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Wang N, Shu L, Liu S, Yang L, Bai T, Shi Z, Liu X. Comparing endoscopic mucosal resection with endoscopic submucosal dissection in colorectal adenoma and tumors: Meta-analysis and system review. PLoS One 2023; 18:e0291916. [PMID: 37768914 PMCID: PMC10538725 DOI: 10.1371/journal.pone.0291916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/07/2023] [Indexed: 09/30/2023] Open
Abstract
AIMS This study aimed to evaluate the safety, efficacy, and long-term outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for treating colorectal adenomas and tumors. METHODS A systematic literature review was conducted using databases including PubMed, Web of Science, and Embase. Parameters such as number of patients or lesions, histological diagnosis, lesion size, surgery time, en-bloc resection, R0 resection, severe postoperative complications, and local recurrence were extracted and pooled for analysis. RESULTS A total of 12 retrospective studies involving 1289 patients and 1850 lesions were included in the analysis. EMR was found to have a shorter operation time by 53.6 minutes (95% CI: 51.3, 55.9, P<0.001) and fewer incidences of severe postoperative complications such as perforation and delayed bleeding (OR = 0.40, 95%CI: 0.23, 0.71, P<0.001). On the other hand, ESD had higher rates of en-bloc resection (OR = 0.15, 95%CI: 0.07, 0.30, P<0.001) and R0 resection (OR = 0.32, 95%CI: 0.16, 0.65, P<0.001). Recurrence after EMR was found to be significantly higher than that after ESD surgery (OR = 5.88, 95%CI: 2.15, 16.07, P = 0.037). CONCLUSIONS The study suggests that the choice of surgical method may have a greater impact on recurrence compared to the pathological type, and that ESD may be more suitable for the treatment of malignant lesions despite its higher rates of severe postoperative complications and longer operation time.
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Affiliation(s)
- Nian Wang
- Division of Gastroenterology, Wuhan No. 1 Hospital, Wuhan, China
| | - Lei Shu
- Division of Gastroenterology, Wuhan No. 1 Hospital, Wuhan, China
| | - Song Liu
- Division of Gastroenterology, Wuhan No. 1 Hospital, Wuhan, China
| | - Lin Yang
- Division of Gastroenterology, Wuhan No. 1 Hospital, Wuhan, China
| | - Tao Bai
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaohong Shi
- Division of Gastroenterology, Wuhan No. 1 Hospital, Wuhan, China
| | - Xinghuang Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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2
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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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Azevedo AASD, Ribeiro MCDPN, Mota FL, Correa PAFP, Loureiro JFM. Evaluation of recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:898-902. [PMID: 33054283 DOI: 10.17235/reed.2020.6695/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM the process that leads to the development of colorectal cancer takes many years and most tumors originate from polyps and non-polypoid lesions. Techniques of endoscopic resection are surgical treatment options, even in case of large lesions or with initial invasion. This study aimed to evaluate the recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions. METHODS a retrospective, longitudinal and descriptive trial was performed via an analysis of colonoscopies with the resection of non-pedunculated lesions larger than 3 cm, performed between 2014 and 2017. RESULTS sixty-two lesions were included from 61 patients and 32 (52.5 %) were female. The age ranged from 36 to 89 years, with a mean age of 60.5 years. Lesions had an average diameter of 40.08 mm, ranging from 30 to 80 mm. Regarding the location of the lesions, the most frequent colonic segments were the ascending and rectum, both accounting for 22.6 %. Considering the morphologic endoscopic classification, 67.7 % were granular laterally spreading tumors (LST), 38.8 % were homogeneous granular and 29 % were mixed granular. The most frequent histological types were tubulovillous adenoma (30.7 %) and intramucosal adenocarcinoma (29 %). The resection technique was piecemeal mucosectomy in 85.5 %. Five lesions were removed by en bloc mucosectomy, two (3.2 %) by endoscopic submucosal dissection (ESD) and two (3.2 %) by a hybrid technique. The recurrence rate was 25.8 %. Three patients needed complementary surgical treatment and the clinical success of endoscopic treatment was 95.1 %. CONCLUSION recurrence rate after endoscopic resection of large colorectal lesions was 25.8 % and surgical complementation rate due to failure in the endoscopic treatment of recurrence was 4.8 %.
