrointestinal bleeding after endoscopic mucosal resection (EMR) of small intestinal polyps. CASE PRESENTATION An 11-year-old boy with PJS was referred to our hospital. Since his mother was diagnosed with PJS, with black pigments being observed on his lips, mouth, and limbs, he underwent upper and lower gastrointestinal endoscopy at the age of 8 years at a previous hospital. EMR for duodenal polyp was performed, and the pathological findings were consistent with hamartoma. His Fbg level was 117 mg/dl at the time, with no post-bleeding being detected after EMR. The small intestine was not assessed at the prior facility and was left neglected for three years. At our hospital, small intestine fluoroscopy was performed and revealed a polyp in the jejunum, and abdominal computed tomography showed two polyps and intussusception. On double-balloon enteroscopy, the resected polyps were hamartoma with diameters of 20 and 30 mm. The patient's Fbg level was 107 mg/dl. The day after EMR, he had melena and black stools. He was diagnosed with post-EMR bleeding and started to stop eating, and hemostatic agents were given. His hemoglobin level dropped to 9.2 g/dl the next day. Genetic testing for congenital Fbg deficiency revealed a heterozygous pathogenic variant in fibrinogen gamma chain Exon 10. Therefore, he was diagnosed with concurrent hypofibrinogenemia and PJS. CONCLUSION To the best of our knowledge, this is the first reported case with concurrent PJS and hypofibrinogenemia. In patients with PJS, hypofibrinogenemia should be considered as one of the risk factors of postoperative bleeding during polypectomy, and appropriate prophylactic measures should be taken.
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Affiliation(s)
- Toshihiko Kakiuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Hironobu Takedomi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Takashi Akutagawa
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Nanae Tsuruoka
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yasuhisa Sakata
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
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Miyakawa A, Kuwai T, Sakuma Y, Kubota M, Nakamura A, Itobayashi E, Shimura H, Suzuki Y, Shimura K. The efficacy of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection on delayed bleeding. Scand J Gastroenterol 2021; 56:1236-1242. [PMID: 34362282 DOI: 10.1080/00365521.2021.1953129] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Although prophylactic clip closure after endoscopic mucosal resection may prevent delayed bleeding, information regarding colorectal endoscopic submucosal dissection (CR-ESD) is lacking. Therefore, this study evaluated the effect of prophylactic clip closure on delayed bleeding rate after CR-ESD. MATERIALS AND METHODS A total of 614 CR-ESD procedures performed in 561 patients were retrospectively reviewed. The primary outcome, which was delayed bleeding rate, was analyzed between the prophylactic clip closure and non-closure groups. Furthermore, the predictors of delayed bleeding were also evaluated. RESULTS The patients were divided into the clip closure group (n = 275) and non-closure group (n = 339). Delayed bleeding rate was significantly lower in the closure group than in non-closure group (6 cases [2.2%] vs. 20 cases [5.9%], p = .026). The univariate logistic regression analyses revealed that delayed bleeding was significantly associated with laterally spreading tumor-granular-nodular mixed type (LST-G-Mix; odds ratio [OR], 3.77; 95% confidence interval [CI], 1.70-8.34; p = .001). By contrast, prophylactic clip closure was significantly associated with low delayed bleeding rate (OR, 0.36; 95%CI, 0.14-0.90; p = .029). The multivariate logistic regression analyses revealed LST-G-Mix as a significant independent delayed bleeding predictor (OR, 3.25; 95%CI, 1.45-7.32; p = .004), whereas, prophylactic clip closure was identified as a significant independent preventive factor of delayed bleeding (OR, 0.39; 95%CI, 0.15-1.00; p = .049). CONCLUSIONS Prophylactic clip closure after CR-ESD is associated with low delayed bleeding rate. LST-G-Mix promotes delayed bleeding, and performing prophylactic clip closure may be advisable.
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Affiliation(s)
- Akihiro Miyakawa
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Yukie Sakuma
- Clinical Research Center, Asahi General Hospital, Asahi, Japan
| | - Manabu Kubota
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Akira Nakamura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Ei Itobayashi
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Haruhisa Shimura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Yoshio Suzuki
- Department of Pathology, Asahi General Hospital, Asahi, Japan
| | - Kenji Shimura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
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Endoscopic characteristics influencing postpolypectomy bleeding in 1147 consecutive pedunculated colonic polyps: a multicenter retrospective study. Gastrointest Endosc 2021; 94:803-811.e6. [PMID: 33857452 DOI: 10.1016/j.gie.2021.03.996] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Postpolypectomy bleeding is the most common adverse event with pedunculated polyps. We clarified the endoscopic characteristics influencing postpolypectomy bleeding for pedunculated colonic polyps. METHODS We reviewed clinical data for 1147 pedunculated colonic polyps removed by polypectomy in 5 Japanese institutions. Pedunculated polyps were defined as polyps with a stalk length ≥5 mm. Analyzed clinical data were age, sex, polyp location/size, stalk length/width, prophylactic clipping or endoloop before polypectomy, injecting the stalk, closing the polypectomy site, antithrombotic agent use, and endoscopist experience. Postpolypectomy bleeding was classified as immediate bleeding or delayed bleeding. RESULTS Immediate and delayed bleeding was observed in 8.5% (97/1147) and 2% (23/1147) of polypectomies, respectively. Comparing immediate bleeding with nonbleeding, multivariate analysis showed that stalk width ≥6 mm (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.4) was a significant risk factor for immediate bleeding. For polyp size ≥15 mm, prophylactic endoloop use (OR, .17; 95% CI, .04-.72) was a significant inhibiting factor. Comparing delayed bleeding with nonbleeding, multivariate analysis showed that prophylactic clipping before polypectomy (OR, 4.2; 95% CI, 1.3-13) and injecting the stalk (OR, 4.0; 95% CI, 1.4-12) were significant risk factors for delayed bleeding. CONCLUSIONS The increased risk for delayed bleeding with injecting the stalk and prophylactic clipping before polypectomy suggests that simple resection with coagulation mode is a suitable strategy in endoscopic resection of pedunculated polyps. Moreover, prophylactic endoloop use was highly likely to inhibit immediate bleeding with polyp size ≥15 mm.
