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Copland AP, Kahi CJ, Ko CW, Ginsberg GG. AGA Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review. Clin Gastroenterol Hepatol 2024; 22:470-479.e5. [PMID: 38032585 DOI: 10.1016/j.cgh.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
DESCRIPTION In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.
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Affiliation(s)
- Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Charles J Kahi
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Cynthia W Ko
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lau LHS, Jiang W, Guo CLT, Lui RN, Tang RSY, Chan FKL. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in aspirin users: a propensity-score analysis. Gastrointest Endosc 2023; 97:517-527.e1. [PMID: 36209766 DOI: 10.1016/j.gie.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Antithrombotic use is a significant risk factor of postpolypectomy bleeding (PPB). Evidence of prophylactic clipping is only available for proximal and large colonic lesions in the general population. Dedicated studies to examine the benefit of prophylactic clipping in patients on aspirin remain scarce. METHODS A propensity score-weighted retrospective cohort study was performed in a tertiary referral center from January 2018 to September 2021. Patients who received aspirin and underwent colonoscopic polypectomy, EMR, or endoscopic submucosal dissection were included. Data on baseline demographics, medications, and endoscopic factors (polyp number, size, location, and morphology; resection method; and prophylactic clipping) were captured. Propensity score-weighted models were developed between prophylactic clipping and no clipping groups. The primary outcome was delayed PPB within 30 days, with a composite endpoint consisting of repeated colonoscopy for hemostasis, requirement of blood transfusion, or hemoglobin drop >2 g/dL. RESULTS A total of 1373 patients with 3952 polyps were included. Baseline characteristics were balanced between the 2 groups. In the multivariate analysis, the largest polyp size was a significant risk factor for PPB (odds ratio, 1.07; 95% confidence interval, 1.02-1.11; P = .002). Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio, 1.34; 95% confidence interval, .83-2.18; P = .240) and did not show any risk reduction in subgroups with different polyp sizes and locations and endoscopic resection techniques. CONCLUSIONS Prophylactic clipping was not associated with a lower risk of PPB in aspirin users after endoscopic resection of colorectal polyps. Aspirin use should not be regarded as the only factor for the routine use of prophylactic clips.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Wei Jiang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Rashid N Lui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
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Response. Gastrointest Endosc 2022; 96:1095-1096. [PMID: 36404095 DOI: 10.1016/j.gie.2022.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/30/2022] [Indexed: 11/19/2022]
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Xu JH, Gao P, Zhou M, Gao S, Dong ZQ, Shen YC, Zhang QS. Clip-assisted endoloop ligation of the mucosal defect after resection of colorectal polyps decreased postprocedural delayed bleeding. Therap Adv Gastroenterol 2022; 15:17562848221131132. [PMID: 36406056 PMCID: PMC9669683 DOI: 10.1177/17562848221131132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Postprocedural delayed bleeding (PDB) remains the most common major complication of colorectal polypectomy. Incomplete clip closure of mucosal defect and unclosed injured blood vessels in gaps between clips may be the risk factors for PDB. OBJECTIVES To observe whether completely no-gap closure of mucosal defect after polypectomy can reduce PDB occurrence. DESIGN Single-center, retrospective case-control study. METHODS In this study based on historical comparisons of patients in 2 time periods, only the patients with polyps sized between 6 and 15 mm were included. A new clip-assisted endoloop ligation (CAEL, treatment group) method was used between January 2019 and December 2020, and a traditional simple clip closure (SCC, control) was used Between January 2017 and December 2018 to prevent PDB after polypectomy. The rate of PDB of two groups and risk factors for PDB were evaluated. RESULTS Totally 4560 patients were included in the study; 2418 patients belong to CAEL group, and 2142 patients belong to SCC group. The overall rate of PDB was significantly lower in CAEL group compared to SCC group (0.6% versus 1.5%, p < 0.00). On multivariate logistic analysis, CAEL was a significant independent preventive factor for PDB (odds ratio (OR), 0.092; 95% confidence interval (CI), 0.029-0.3335; p = 0.000). Polyps located at rectum (colon versus rectum) represented a significant independent risk factor for PDB (OR, 11.888; 95% CI, 3.343-42.269; p = 0.001). CONCLUSION Completely no-gap closure of mucosal defect after polypectomy further reduced the rate of PDB for polyps sized between 6 and 15 mm. CAEL may be a significant independent preventive factor for PDB. Polyps located at the rectum may be a significant independent risk factor for PDB.