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Raju G, Lum P, Ross W, Thirumurthi S, Miller E, Lynch P, Lee J, Bhutani MS, Shafi MA, Weston B, Blechacz B, Chang GJ, Hagan K, Rashid A, Davila M, Stroehlein J. Quality of endoscopy reporting at index colonoscopy significantly impacts outcome of subsequent EMR in patients with > 20 mm colon polyps. Endosc Int Open 2019; 7:E361-E366. [PMID: 30834295 PMCID: PMC6395098 DOI: 10.1055/a-0746-3520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/09/2018] [Indexed: 12/26/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is safe and cost-effective in management of patients with colon polyps. However, very little is known about the actions of the referring endoscopist following identification of these lesions at index colonoscopy, and the impact of those actions on the outcome of subsequent referral for EMR. The aim of this study was to identify practices at index colonoscopy that lead to failure of subsequent EMR. Patients and methods Two hundred and eighty-nine consecutive patients with biopsy-proven non-malignant colon polyps (> 20 mm) referred for EMR were analyzed to identify practices that could be improved from the time of identifying the lesion at index colonoscopy until completion of therapy. Results EMR was abandoned at colonoscopy at the EMR center in 71 of 289 patients (24.6 %). Reasons for abandoning EMR included diagnosis of invasive carcinoma (n = 9; 12.7 %), tethered lesions (n = 21; 29.6 %) from prior endoscopic interventions, and overly large (n = 22; 31 %) and inaccessible lesions (n = 17; 24 %) for complete and safe resection whose details were not recorded in the referring endoscopy report, or polyposis syndromes (n = 2; 2.8 %) that were not recognized. Conclusions In our practice, one in four EMR attempts were abandoned as a result of inadequate diagnosis or management by the referring endoscopist, which could be improved by education on optical diagnosis of polyps, comprehensive documentation of the procedure and avoidance of interventions that preclude resection.
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Affiliation(s)
- Gottumukkala Raju
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States,Corresponding author Gottumukkala Raju The University of Texas MD Anderson Cancer CenterGastroenterology, Hepatology and Nutrition1515 Holcombe BoulevardGI Division – Unit 1466Houston, TX 77030-4009United States+1-713-563-4408
| | - Phillip Lum
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - William Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ethan Miller
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Patrick Lynch
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jeffrey Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Mehnaz A. Shafi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Brian Weston
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Boris Blechacz
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Katherine Hagan
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Asif Rashid
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Marta Davila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - John Stroehlein
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Sehdev A, Sherer EA, Hui SL, Wu J, Haggstrom DA. Patterns of computed tomography surveillance in survivors of colorectal cancer at Veterans Health Administration facilities. Cancer 2017; 123:2338-2351. [PMID: 28211937 DOI: 10.1002/cncr.30569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/21/2016] [Accepted: 12/26/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Annual computed tomography (CT) scans are a component of the current standard of care for the posttreatment surveillance of survivors of colorectal cancer (CRC) after curative-intent resection. The authors conducted a retrospective study with the primary aim of assessing patient, physician, and organizational characteristics associated with the receipt of CT surveillance among veterans. METHODS The Department of Veterans Affairs Central Cancer Registry was used to identify patients diagnosed with AJCC collaborative stage I to III CRC between 2001 and 2009. Patient sociodemographic and clinical (ie, CRC stage and comorbidity) characteristics, provider specialty, and organizational characteristics were