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10
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Yang TC, Wu YH, Lee PC, Chang CY, Lu HS, Chen YJ, Huang YH, Lee FY, Hou MC. Prophylactic clipping after endoscopic mucosal resection of large nonpedunculated colorectal lesions: A meta-analysis. J Gastroenterol Hepatol 2021; 36:1778-1787. [PMID: 33638894 DOI: 10.1111/jgh.15472] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM It is not clear whether prophylactic clipping after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions (LNPCLs) prevents delayed bleeding (DB). We aimed to conduct a meta-analysis to clarify the efficacy of prophylactic clipping in prevention of DB following EMR of LNPCLs. METHODS We searched PubMed, EMBASE, Web of Science, ScienceDirect, Cochrane Library databases, and ClinicalTrials.gov for studies that compared clipping versus (vs) nonclipping in prevention of DB following EMR of LNPCLs. Pooled odds ratio (OR) was determined using a random effects model. The pooled ORs of DB, perforation, and post-polypectomy syndrome in the clipping group compared with the nonclipping group comprised the outcomes. Subgroup analyses based on study design, polyp location, and completeness of wound closure were performed. RESULTS Five studies with a total of 3112 LNPCLs were extracted. Prophylactic clipping reduced the risk of DB compared with nonclipping (3.3% vs 6.2%, OR: 0.494, P = 0.002) following EMR of LNPCLs. In subgroup analysis, prophylactic clipping reduced DB of LNPCLs at proximal location (3.8% vs 9.8%, P = 0.029), but not of them at distal location (P = 0.830). Complete wound closure showed superior efficacy to prevent DB compared with partial closure (2.0% vs 5.4%, P = 0.004). No benefit of clipping for preventing perforation or post-polypectomy syndrome was observed (P = 0.301 and 0.988, respectively). CONCLUSIONS Prophylactic clipping can reduce DB following EMR of LNPCLs at proximal location. Besides, complete wound closure showed superior efficacy to prevent DB compared with partial closure. Further cost analyses should be conducted to implement the most cost-effective strategies.
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Affiliation(s)
- Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Hui Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Yu Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiao-Sheng Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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11
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Inoue T, Ishihara R, Nishida T, Akasaka T, Hayashi Y, Nakamatsu D, Ogiyama H, Yamaguchi S, Yamamoto K, Mukai A, Kinoshita K, Yakushijin T, Iijima H, Takehara T. Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial. J Gastroenterol Hepatol 2021; 36:383-390. [PMID: 32511792 DOI: 10.1111/jgh.15134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Prophylactic clipping (PC) after polypectomy has the potential to prevent post-polypectomy bleeding (PPB). We aimed to evaluate the effectiveness of PC in preventing PPB for < 20-mm polyps. METHODS This multicenter, open-label, randomized controlled trial conducted from December 2013 to June 2017 at 10 institutions randomly assigned 1080 patients with < 20-mm colon polyps to the non-PC and PC groups. Allocation factors were institution, antiplatelet drug use, and polyp number. The primary endpoint was differences in PPB rates between the groups. The severity of PPB and post-procedural abdominal symptoms were also investigated. These endpoints in intention-to-treat and per-protocol (PP) analyses were evaluated. RESULTS We investigated 1039 patients with 2960 lesions. There was no significant difference between the groups in characteristics including age, sex, hypertension, diabetes, hyperlipidemia, antiplatelet drug use, and lesion characteristics such as type and size. Excluding the clip used in the non-PC group, intraoperative bleeding, and deviation of protocol, 903 patients were investigated in PP analysis. There was no significant difference in the PPB rate between the non-PC and PC groups (2.7% vs 2.3%, P = 0.6973 [intention-to-treat analysis]; 3.0 vs 2.4%, P = 0.7353 [PP analysis]). Severe PPB (≥ grade 3) was similar between the groups. Total procedure time was significantly shorter in the non-PC group than in the PC group (31 vs 36 min, P = 0.0002). Post-procedural abdominal fullness was less common in the non-PC group than in the PC group (20.8% vs 25.6%, P = 0.0833). CONCLUSION Prophylactic clipping is not effective in preventing PBB for < 20-mm colon polyps (UMIN000012163).
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Affiliation(s)
- Takuya Inoue
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan.,Department of Gastroenterology and Hepatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterology, Kaizuka City Hospital, Kaizuka, Japan
| | - Hideharu Ogiyama
- Department of Gastroenterology, Itami City Hospital, Itami, Japan
| | | | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Akira Mukai
- Department of Gastroenterology, Sumitomo Hospital, Osaka, Japan
| | - Kazuo Kinoshita
- Department of Gastroenterology, Otemae Hospital, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Osaka Gut Forum, Osaka, Japan
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12
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Turan AS, Moons LMG, Schreuder RM, Schoon EJ, Terhaar Sive Droste JS, Schrauwen RWM, Straathof JW, Bastiaansen BAJ, Schwartz MP, Hazen WL, Alkhalaf A, Allajar D, Hadithi M, van der Spek BW, Heine DGDN, Tan ACITL, de Graaf W, Boonstra JJ, Voogd FJ, Roomer R, de Ridder RJJ, Kievit W, Siersema PD, Didden P, van Geenen EJM. Clip placement to prevent delayed bleeding after colonic endoscopic mucosal resection (CLIPPER): study protocol for a randomized controlled trial. Trials 2021; 22:63. [PMID: 33461579 PMCID: PMC7813164 DOI: 10.1186/s13063-020-04996-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) for large colorectal polyps is in most cases the preferred treatment to prevent progression to colorectal carcinoma. The most common complication after EMR is delayed bleeding, occurring in 7% overall and in approximately 10% of polyps ≥ 2 cm in the proximal colon. Previous research has suggested that prophylactic clipping of the mucosal defect after EMR may reduce the incidence of delayed bleeding in polyps with a high bleeding risk. METHODS The CLIPPER trial is a multicenter, parallel-group, single blinded, randomized controlled superiority study. A total of 356 patients undergoing EMR for large (≥ 2 cm) non-pedunculated polyps in the proximal colon will be included and randomized to the clip group or the control group. Prophylactic clipping will be performed in the intervention group to close the resection defect after the EMR with a distance of < 1 cm between the clips. Primary outcome is delayed bleeding within 30 days after EMR. Secondary outcomes are recurrent or residual polyps and clip artifacts during surveillance colonoscopy after 6 months, as well as cost-effectiveness of prophylactic clipping and severity of delayed bleeding. DISCUSSION The CLIPPER trial is a pragmatic study performed in the Netherlands and is powered to determine the real-time efficacy and cost-effectiveness of prophylactic clipping after EMR of proximal colon polyps ≥ 2 cm in the Netherlands. This study will also generate new data on the achievability of complete closure and the effects of clip placement on scar surveillance after EMR, in order to further promote the debate on the role of prophylactic clipping in everyday clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT03309683 . Registered on 13 October 2017. Start recruitment: 05 March 2018. Planned completion of recruitment: 31 August 2021.