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Affiliation(s)
- Jian-hua Xu
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Peng Gao
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Min Zhou
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Shuang Gao
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Zhi-qi Dong
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
| | - Yu-cui Shen
- Department of Gastroenterology, Shanghai Fourth
People’s Hospital Affiliated to Tongji University, Shanghai, China
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Forbes N, Gupta S, Frehlich L, Meng ZW, Ruan Y, Montori S, Chebaa BR, Dunbar KB, Heitman SJ, Feagins LA, Albéniz E, Pohl H, Bourke MJ. Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials. Gastrointest Endosc 2022; 96:721-731.e2. [PMID: 35667388 DOI: 10.1016/j.gie.2022.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm. METHODS We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses. RESULTS From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of .31 (95% confidence interval [CI], .17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of .78 (95% CI, .17-3.54) and .67 (95% CI, .20-2.22), respectively. CONCLUSIONS Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Benjamin R Chebaa
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Kerry B Dunbar
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven J Heitman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Linda A Feagins
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eduardo Albéniz
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain; Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA; Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA; Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Lau LHS, Guo CLT, Lee JKK, Chan CST, Mak JWY, Wong SH, Yip TCF, Wong GLH, Wong VWS, Chan FKL, Tang RSY. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in oral anticoagulant users: a propensity-score analysis. Gastrointest Endosc 2022; 96:530-542.e1. [PMID: 35413329 DOI: 10.1016/j.gie.2022.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Evidence of prophylactic clipping is inconsistent except for proximal and large colonic lesions in the general population. Although warfarin and direct oral anticoagulants (DOACs) are significant risk factors of postpolypectomy bleeding (PPB), dedicated studies to examine the benefit of prophylactic clipping in these high-risk patients remain limited. METHODS We performed a propensity score-weighted retrospective cohort study from 2012 to 2020. Patients who received an oral anticoagulant and underwent colonoscopic polypectomy were included. Data were collected on baseline demographics, medications (anticoagulant, antiplatelet, and heparin bridging), and endoscopies (polyp number, location, size, morphology, histopathology, resection method and prophylactic clipping). Propensity-score models with inverse probability of treatment weighting were developed between prophylactic clipping and no clipping groups. Unbalanced variables were included in a doubly robust model with multivariate analysis. The primary outcome was clinically significant delayed PPB, defined as a composite endpoint of hemoglobin drop ≥2 g/dL, blood transfusion, or repeat colonoscopy for hemostasis within 30 days. RESULTS Five hundred forty-seven patients with 1485 polyps were included. Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio [OR], 1.19; 95% confidence interval [CI], .73-1.95; P = .497). The hot resection method was associated with a significantly higher risk of PPB (OR, 9.76; 95% CI, 3.94-32.60; P < .001) compared with cold biopsy or snare polypectomy. In a subgroup analysis, prophylactic clipping was associated with a lower PPB risk in patients on DOACs (OR, .36; 95% CI, .16-.82; P = .015). CONCLUSIONS Prophylactic clipping was not associated with an overall reduced risk of PPB in patients on oral anticoagulants. The use of cold snare polypectomy should be maximized in anticoagulated patients.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Joyce K K Lee
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Clive S T Chan
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Sunny H Wong
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Terry C F Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions. Am J Gastroenterol 2022; 117:1080-1088. [PMID: 35765907 DOI: 10.14309/ajg.0000000000001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/27/2022] [Indexed: 12/11/2022]
Abstract
The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.
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Bourke MJ. Top tips for cold snare polypectomy (with video). Gastrointest Endosc 2022; 95:1226-1232. [PMID: 35007545 DOI: 10.1016/j.gie.2021.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/29/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Uraoka T, Takizawa K, Tanaka S, Kashida H, Saito Y, Yahagi N, Yamano HO, Saito S, Hisabe T, Yao T, Watanabe M, Yoshida M, Saitoh Y, Tsuruta O, Igarashi M, Toyonaga T, Ajioka Y, Fujimoto K, Inoue H. Guidelines for Colorectal Cold Polypectomy (supplement to "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection"). Dig Endosc 2022; 34:668-675. [PMID: 35113465 DOI: 10.1111/den.14250] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 02/08/2023]
Abstract
The Japan Gastroenterological Endoscopy Society published the second edition of the "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection" in 2019 to clarify the indications for colorectal endoscopic mucosal resection (EMR) and endoscopic submucosal dissection and to ensure appropriate preoperative diagnoses as well as effective and safe endoscopic treatment in front-line clinical settings. Endoscopic resection with electrocautery, including polypectomy and EMR, is indicated for colorectal polyps. Recently, the number of facilities introducing and implementing cold polypectomy without electrocautery has increased. Herein, we establish supplementary guidelines for cold polypectomy. Considering that the level of evidence for each statement is limited, these supplementary guidelines must be verified in clinical practice.