measured. Hierarchical multivariable logistic regression models were used to assess the association between patient, provider, and organizational characteristics on receipt of 1) consistently guideline-concordant care (at least 1 CT every 12 months for both of the first 2 years of CRC surveillance) versus no CT receipt and 2) potential overuse (>1 CT every 12 months during the first 2 years of CRC surveillance) of CRC surveillance using CT. The authors also analyzed the impact of the 2005 American Society of Clinical Oncology update in CRC surveillance guidelines on care received over time. RESULTS For 2263 survivors of stage II/III CRC who were diagnosed after 2005, 19.4% of patients received no surveillance CT, whereas potential overuse occurred in both surveillance years for 14.9% of patients. Guideline-concordant care was associated with younger age, higher stage of disease (stage III vs stage II), and geographic region. In adjusted analyses, younger age and higher stage of disease (stage III vs stage II) were found to be associated with overuse. There was no significant difference in the annual rate of CT scanning noted across time periods (year ≤ 2005 vs year > 2005). CONCLUSIONS Among a minority of veteran survivors of CRC, both underuse and potential overuse of CT surveillance were present. Patient factors, but no provider or organizational characteristics, were found to be significantly associated with patterns of care. The 2005 change in American Society of Clinical Oncology guidelines did not appear to have an impact on rates of surveillance CT. Cancer 2017;123:2338-2351. © 2017 American Cancer Society.
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Affiliation(s)
- Amikar Sehdev
- Division of Hematology and Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana.,Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Eric A Sherer
- Department of Chemical Engineering, Louisiana Tech University, Ruston, Louisiana.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana
| | - Siu L Hui
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Jingwei Wu
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, Pennsylvania
| | - David A Haggstrom
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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6
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Belle S, von Boscamp M, Sold M, Mack S, Pilz L, Ebert M, Kaehler G. Submucosal injection with waterjet improves endoscopic mucosal resection of colorectal adenoma - a randomised controlled clinical trial. Scand J Gastroenterol 2017; 52:222-227. [PMID: 27797282 DOI: 10.1080/00365521.2016.1246606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Endoscopic mucosal resection (EMR) of colorectal adenomas leads to a reduced incidence of, and mortality from, colorectal carcinoma. Large adenomas are especially difficult to resect. Submucosal injection is a key part of EMR, as it allows for complete resection and decreased complications. We previously demonstrated in both animal models and a clinical trial that a focussed fluid beam applied to the mucosa creates selective fluid cushions in the submucosa selective tissue elevation by pressure (STEP). In this study, we examined the potential of this new technique compared to the standard inject and cut technique. METHODS This was a monocentric prospective two armed randomised controlled clinical trial comparing the STEP technique to the standard needle injection. We included patients with Yamada I and II adenomas ≥12 mm. RESULTS One hundred fifty-five patients were treated in the trial. With the STEP technique there was a significantly higher rate of en-bloc resection, whereas piecemeal resection was more common in the standard arm. The odds ratio of piecemeal resection was 2.422 with a 95% confidence interval of 1.163-5.045 (p value .0195). There was no significant difference in resection time between the two techniques, while there was a significant difference in resections speed for the STEP technique. There was also no difference in complication rates. CONCLUSIONS This study demonstrated that the new STEP technique leads to a higher rate of en-bloc resections than the standard injection technique in endoscopic mucosa resection of colorectal adenomas. The STEP technique can play an important role in the future of EMR.