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands.
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Màxima Medical Center, Veldhoven, Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, Netherlands
| | - Daud Allajar
- Department of Gastroenterology and Hepatology, Hospital St. Jansdal, Harderwijk, Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Bas W van der Spek
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Dimitri G D N Heine
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina hospital, Nijmegen, Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leids University Medical Center, Leiden, Netherlands
| | - Fia J Voogd
- Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Wietske Kievit
- IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
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13
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Kishino T, Oyama T, Hotta K, Ishii E, Momoi T, Shimizu T, Kunieda K, Takeda S, Komatsu H. Risk of colonoscopic post-polypectomy bleeding in patients after the discontinuation of antithrombotic therapy. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:752-759. [PMID: 33361037 DOI: 10.5152/tjg.2020.19428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Few studies have examined the incidence of post-polypectomy bleeding (PPB) after discontinuation of antithrombotic therapies. Therefore, this study aimed to evaluate the incidence of PPB and thromboembolic events in patients whose antithrombotic agents were discontinued before colonoscopy. MATERIALS AND METHODS We retrospectively selected all patients who underwent colon polypectomy at a community hospital. A total of 282 patients (540 polypectomies) discontinued antithrombotic agents (group 1), and 1,648 patients (2,827 polypectomies) did not take antithrombotic agents (group 2). The cessation periods before and after polypectomies were 4 and 3 days for warfarin, 5 and 3 days for anti-platelet agents, and 7 and 5 days of combination therapy, respectively. Main outcome measurements were the incidence of PPB and thromboembolic events. RESULTS Immediate PPB rates were 3.9% (11/282) in group 1 and 4.6% (76/1648) in group 2 (adjusted odds ratio [OR], 0.85; 95% confidence interval [CI], 0.42-1.72; p=0.65). Delayed PPB rates were 1.4% (4/282) in group 1 and 1.1% (18/1648) in group 2 (adjusted OR, 1.24; 95% CI, 0.36-4.24; p=0.732). No thromboembolic events were observed in either group. CONCLUSION Our cessation periods were appropriate, and further shortening of these periods is possible.
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Affiliation(s)
- Takaaki Kishino
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan; Department of Gastroenterology, Nara City Hospital, Nara, Japan
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Kinichi Hotta
- Division of Endoscopy and Gastrointestinal Oncology, Shizuoka Cancer Center, Nagaizumi, Japan
| | | | - Tamaki Momoi
- Department of Gastroenterology, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Takehiro Shimizu
- Department of Gastroenterology, Isesaki Municipal Hospital, Isesaki, Japan
| | - Kenji Kunieda
- Department of Medical Oncology, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Shinichiro Takeda
- Department of Gastroenterology, Matsudo City Hospital, Matsudo, Japan
| | - Hirokazu Komatsu
- Department of Community Care, Saku Central Hospital, Saku, Japan
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14
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Li R, Cai S, Sun D, Shi Q, Ren Z, Qi Z, Li B, Yao L, Xu M, Zhou P, Zhong Y. Risk factors for delayed bleeding after endoscopic submucosal dissection of colorectal tumors. Surg Endosc 2020; 35:6583-6590. [PMID: 33237467 DOI: 10.1007/s00464-020-08156-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 11/06/2020] [Indexed: 12/23/2022]
Abstract
AIM To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) for colorectal neoplasms. METHODS We retrospectively reviewed the medical records of 991 consecutive patients who underwent ESD for colorectal neoplasms at our hospital from January 2007 to November 2016. Delayed post-ESD bleeding was defined as bleeding within 6 h to 30 days after ESD that resulted in either of the three situations: overt hematochezia, bleeding spots confirmed by repeat colonoscopy, or the requirement of a blood transfusion. Delayed bleeding was furtherly separated into early and late delayed bleeding by the end of post-ESD day 2. We analyzed the relationship between delayed bleeding and candidate factors including patient-, lesion-, and treatment-related details. RESULTS Delayed post-ESD bleeding was found in 47 patients (4.7%), of which 18 cases were late delayed bleeding. Among all patients, 14 patients required a second colonoscopy, and 2 other patients were transferred to surgery. Univariate analysis revealed that patients with hypertension (p = 0.017) and using hot biopsy forceps for wound management (p = 0.028) were significantly associated with late delayed bleeding. Both risk factors remained significant after multivariate analysis: hypertension (OR 2.829, 95% CI 1.101-7.265, p = 0.031), hot biopsy forceps (OR 2.873, 95% CI 1.013-8.147, p = 0.047). Using hot biopsy forceps was also the significant risk factor for late delayed bleeding compared with early delayed bleeding. CONCLUSION Patient with hypertension and using hot biopsy forceps for wound management during procedure call for attention on high risk of delayed post-ESD bleeding. Therefore, additional perioperative treatment is recommended in patients with these risk factors.
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Affiliation(s)
- Ran Li
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shilun Cai
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Di Sun
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Qiang Shi
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhong Ren
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhipeng Qi
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Bing Li
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Liqing Yao
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Meidong Xu
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Pinghong Zhou
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yunshi Zhong
- Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, 200032, China. .,Endoscopy Research Institute of Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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15
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Xu Y, Zhong S, Liang W, Lin XL. The risk factors for delayed bleeding after endoscopic resection of colorectal tumors: a meta-analysis. Expert Rev Gastroenterol Hepatol 2020; 14:1083-1092. [PMID: 32721191 DOI: 10.1080/17474124.2020.1801416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The most common complication of post-colorectal endoscopic resection is delayed bleeding. The assessment of risk factors for delayed bleeding provides important and useful information in standard clinical operations. The risk factors have been previously reported; however, they remain inconsistent across different studies. AREAS COVERED In this meta-analysis, the patient conditions, lesion-related factors, and operation-related factors were compared between delayed bleeding and no bleeding. PubMed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched to identify eligible studies. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated along with heterogeneity. EXPERT OPINION This study is the first meta-analysis to investigate risk factors for colorectal delayed bleeding. We found several risk factors contributing to this condition: colorectal tumors located in the proximal colon, a history of antithrombotic drug use, high-grade intraepithelial neoplasia or early cancer, piecemeal resection, intraoperative hemorrhage, no clip placement, and severe submucosal fibrosis. Despite our findings, we also conclude that more high-quality, large-scale clinical randomized controlled studies are needed due to limited retrospective studies at present. Future therapeutic colonoscopies should focus on precise diagnosis, treatment safety, and management during the perioperative period.