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Affiliation(s)
- Toshio Uraoka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kohei Takizawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shinji Tanaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Yutaka Saito
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiro-O 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
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Yusuke Saitoh
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Osamu Tsuruta
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Yoichi Ajioka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Miao YD, Tang XL, Wang JT, Mi DH. Prevention of late complications of endoscopic resection of colorectal lesions with a coverage agent: Current status of gastrointestinal endoscopy. World J Gastrointest Oncol 2022; 14:543-546. [PMID: 35317316 PMCID: PMC8919008 DOI: 10.4251/wjgo.v14.i2.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/31/2021] [Accepted: 01/25/2022] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ectomy of large nonpedunculated colorectal lesions (≥ 20 mm) might cause significant adverse incidents, such as delayed perforation and delayed bleeding, despite the closure of mucosal lesions with clips. The conventional utilization of prophylactic clipping has not decreased the risk of postprocedural delayed adverse events, and additional outcomes and cost-effectiveness research is needed for patients with proximal lesions ≥ 20 mm, in whom prophylactic clipping might be useful. Coverage of the wound after endoscopic excision offers shield protection against delayed concomitant diseases.
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Affiliation(s)
- Yan-Dong Miao
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xiao-Long Tang
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jiang-Tao Wang
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Deng-Hai Mi
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
- Dean's office, Gansu Academy of Traditional Chinese Medicine, Lanzhou 730000, Gansu Province, China
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Turan AS, Pohl H, Matsumoto M, Lee BS, Aizawa M, Desideri F, Albéniz E, Raju GS, Luba D, Barret M, Gurudu SR, Ramirez FC, Lin WR, Atsma F, Siersema PD, van Geenen EJM. The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis. Clin Gastroenterol Hepatol 2022; 20:362-371.e23. [PMID: 33991691 DOI: 10.1016/j.cgh.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. METHODS An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. RESULTS Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52). CONCLUSIONS Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.).
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Heiko Pohl
- Section of Gastroenterology and Hepatology, VA White River Junction, White River Junction, Vermont
| | - Mio Matsumoto
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | - Brian S Lee
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, California
| | - Masato Aizawa
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Aizuwakamatsu, Japan
| | - Federico Desideri
- Digestive and Liver Disease Department, Endoscopy Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; Gastroenterology Department, San Maurizio Hospital, Bolzano, Italy
| | - Eduardo Albéniz
- Department of Gastroenterology, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | | | - Daniel Luba
- Monterey Bay Gastroenterology Consultants, Monterey, California
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, AP-HP, Université de Paris, Paris, France
| | | | | | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Femke Atsma
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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12
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Gupta S, Sidhu M, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Byth K, Brown G, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 7:152-160. [PMID: 34801133 DOI: 10.1016/s2468-1253(21)00384-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. METHODS We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. FINDINGS Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. INTERPRETATION Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. FUNDING None.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Eric Yong Tat Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Stephen John Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Nicholas Graeme Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael John Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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13
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Forbes N, Hilsden RJ, Ruan Y, Poirier AE, O’Sullivan DE, Craig KM, Kerrison D, Brenner DR, Heitman SJ. Endocuff Vision improves adenoma detection rate in a large screening-related cohort. Endosc Int Open 2021; 9:E1583-E1592. [PMID: 34712550 PMCID: PMC8545492 DOI: 10.1055/a-1533-6183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/06/2021] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Endocuff Vision (ECV) increases adenoma detection rate (ADR) in randomized clinical trials; however, observational effectiveness data are lacking. We evaluated the effectiveness, safety, and practical aspects of ECV use in a large screening-related real-world cohort. Patients and methods In this observational study, patients undergoing screening-related colonoscopy from November 2018 to April 2019 comprised the baseline period, and those undergoing it from June to November 2019 comprised the ECV period, where ECV use was discretionary. The primary outcome was ADR, compared: 1) between ECV use and standard colonoscopy across both periods; and 2) between time periods. Secondary outcomes included indication-specific ADR, sessile serrated ADR (SSADR), cecal intubation rate (CIR), procedure times, patient comfort scores, and sedation use. Multilevel logistic regression was performed, yielding adjusted odds ratios (AOR) with 95 % confidence intervals (CIs). Results In 15,814 colonoscopies across both time periods, ADR was 46.7 % with standard colonoscopy and 54.6 % when ECV was used ( P < 0.001). Endoscopists used ECV in 77.6 % of procedures in the ECV period, during which overall ADR rose to 53.2 % compared to 46.3 % in the baseline period ( P < 0.001). ECV use was significantly associated with higher ADR (AOR 1.24, 95 % CI 1.10 to 1.40) after adjusting for relevant covariates including time period. ECV use did not result in lower CIR, longer procedure time, increased sedation use, or poorer comfort scores. Conclusions ECV use is associated with improved ADR without negatively impacting other key procedure and patient-related factors. Future studies should evaluate the cost-effectiveness of incorporating ECV into routine screening-related practice.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert J. Hilsden
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Cancer Epidemiology and Prevention Research, CancerControl Alberta, Alberta Health Services, Calgary, Alberta, Canada,Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abbey E. Poirier
- Department of Cancer Epidemiology and Prevention Research, CancerControl Alberta, Alberta Health Services, Calgary, Alberta, Canada,Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dylan E. O’Sullivan
- Department of Cancer Epidemiology and Prevention Research, CancerControl Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Kyla M. Craig
- Alberta Health Services (Calgary Zone), Calgary, Alberta, Canada
| | - Diana Kerrison
- Alberta Health Services (Calgary Zone), Calgary, Alberta, Canada
| | - Darren R. Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Cancer Epidemiology and Prevention Research, CancerControl Alberta, Alberta Health Services, Calgary, Alberta, Canada,Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J. Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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14
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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: 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: 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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15
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Chua TY, Kyanam Kabir Baig KR, Leung FW, Ashat M, Jamidar PA, Mulki R, Singh A, Yu JX, Lightdale JR. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020. Gastrointest Endosc 2021; 94:441-451. [PMID: 34147512 DOI: 10.1016/j.gie.2021.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.