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Affiliation(s)
- Sebastian Belle
- a Department of Internal Medicine II , Medical Faculty Mannheim, University of Heidelberg , Mannheim , Germany
| | - Manuel von Boscamp
- a Department of Internal Medicine II , Medical Faculty Mannheim, University of Heidelberg , Mannheim , Germany
| | - Moritz Sold
- b Department of Surgery, Medical Faculty Mannheim , University of Heidelberg , Mannheim , Germany
| | - Susanne Mack
- b Department of Surgery, Medical Faculty Mannheim , University of Heidelberg , Mannheim , Germany
| | - Lothar Pilz
- d Department of Paediatrics, Medical Faculty Mannheim , University of Heidelberg , Germany
| | - Matthias Ebert
- a Department of Internal Medicine II , Medical Faculty Mannheim, University of Heidelberg , Mannheim , Germany
| | - Georg Kaehler
- c Medical Faculty Mannheim , University of Heidelberg, Central Interdisciplinary Endoscopy , Germany
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7
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Bronsgeest K, Huisman JF, Langers A, Boonstra JJ, Schenk BE, de Vos tot Nederveen Cappel WH, Vasen HFA, Hardwick JCH. Safety of endoscopic mucosal resection (EMR) of large non-pedunculated colorectal adenomas in the elderly. Int J Colorectal Dis 2017; 32:1711-1717. [PMID: 28884225 PMCID: PMC5691088 DOI: 10.1007/s00384-017-2892-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) has been proven to be safe and effective for the treatment of colorectal adenomas. However, data are limited on the safety of this technique for large polyps and in elderly patients. Aims of our study were to examine the bleeding and perforation rates in patients with large non-pedunculated adenomas (≥20mm) and to evaluate the influence of size (≥40mm) and age (≥75 years) on the complication rates. METHODS In this multicenter retrospective study, patients who underwent EMR of non-pedunculated adenomas ≥20mm between January 2012 and March 2016 were included. The demographics of the patients, the use of antithrombotic drugs, size of the polyps, type of resection, pathology report, occurrence of post-polypectomy bleeding, and perforation- and recurrence rate were collected. RESULTS In 343 patients, 412 adenomas were removed. Eighty patients (23.3%) were ≥75 years of age, 138 polyps (33.5%) were ≥40mm. Bleeding complications were observed in 28 cases (6.8%) and were found significantly more frequent in adenomas ≥40mm, independent of the use of antithrombotic therapy. Five perforations (1.2%) were described, not related to the size of the polyp. There was no significant difference in complication rates between patients <75 years and patients ≥75 years. Bleeding complications rates were significantly higher in patients receiving double antithrombotic therapy. CONCLUSION EMR is safe in elderly patients. EMR of adenomas of ≥40mm was associated with more bleeding complications. Future studies should address how the bleeding rates can be reduced in these patients, especially in those who use double antithrombotic treatment.
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Affiliation(s)
- K. Bronsgeest
- Department of Gastroenterology and Hepathology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - J. F. Huisman
- Department of Gastroenterology and Hepathology, Isala, Zwolle, The Netherlands
| | - A. Langers
- Department of Gastroenterology and Hepathology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - J. J. Boonstra
- Department of Gastroenterology and Hepathology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - B. E. Schenk
- Department of Gastroenterology and Hepathology, Isala, Zwolle, The Netherlands
| | | | - H. F. A. Vasen
- Department of Gastroenterology and Hepathology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - J. C. H. Hardwick
- Department of Gastroenterology and Hepathology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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8
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Bhurwal A, Bartel MJ, Heckman MG, Diehl NN, Raimondo M, Wallace MB, Woodward TA. Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia. Gastrointest Endosc 2016; 84:959-968.e7. [PMID: 27109458 DOI: 10.1016/j.gie.2016.04.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/12/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Colorectal EMR for nonpolypoid neoplasia achieves better outcomes when performed by expert endoscopists. The time point at which the endoscopist achieves expert level remains to be defined. The objective of this study was to establish a learning curve of colorectal EMR for nonpolypoid neoplasia based on residual tissue on surveillance colonoscopy and adverse event rate. METHODS Five hundred seventy-eight consecutive patients underwent EMR of colorectal neoplasia by 1 of 3 primary endoscopists between December 2004 and September 2013 in a tertiary academic center. Primary analyses focused on the largest lesion for patients with more than 1 lesion (median age, 69 years; median polyp size, 30 mm; 51% en bloc resection). Data on surveillance colonoscopy were available for 74%. Learning curves were calculated for each of the 3 main outcome measurements: the presence of residual neoplasia on surveillance colonoscopy, endoscopic assessment of incomplete EMR, and the occurrence of an immediate bleeding adverse event. RESULTS Residual neoplasia on surveillance colonoscopy was present for 23.2% of patients, the rate of endoscopist-assessed incomplete EMR was 27.6%, and immediate bleeding adverse events occurred in 6.9% of patients. Although there was between-endoscopist variability, the overall rates of residual neoplasia and incomplete EMR decreased to below 20% to 25% after 100 EMRs; initial decreases in both rates were observed for earlier EMRs. Immediate bleeding adverse events occurred at a low frequency for each endoscopist across all EMRs. Perforation requiring surgical intervention occurred in 1 patient (0.2%). CONCLUSIONS This study demonstrated that an unexpectedly high number of 100 colorectal EMR procedures for large nonpolypoid colorectal neoplasia are required to achieve a plateau phase for crucial outcomes.