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Affiliation(s)
- Yanqin Xu
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Shishun Zhong
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Wei Liang
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Xiao Lu Lin
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
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16
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Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
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17
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Periprocedural adverse events after endoscopic resection of T1 colorectal carcinomas. Gastrointest Endosc 2020; 91:142-152.e3. [PMID: 31525362 DOI: 10.1016/j.gie.2019.08.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS In contrast to the adverse event (AE) risk of endoscopic resection (ER) of adenomas, the intra- and postprocedural AE risks of ER of T1 colorectal cancer (CRC) are scarcely reported in the literature. It is unclear whether ER of early CRCs, which grow into the submucosal layer and sometimes show incomplete lifting, is associated with an increased AE risk. We aimed to identify the AE rate after ER of T1 CRCs and to identify the risk factors associated with these AEs. METHODS Medical records of patients with T1 CRCs diagnosed between 2000 and 2014 in 15 hospitals in the Netherlands were reviewed. Patients who underwent primary ER were selected. The primary outcome was the occurrence of endoscopy-related AEs. The secondary outcome was the identification of risk factors. Multivariate logistic regression was performed. RESULTS Endoscopic AEs occurred in 59 of 1069 (5.5%) patients, among which 37.3% were classified as mild, 59.3% as moderate, and 3.4% as severe. AEs were postprocedural bleeding (n = 40, 3.7%), perforation (n = 13, 1.2%), and postpolypectomy electrocoagulation syndrome (n = 6, 0.6%). No fatal AEs were observed. Independent predictors for AEs were age >70 years (odds ratio, 2.11; 95% confidence interval, 1.12-3.96) and tumor size >20 mm (odds ratio, 2.22; 95% confidence interval, 1.05-4.69). CONCLUSIONS In this large multicenter retrospective cohort study, AE rates of ER of T1 CRC (5.5%) are comparable with reported AE rates for adenomas. Larger tumor size and age >70 years are independent predictors for AEs. This study suggests that endoscopic treatment of T1 CRCs is not associated with an increased periprocedural AE risk.
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18
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Tanaka S, Kashida H, Saito Y, Yahagi N, Yamano H, Saito S, Hisabe T, Yao T, Watanabe M, Yoshida M, Saitoh Y, Tsuruta O, Sugihara KI, Igarashi M, Toyonaga T, Ajioka Y, Kusunoki M, Koike K, Fujimoto K, Tajiri H. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2020; 32:219-239. [PMID: 31566804 DOI: 10.1111/den.13545] [Citation(s) in RCA: 204] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 12/13/2022]
Abstract
Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also several types of precarcinomatous adenomas. It is important to establish practical guidelines wherein preoperative diagnosis of colorectal neoplasia and selection of endoscopic treatment procedures are appropriately outlined and to ensure that actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society compiled colorectal endoscopic submucosal dissection/endoscopic mucosal resection guidelines by using evidence-based methods in 2014. The first edition of these guidelines was published 5 years ago. Accordingly, we have published the second edition of these guidelines based on recent new knowledge and evidence.
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Affiliation(s)
- Shinji Tanaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan.,Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan.,Japanese Society of Coloproctology, Tokyo, Japan.,Japanese Society of Gastroenterology, Tokyo, Japan
| | | | - Yutaka Saito
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan.,Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
| | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroo Yamano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shoichi Saito
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takashi Hisabe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takashi Yao
- Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
| | - Masahiko Watanabe
- Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan.,Japanese Society of Coloproctology, Tokyo, Japan
| | - Masahiro Yoshida
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan.,Japanese Society of Gastroenterology, Tokyo, Japan
| | - Yusuke Saitoh
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Osamu Tsuruta
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | | | - Yoichi Ajioka
- Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
| | | | | | | | - Hisao Tajiri
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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19
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Arimoto J, Chiba H, Ashikari K, Fukui R, Anan H, Tachikawa J, Suto T, Kawano N, Niikura T, Kuwabara H, Nakaoka M, Kato S, Ida T, Morohashi T, Goto T, Nakajima A. Safety of Cold Snare Polypectomy in Patients Receiving Treatment with Antithrombotic Agents. Dig Dis Sci 2019; 64:3247-3255. [PMID: 30684074 DOI: 10.1007/s10620-019-5469-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/16/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND With the aging of the population and rising incidence of thromboembolic events, the clinical use of antithrombotic agents is also increasing. There are few reports yet on the management of antithrombotic agent use in patients undergoing cold snare polypectomy (CSP). AIMS The aim of this study was to evaluate whether continued administration of antithrombotic agents in patients undergoing CSP would be associated with an increased rate of delayed post-polypectomy bleeding (DPPB). METHODS A total of 1177 colorectal polyps in 501 patients were resected at Omori Red Cross Hospital between October 2017 and March 2018. The polyps were divided into two groups depending on whether the patients received antithrombotic agent treatment or not: the antithrombotic group (911 polyps) and the no-antithrombotic group (266 polyps). RESULTS Among the 1177 polyp resections, there was no case of DPPB, including in the antithrombotic group. Immediate bleeding occurred in a total of 63 (5.4%) cases. Polyp location in the rectum (OR (95% CI) 2.64 (1.223-5.679); p = 0.013), polyp size ≥ 6 mm (OR (95% CI) 4.64 (2.719-7.933); p < 0.001), polypoid growth pattern (OR (95% CI) 2.78 (1.607-4.793); p < 0.001), and antithrombotic agent use (OR (95% CI) 2.98 (1.715-5.183); p < 0.001) were identified as significant risk factors of immediate bleeding. CONCLUSIONS Continued use of antithrombotic agents does not increase the risk of DPPB, even in those receiving multiple antithrombotic agents. Thus, it is safe to perform CSP even in multiple agent users. Prospective, randomized studies are necessary to confirm our results.