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Affiliation(s)
- Tiffany Y Chua
- Division of Digestive Diseases, Harbor-University of California Los Angeles, Torrance, California, USA
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Felix W Leung
- VA Sepulveda Ambulatory Care Center, North Hills, California, USA
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ajaypal Singh
- Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica X Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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16
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Prophylactic clipping for delayed postpolypectomy bleeding: Moderately effective, but is it feasible in daily practice? Gastrointest Endosc 2021; 93:816-817. [PMID: 33741086 DOI: 10.1016/j.gie.2020.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
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17
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Zhang LY, Ngamruengphong S. Contemporary management of antithrombotic agents for patients undergoing peroral endoscopic myotomy. Gastrointest Endosc 2021; 93:850-852. [PMID: 33741088 DOI: 10.1016/j.gie.2020.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Linda Yun Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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18
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Bishay K, Meng ZW, Frehlich L, James MT, Kaplan GG, Bourke MJ, Hilsden RJ, Heitman SJ, Forbes N. Prophylactic clipping to prevent delayed colonic post-polypectomy bleeding: meta-analysis of randomized and observational studies. Surg Endosc 2021; 36:1251-1262. [PMID: 33751224 DOI: 10.1007/s00464-021-08398-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/12/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Delayed post-polypectomy bleeding (DPPB) is a commonly described adverse event following polypectomy. Prophylactic clipping may prevent DPPB in some patient subgroups. We performed a meta-analysis to assess both the efficacy and real-world effectiveness of prophylactic clipping. METHODS We performed a database search through March 2020 for clinical trials or observational studies assessing prophylactic clipping and DPPB. Pooled risk ratios (RR) were calculated using random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to elucidate clinical or methodological factors associated with effects on outcomes. RESULTS A total of 2771 citations were screened, with 11 randomized controlled trials (RCTs) and 9 observational studies included, representing 24,670 colonoscopies. DPPB occurred in 2.0% of patients overall. The pooled RR of DPPB was 0.47 (95% CI 0.29-0.77) from RCTs enrolling only patients with polyps ≥ 20 mm. Remaining pooled RCT data did not demonstrate a benefit for clipping. The pooled RR of DPPB was 0.96 (95% CI 0.61-1.51) from observational studies including all polyp sizes. For patients with proximal polyps of any size, the RR was 0.73 (95% CI 0.33-1.62) from RCTs. Meta-regression confirmed that polyp size ≥ 20 mm significantly influenced the effect of clipping on DPPB. CONCLUSION Pooled evidence demonstrates a benefit when clipping polyps measuring ≥ 20 mm, especially in the proximal colon. In lower-risk subgroups, prophylactic clipping likely results in little to no difference in DPPB.
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Affiliation(s)
- Kirles Bishay
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Zhao Wu Meng
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Matthew T James
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia.,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Robert J Hilsden
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada
| | - Steven J Heitman
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada
| | - Nauzer Forbes
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada. .,Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada.
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19
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Forbes N, Heitman SJ, Bourke MJ. When Evaluating the Benefit of Prophylactic Clipping Following Polypectomy, Not All of the Answers Are Found in Randomized Trials. Gastroenterology 2021; 160:1428-1429. [PMID: 32931785 DOI: 10.1053/j.gastro.2020.04.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/30/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Nauzer Forbes
- Department of Community Health Sciences, University of Calgary and Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Community Health Sciences, University of Calgary and Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital and Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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20
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Mack A, Mangira D, Moss A. Prevention of delayed post-polypectomy bleeding: Should we amend the 2017 ESGE Guideline? Endosc Int Open 2020; 8:E1111-E1114. [PMID: 32898199 PMCID: PMC7458743 DOI: 10.1055/a-1196-1602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Alexandra Mack
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
| | - Dileep Mangira
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
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