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Affiliation(s)
- Abhishek Bhurwal
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael J Bartel
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
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9
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Saunders BP, Tsiamoulos ZP. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 2016; 13:486-96. [PMID: 27353401 DOI: 10.1038/nrgastro.2016.96] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.
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Affiliation(s)
- Brian P Saunders
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
| | - Zacharias P Tsiamoulos
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
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10
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Law R, Das A, Gregory D, Komanduri S, Muthusamy R, Rastogi A, Vargo J, Wallace MB, Raju GS, Mounzer R, Klapman J, Shah J, Watson R, Wilson R, Edmundowicz SA, Wani S. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis. Gastrointest Endosc 2016; 83:1248-57. [PMID: 26608129 DOI: 10.1016/j.gie.2015.11.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP. METHODS A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges. RESULTS LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000. CONCLUSIONS Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ananya Das
- Arizona Digestive Health, Gilbert, Arizona, USA
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Raman Muthusamy
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Amit Rastogi
- Division of Gastroenterology, The University of Kansas Hospital, Kansas City, Kansas, USA
| | - John Vargo
- Digestive Diseases Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic-Jacksonville, Jacksonville, Florida, USA
| | - G S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jason Klapman
- Gastrointestinal Oncology Department, Moffitt Cancer Center, Tampa, Florida, USA
| | - Janak Shah
- Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra Watson
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Robert Wilson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Seo JY, Chun J, Lee C, Hong KS, Im JP, Kim SG, Jung HC, Kim JS. Novel risk stratification for recurrence after endoscopic resection of advanced colorectal adenoma. Gastrointest Endosc 2015; 81:655-64. [PMID: 25500328 DOI: 10.1016/j.gie.2014.09.064] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 09/29/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Advanced colorectal adenoma (ACA) refers to adenomas with the following predictive characteristics: ≥1 cm in diameter, and/or villous component, and/or high-grade dysplasia. ACA has high risk of transforming to colorectal cancer, and the recurrence rate is relatively high. OBJECTIVE To assess the outcomes of patients with ACA undergoing endoscopic resection and to identify risk factors for local recurrence and development of metachronous advanced neoplasm. DESIGN Retrospective cohort study. SETTING Tertiary care medical center. PATIENTS From 2005 to 2011, the records of 3625 patients who underwent colonoscopic polypectomy at Seoul National University Hospital were retrospectively reviewed. Patients with synchronous colorectal cancers, inflammatory bowel disease, previous colorectal resection, loss to follow-up, and incomplete resection were excluded. INTERVENTION Endoscopic resection for ACA. MAIN OUTCOME MEASUREMENTS Local recurrence and metachronous advanced neoplasm. RESULTS The study included 917 patients with 1206 ACAs. The median duration of follow-up was 28.5 months (interquartile range, 12.8-51.7). Independent risk factors for local recurrence included ACA with 2 or more predictive characteristics (adjusted hazard ratio [HR], 2.46; 95% confidence interval [CI], 1.11-5.48; P = .027) and piecemeal resection (adjusted HR, 6.96; 95% CI, 1.58-30.71; P = .010). Independent risk factors for metachronous advanced neoplasm were male gender (adjusted HR, 1.65; 95% CI, 1.02-2.65; P = .041), ≥3 adenomas (adjusted HR, 2.56; 95% CI, 1.72-3.82; P < .001), and ≥3 ACAs (adjusted HR, 1.44; 95% CI, 1.01-2.06; P = .045). LIMITATIONS Retrospective design. CONCLUSION ACAs with 2 or more predictive characteristics recurred locally at a higher rate than ACAs with 1 predictive characteristic. These results suggest that patients who are found to have ACAs with 2 or more predictive factors at index colonoscopy are at higher risk for local recurrence, and follow-up colonoscopy should be performed sooner.