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Affiliation(s)
- Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan.
| | - Keiichi Ashikari
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Ryo Fukui
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Hideyuki Anan
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Takuma Suto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Naoya Kawano
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Toshihiro Niikura
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Tomonori Ida
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Taiki Morohashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Tohru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
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20
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Turan AS, Ultee G, Van Geenen EJM, Siersema PD. Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection. Expert Rev Med Devices 2019; 16:493-501. [PMID: 31109217 DOI: 10.1080/17434440.2019.1618707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The most commonly used treatment for advanced colorectal adenomas is endoscopic mucosal resection (EMR). The increased number of EMRs since the introduction of the screening program for colorectal cancer has resulted in an increase in EMR-related complications. This review summarizes the current knowledge for the use of clips for the treatment and prevention of complications after EMR. AREAS COVERED The historical development of clips is summarized and their properties are evaluated. An overview is presented of the evidence for therapeutic and prophylactic clipping for bleeding or perforation after EMR in the colon. Several clipping techniques are discussed in relation to the efficacy of wound closure. Furthermore, new techniques that will likely influence the use of clips in the future endoscopic practice, such as endoscopic full-thickness resection (eFTR) are also highlighted. EXPERT COMMENTARY Most research focuses on prophylactic clipping for delayed bleeding after EMR of large adenomas. We advocate a distance of 0.5-1.0 cm between aligning clips. This focus may likely shift from bleeding to perforation. Here, endoscopic treatment with through-the-scope clips and large-diameter clips may well replace surgery. The future role of clips will also depend on the further development of new endoscopic technologies, such as eFTR.
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Affiliation(s)
- A S Turan
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - G Ultee
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - E J M Van Geenen
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - P D Siersema
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
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21
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Ayoub F, Westerveld DR, Forde JJ, Forsmark CE, Draganov PV, Yang D. Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis. World J Gastroenterol 2019; 25:2251-2263. [PMID: 31143075 PMCID: PMC6526150 DOI: 10.3748/wjg.v25.i18.2251] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/22/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes.
AIM To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm.
METHODS We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using a random-effects model.
RESULTS Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies (I2 = 0%, P = 0.67).
CONLUSION Prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Donevan R Westerveld
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Justin J Forde
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
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22
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Kim ER, Chang DK. Management of Complications of Colorectal Submucosal Dissection. Clin Endosc 2019; 52:114-119. [PMID: 30959586 PMCID: PMC6453857 DOI: 10.5946/ce.2019.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/21/2010] [Indexed: 12/11/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of superficial gastrointestinal neoplasm. Compared with endoscopic mucosal resection (EMR), ESD has several benefits, which include resectability of various difficult lesion, accurate histologic assessment of specimen, and lower recurrence rate. However, the risk of procedure- related complications is higher with ESD than with EMR. Moreover, because the colon has a thin wall and limited endoscopic maneuverability, ESD is considered a more challenging and risky procedure when performed in the colon than in the stomach. ESD-related complications are more likely to occur. The significant complications associated with ESD are bleeding, perforation, coagulation syndrome and stenosis, most of which can be treated and prevented by endoscopic intervention and preparation. Therefore, it is important to know how to occur and manage the ESD related complication.
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Affiliation(s)
- Eun Ran Kim
- Division of Gastroenterology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Division of Gastroenterology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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23
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Continued Use of a Single Antiplatelet Agent Does Not Increase the Risk of Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection. Dig Dis Sci 2018; 63:218-227. [PMID: 29177848 PMCID: PMC5760603 DOI: 10.1007/s10620-017-4843-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND With the aging of the population and rising incidence of thromboembolic events, the usage of antiplatelet agents is also increasing. There are few reports yet on the management of antiplatelet agents for patients undergoing colorectal endoscopic submucosal dissection (ESD). AIMS The aim of this study is to evaluate whether continued administration of antiplatelet agents is associated with an increased rate of delayed bleeding after colorectal ESD. METHODS A total of 1022 colorectal neoplasms in 927 patients were dissected at Yokohama City University Hospital and its three affiliate hospitals between July 2012 and June 2017. We included the data of 919 lesions in the final analysis. The lesions were divided into three groups: the no-antiplatelet group (783 neoplasms), the withdrawal group (110 neoplasms), and the continuation group (26 neoplasms). RESULTS Among the 919 lesions, bleeding events occurred in a total of 31 (3.37%). The rate of bleeding after ESD was 3.3% (26/783), 4.5% (5/110), and 0% (0/26), respectively. There were no significant differences in the rate of bleeding after ESD among the three groups (the withdrawal group vs. the no-antiplatelet group, the continuation group vs. the no-antiplatelet group, and the withdrawal group vs. the continuation group). CONCLUSIONS Continued administration of antiplatelet agents is not associated with any increase in the risk of delayed bleeding after colorectal ESD. Prospective, randomized studies are necessary to determine whether treatment with antiplatelet agents must be interrupted prior to colorectal ESD in patients who are at a high risk of thromboembolic events.
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Yamashina T, Fukuhara M, Maruo T, Tanke G, Marui S, Sada R, Taki M, Ohara Y, Sakamoto A, Henmi S, Sawai Y, Saito S, Nishijima N, Nasu A, Komekado H, Sekikawa A, Asada M, Tumura T, Kita R, Kimura T, Osaki Y. Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis. Endosc Int Open 2017; 5:E587-E594. [PMID: 28670615 PMCID: PMC5482743 DOI: 10.1055/s-0043-105578] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 02/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Cold snare polypectomy (CSP) for small colorectal polyps has lower incidence of adverse events, especially delayed postpolypectomy bleeding (DPPB). However, few data are available on comparisons of the incidence of DPPB of CSP and hot polypectomy (HP). The aim of this study was to evaluate the incidence of DPPB after CSP and compare it with that of HP. A propensity score model was used as a secondary analysis. PATIENTS AND METHODS This was a retrospective cohort study conducted in a single municipal hospital. We identified 539 patients with colorectal polyps from 2 mm to 11 mm in size who underwent CSP (804 polyps in 330 patients) or HP (530 polyps in 209 patients) between July 2013 and June 2015. RESULTS There were no cases of DPPB in the CSP group. Conversely, DPPB occurred in 4 patients (1.9 %) after HP, resulting in a significant difference between the CSP and HP groups (0.008 % vs 0 %, P = 0.02). Propensity score-matching analysis created 402 matched pairs, yielding a significantly higher DPPB rate in the HP group than CSP group (0.02 % vs 0 %, P = 0.04). However, significantly more patients in the CSP group had unclear horizontal margins that precluded assessment (83 vs 38 cases, P < 0.001). The retrieval failure rate was significantly higher in the CSP group than in the HP group (3 % vs 0.7 %, P = 0.01). CONCLUSIONS DPPB was less frequent with CSP than HP, as selected by the propensity score-matching model. Our findings indicate that CSP is recommended polypectomy in daily clinical setting. However, special care should be taken during polyp retrieval and horizontal margin assessment, and these issues could be taken into account in follow-up after CSP.
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Affiliation(s)
- Takeshi Yamashina
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan,Corresponding author Takeshi Yamashin Department of Gastroenterology and HepatologyOsaka Red Cross HospitalOsaka, Japan30 Fudegasaki, Tenouji, Osaka 543-8555Japan(+81) 6-(6774)-5131
| | - Manabu Fukuhara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takanori Maruo
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Gensho Tanke
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryota Sada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Mio Taki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yoshiaki Ohara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Azusa Sakamoto
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shinichiro Henmi
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yugo Sawai
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Sumio Saito
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Norihiro Nishijima
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akihiro Nasu
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hideyuki Komekado
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akira Sekikawa
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takehiko Tumura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryuichi Kita
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Toru Kimura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yukio Osaki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
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25
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Tullavardhana T, Akranurakkul P, Ungkitphaiboon W, Songtish D. Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies. Ann Med Surg (Lond) 2017; 19:65-73. [PMID: 28652912 PMCID: PMC5476974 DOI: 10.1016/j.amsu.2017.05.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Bleeding is the most common major complication following colonoscopic polypectomy. The purpose of this study is to evaluate whether submucosal epinephrine injections could prevent the occurrence of postpolypectomy bleeding. Method The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for appropriate randomized controlled studies published before April 2015. A meta-analysis was conducted to investigate the preventative effect of submucosal epinephrine injection for overall, early, and delayed postpolypectomy bleeding. Results The final analysis examined the findings of six studies, with data from 1388 patients. The results demonstrated that prophylactic treatment with epinephrine injection significantly reduced the occurrence of overall (OR = 0.38, 95% CI: 0.21, 0.66; p = 0.0006) and early bleeding (OR = 0.38, 95% CI: 0.20, 0.69; p = 0.002). However, for delayed bleeding complications, epinephrine injections were not found to be any more effective than treatment with saline injection or no injection (OR = 0.45, 95% CI: 0.11, 1.81; p = 0.26). Moreover, for patients with polyps larger than 20 mm, mechanical hemostasis devices (endoloops or clips) were found to be more effective than epinephrine injection in preventing overall bleeding (OR = 0.33, 95% CI: 0.13, 0.87; p = 0.03) and early bleeding (OR = 0.29, 95% CI: 0.08, 1.02; p = 0.05). This was not established for delayed bleeding. Conclusion The routine use of prophylaxis submucosal epinephrine injection is safe and beneficial preventing postpolypectomy bleeding.
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Affiliation(s)
- Thawatchai Tullavardhana
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Prinya Akranurakkul
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Withoon Ungkitphaiboon
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Dolrudee Songtish
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
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26
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Nishizawa T, Suzuki H, Goto O, Ogata H, Kanai T, Yahagi N. Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies. United European Gastroenterol J 2017; 5:859-867. [PMID: 29026600 DOI: 10.1177/2050640616687837] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/06/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIM The efficacy of clipping for preventing delayed bleeding after colorectal endoscopic resection is still controversial. To assess the efficacy of prophylactic clipping, we conducted a meta-analysis of randomized controlled trials. METHODS We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified seven eligible randomized trials from the database search, and compared the effect of clipping versus non-clipping with respect to delayed bleeding and perforation. Data from eligible studies were combined to calculate pooled odds ratios (ORs). RESULTS Postoperative bleeding was observed in 41 of 1526 cases (2.7%) without clipping and in 32 of 1533 cases (2.1%) with clipping (OR 0.76, 95% CI: 0.39-1.47, p = 0.414). There was no significant heterogeneity among the trial results (I-Square = 26.7%, p = 0.22). In the subgroup analysis based on small tumor size (<20 mm) and large tumor size (≥20 mm), there were no significant differences. Compared with non-clipping, the pooled OR of developing perforation with clipping was 1.00 (95% CI: 0.14-7.25), indicating no significant difference between the two groups. CONCLUSIONS Prophylactic clipping did not decrease the occurrence of delayed bleeding after colorectal endoscopic resection. Clipping could be of interest in patients with a high risk of bleeding (anticoagulation) or large lesions, but with the available trials data to prove this are scarce.
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekazu Suzuki
- Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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27
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Boumitri C, Mir FA, Ashraf I, Matteson-Kome ML, Nguyen DL, Puli SR, Bechtold ML. Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review. Ann Gastroenterol 2016; 29:502-508. [PMID: 27708518 PMCID: PMC5049559 DOI: 10.20524/aog.2016.0075] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/01/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Bleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding. METHODS Multiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip. RESULTS Five hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56-4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42-1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69-2.24; P=0.47) were analyzed. CONCLUSIONS The use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.
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Affiliation(s)
- Christine Boumitri
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Fazia A Mir
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Imran Ashraf
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Michelle L Matteson-Kome
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Douglas L Nguyen
- Department of Medicine, University of California, Irvine (Douglas L. Nguyen), USA
| | - Srinivas R Puli
- Department of Medicine, University of Illinois, Peoria (Srinivas R. Puli), USA, USA
| | - Matthew L Bechtold
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
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28
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Fang X, Baillargeon JG, Jupiter DC. Continued Antiplatelet Therapy and Risk of Bleeding in Gastrointestinal Procedures: A Systematic Review. J Am Coll Surg 2016; 222:890-905.e11. [PMID: 27016908 DOI: 10.1016/j.jamcollsurg.2016.01.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated with perioperative use of antiplatelet medication. However, cessation of these drugs may be unsafe for patients who are required to maintain antiplatelet use due to cardiovascular conditions. The objective of this systematic review was to compare the risk of intraoperative or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy) with the risk among those not taking continuous antiplatelet medication. STUDY DESIGN We reviewed articles published between January 2000 and July 2015 from the Medline Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies involving any GI procedures were included if the articles met our inclusion criteria (listed in Methods). The following key words were used for the search: clopidogrel, Plavix, aspirin, antiplatelet, bleeding, hemorrhage, and digestive system surgical procedures. Quality of the studies was assessed, depending on their study design, using the Newcastle-Ottawa score or the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Twenty-two studies were eligible for inclusion in the systematic review. Five showed that the risk of intraoperative bleeding or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy was higher compared that for those not on continuous therapy. The remaining 17 studies reported that there was no statistically significant difference in the risks of bleeding between the continuous antiplatelet therapy group and the group without continuous antiplatelet therapy. CONCLUSIONS The risk of bleeding associated with GI procedures in patients receiving antiplatelet therapy was not significantly higher than in patients with no antiplatelet or interrupted antiplatelet therapy.
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Affiliation(s)
- Xiao Fang
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
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29
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Ninomiya Y, Oka S, Tanaka S, Nishiyama S, Tamaru Y, Asayama N, Shigita K, Hayashi N, Chayama K. Risk of bleeding after endoscopic submucosal dissection for colorectal tumors in patients with continued use of low-dose aspirin. J Gastroenterol 2015; 50:1041-6. [PMID: 25682173 DOI: 10.1007/s00535-015-1053-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 02/02/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although Japanese guidelines proposed by the Japan Gastroenterological Endoscopy Society for endoscopic submucosal dissection (ESD) for colorectal tumors recommend continued use of low-dose aspirin (LDA), this strategy is controversial. It was our practice to interrupt LDA therapy 5-7 days before ESD until December 2010, when we instituted the new guidelines and performed ESD without interrupting LDA therapy. The aim of the present study was to confirm the validity of the noninterrupted use of LDA inpatients undergoing ESD for colorectal tumors. METHODS We studied 582 consecutive patients with 609 colorectal tumors who underwent ESD at Hiroshima University Hospital between January 2006 and July 2014. The patients comprised three groups: LDA-interrupted group (13 patients with 13 colorectal tumors), LDA-continued group (28 patients with 31 colorectal tumors), and no anticoagulant/antiplatelet group (541 patients with 565 colorectal tumors). RESULTS The en bloc resection rate was 100% (13/13) in the LDA-interrupted group and 90.3% (28/31) in the LDA-continued group. Incidences of poor bleeding control during the procedure and bleeding after the procedure were 7.7% (1/13) and 15.4% (2/13) of patients, respectively, in the LDA-interrupted group, and 3.2% (1/31) and 16.1% (5/31) of patients, respectively, in the LDA-continued group. No patients experienced ischemic events in the perioperative period. CONCLUSIONS Our data suggest that continued use of LDA increased the risk of bleeding after ESD for colorectal tumors compared with nonuse of anticoagulant/antiplatelets. No significant difference was seen between the LDA-continued group and the LDA-interrupted group.
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Affiliation(s)
- Yuki Ninomiya
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Soki Nishiyama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yuzuru Tamaru
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Naoki Asayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenjiro Shigita
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nana Hayashi
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Endoscopic mucosal resection of early oesophageal neoplasia in patients requiring anticoagulation: is it safe? Surg Endosc 2015; 30:2390-5. [PMID: 26307599 DOI: 10.1007/s00464-015-4489-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 08/01/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Endoscopic mucosal resection (EMR) has become the standard treatment for early oesophageal neoplasia. The mucosal defect caused by EMR usually takes several weeks to heal. Despite guidelines on high-risk endoscopic procedures in patients on anticoagulation, evidence is lacking whether EMR is safe in such patients. We investigated the immediate and delayed bleeding risk in patients undergoing diagnostic or therapeutic oesophageal EMR comparing patients requiring warfarin anticoagulation with a control group. METHODS Warfarin was stopped 5 days before the planned EMR and restarted on the evening following the procedure. Patients with high-risk conditions, such as recent pulmonary thromboemboli, received bridging with low molecular weight heparin. All EMRs were performed when the INR was <1.5. Bleeding events on the day of the EMR and within 3 months post-procedure were documented. RESULTS One hundred and seventeen consecutive patients with early oesophageal neoplasia were included. Sixty-eight EMRs were performed in 15 patients requiring anticoagulation. One patient on warfarin was readmitted 10 days after EMR with haematemesis and melaena. Out of 400 EMRs in 102 controls, 26 immediate bleeding events occurred requiring endoscopic intervention. One delayed bleeding event (melaena) occurred in the control group. The number of bleeding events did not differ between groups [p = 0.99; odds ratio 1.01 (0.30-3.44)], neither for acute (p = 0.76) nor delayed bleeding (p = 0.24). CONCLUSION EMR of early oesophageal neoplasia can be safely performed in patients requiring anticoagulation when warfarin is discontinued 5 days before the endoscopic intervention and reinstituted on the evening of the procedure day.
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Tanaka S, Kashida H, Saito Y, Yahagi N, Yamano H, Saito S, Hisabe T, Yao T, Watanabe M, Yoshida M, Kudo SE, Tsuruta O, Sugihara KI, Watanabe T, Saitoh Y, Igarashi M, Toyonaga T, Ajioka Y, Ichinose M, Matsui T, Sugita A, Sugano K, Fujimoto K, Tajiri H. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27:417-434. [PMID: 25652022 DOI: 10.1111/den.12456] [Citation(s) in RCA: 398] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/02/2015] [Indexed: 12/12/2022]
Abstract
Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence-based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas.
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Affiliation(s)
- Shinji Tanaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan.,Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
| | | | - Yutaka Saito
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroo Yamano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shoichi Saito
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takashi Hisabe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takashi Yao
- Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
| | - Masahiko Watanabe
- Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan.,Japanese Society of Coloproctology, Tokyo, Japan
| | | | - Shin-Ei Kudo
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Osamu Tsuruta
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Yusuke Saitoh
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Yoichi Ajioka
- Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
| | - Masao Ichinose
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Toshiyuki Matsui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan.,Japanese Society of Coloproctology, Tokyo, Japan
| | - Akira Sugita
- Japanese Society of Coloproctology, Tokyo, Japan
| | | | | | - Hisao Tajiri
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Geraghty J, O'Toole P, Anderson J, Valori R, Sarkar S. National survey to determine current practices, training and attitudes towards advanced polypectomy in the UK. Frontline Gastroenterol 2015; 6:85-93. [PMID: 28839795 PMCID: PMC5369560 DOI: 10.1136/flgastro-2014-100516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/24/2014] [Accepted: 10/27/2014] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Developments in advanced polypectomy technique provide an alternative to surgery in the management of large and complex colorectal polyps. These endoscopic techniques require expertise and can potentially incur high complication rates. This survey evaluates current UK practice, attitudes and training in advanced polypectomy. DESIGN Anonymous online questionnaire. SETTING Colonoscopists within the UK were asked about their approach to large polyps (>2 cm). RESULTS Among the 268 respondents (64% of whom were BCSP accredited), 86% were confident in removing lesions >2 cm by endoscopic mucosal resection (EMR). Of these, 27% were classed as low volume operators (<10 lesions resected/annum) and 14% as high volume operators (>50/annum). By comparison, only 3% currently performed endoscopic submucosal dissection (ESD). Referring one or more benign polyps for surgery a year was common among responders of all levels (11-68%). Training deficiencies were common: only 21% of responders had received a period of training dedicated to advanced polypectomy; 58% of responders would welcome a national training scheme and a majority supported the implementation of advanced polypectomy accreditation with national guidelines. However, while 41% wanted nominated regional EMR experts, only 18% would welcome an integrated national referral network for large/complex polyps. CONCLUSIONS EMR is practised widely while ESD service provision is very limited. Most experienced colonoscopists are confident to perform piecemeal EMR, even if their training is suboptimal and annual numbers low. Practices and attitudes were variable, even among self-defined level 4 operators. Improving training and implementation of accreditation were welcomed, but there was little appetite for mandated referral to subspecialist 'experts' and national networks.
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Affiliation(s)
- Joe Geraghty
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Paul O'Toole
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Royal Hospital,Gloucester, UK
| | - Sanchoy Sarkar
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK,University of Liverpool, Liverpool, UK
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Hoteya S, Kaise M, Iizuka T, Ogawa O, Mitani T, Matsui A, Kikuchi D, Furuhata T, Yamashita S, Yamada A, Kimura R, Nomura K, Kuribayashi Y, Miyata Y, Yahagi N. Delayed bleeding after endoscopic submucosal dissection for non-ampullary superficial duodenal neoplasias might be prevented by prophylactic endoscopic closure: analysis of risk factors. Dig Endosc 2015; 27:323-30. [PMID: 25186455 DOI: 10.1111/den.12377] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 08/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Duodenal endoscopic submucosal dissection (ESD) is technically challenging because of anatomical specificities and, to date, has not been validated concerning the high rate of complications such as perforation and delayed bleeding. In the present study, the risk factors for delayed bleeding after duodenal ESD are presented with the goal of establishing preventive measures. METHODS We analyzed 63 patients with non-ampullary superficial duodenal neoplasias treated by ESD from April 2005 to March 2014. To analyze the risk factors of delayed bleeding after duodenal ESD, we divided the patients into a delayed bleeding group and a non-bleeding group. To verify the risk factors of delayed bleeding after duodenal ESD, we analyzed various patient-, lesion-, and treatment-related factors. RESULTS Delayed bleeding was experienced in 11 patients (17.5%) Univariate analysis of patient-related risk factors of delayed bleeding indicated no significant risk factor. Univariate analysis of lesion-related and treatment-related risk factors indicated only endoscopic closure as a significant risk factor. Multivariate analysis also identified endoscopic closure (not done > done: P = 0.049) as an independent factor significantly associated with delayed bleeding after duodenal ESD. Hypertension (present > absent: P = 0.055) showed a non-significant tendency of association by multivariate analysis. CONCLUSIONS This retrospective evaluation found that endoscopic closure was associated with a reduced risk of delayed bleeding after duodenal ESD. Delayed bleeding after duodenal ESD might be prevented by prophylactic endoscopic closure.
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Affiliation(s)
- Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
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A randomized study on the effectiveness of prophylactic clipping during endoscopic resection of colon polyps for the prevention of delayed bleeding. BIOMED RESEARCH INTERNATIONAL 2015; 2015:490272. [PMID: 25722979 PMCID: PMC4332985 DOI: 10.1155/2015/490272] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/19/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUNDS The efficacy of clipping for preventing the delayed bleeding after the removal of colon polyps is still controversial. In order to clarify this efficacy, a randomized controlled study was performed. METHODS One hundred and fifty-six patients with colon neoplasms (288 lesions) were enrolled in the study. The patients were randomly divided into two groups: clipping or nonclipping groups using a sealed envelope method before the endoscopic resections. Eight specialists and nine residents were invited to perform this procedure. The risk factors and the rates of delayed bleeding after the endoscopic resections in each group were investigated. RESULTS There were no significant differences in the bleeding rate between the clipping and nonclipping groups, while the length of the procedure was significantly longer and the cost was higher in the clipping group than in the nonclipping group. The rate of bleeding was significantly higher in cases with polyps 2 cm or larger and with a longer procedure time, while none of the other factors affected the bleeding rate. CONCLUSIONS This randomized controlled study revealed no significant effect of prophylactic clipping for preventing delayed bleeding after the endoscopic resection of colon polyps.
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Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms. Int J Colorectal Dis 2014; 29:877-82. [PMID: 24825723 DOI: 10.1007/s00384-014-1901-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Although delayed bleeding is a major complication of endoscopic submucosal dissection (ESD) for colorectal neoplasms, few reports have assessed the risk factors for delayed bleeding after colorectal ESD. METHODS This study included 363 consecutive patients in whom 377 colorectal neoplasms were resected using ESD between April 2006 and August 2012. We classified patients and lesions into two groups on the basis of presence or absence of delayed bleeding and retrospectively compared the clinicopathological characteristics and clinical outcomes of ESD between the two groups. RESULTS Delayed bleeding occurred in 25 (6.6 %) of 377 lesions, and all cases of delayed bleeding were successfully controlled by endoscopic procedures. With respect to patient-related factors, there was no significant difference between the groups in mean age, sex ratio, and current use of antithrombotic agents. With respect to lesion-related factors, there was no significant difference between the groups in mean lesion size, growth pattern, and mean procedure time (p = 0.6). Lesions located in the rectum (vs colon, p = 0.0005) and lesions with severe submucosal fibrosis (vs no or mild fibrosis, p = 0.022) were significantly related to delayed bleeding. Upon multivariate analysis, lesions located in the rectum (vs colon, odds ratio 4.19; p = 0.0009) were significantly related to delayed bleeding after colorectal ESD. CONCLUSIONS This study demonstrated that location of lesions in the rectum was a significant independent risk factor for delayed bleeding after ESD for colorectal neoplasms.
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Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video). Gastrointest Endosc 2013; 78:370-4. [PMID: 23680177 DOI: 10.1016/j.gie.2013.04.172] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 04/10/2013] [Indexed: 02/08/2023]
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