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Affiliation(s)
- Ji Yeon Seo
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Kyoung Sup Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Bordaçahar B, Barret M, Terris B, Dhooge M, Dreanic J, Prat F, Coriat R, Chaussade S. Sessile serrated adenoma: from identification to resection. Dig Liver Dis 2015; 47:95-102. [PMID: 25445408 DOI: 10.1016/j.dld.2014.09.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/13/2014] [Indexed: 02/07/2023]
Abstract
Until the past two decades, almost all colorectal polyps were divided into two main groups: hyperplastic polyps and adenomas. Sessile serrated adenomas presented endoscopic, pathological and molecular profiles distinct from others polyps. Previously under-diagnosed, physicians now identified sessile serrated adenomas. The serrated neoplastic pathway is accounting for up to one-third of all sporadic colorectal cancers and sessile serrated adenomas have been identified as the main precursor lesions in serrated carcinogenesis. By analogy with the adenoma-adenocarcinoma sequence, the sessile serrated adenomas-adenocarcinoma sequence, has been identified. The development of endoscopic resection techniques permits the consideration of a non-surgical approach as the first option regardless of the size of the lesion. Sessile serrated adenoma warrants the watchfulness of physicians and requires an optimal quality of the colonoscopy procedure, a thorough evaluation of the lesion, an adequate endoscopic resection and follow-up colonoscopies in accordance with sessile serrated adenomas guidelines. We herein present a review on sessile serrated adenomas focusing on their pathological specificities, epidemiology, treatment modalities and follow-up.
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Affiliation(s)
- Benoît Bordaçahar
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Benoît Terris
- Paris Descartes University, Sorbonne Paris Cité, Paris, France; Department of Pathology, Cochin Teaching Hospital, AP-HP, Paris, France
| | - Marion Dhooge
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Johann Dreanic
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Frédéric Prat
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Romain Coriat
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France.
| | - Stanislas Chaussade
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
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Hong YM, Kim HW, Park SB, Choi CW, Kang DH. Endoscopic mucosal resection with circumferential incision for the treatment of large sessile polyps and laterally spreading tumors of the colorectum. Clin Endosc 2015; 48:52-8. [PMID: 25674527 PMCID: PMC4323433 DOI: 10.5946/ce.2015.48.1.52] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 05/12/2014] [Accepted: 06/02/2014] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Endoscopic mucosal resection (EMR) is the standard treatment for colorectal polyps such as adenomas and early cancers with no risk of lymph node metastasis. However, endoscopic resection of large colorectal polyps (≥20 mm diameter) is difficult to perform. We evaluated the clinical outcomes of EMR with circumferential incision (EMR-CI) for the resection of large sessile polyps (Is) and laterally spreading tumors (LSTs) in the colorectum. Methods Between February 2009 and March 2011, we resected 80 large colorectal polyps by EMR-CI. We retrospectively investigated the en bloc resection rate, histologic complete resection rate, recurrence rate, and complications. Results The median polyp size was approximately 25 mm (range, 20 to 50), and the morphologic types included Is (13 cases), LST-granular (37 cases), and LST-nongranular (30 cases). The en bloc and complete histologic resection rates were 66.3% and 45.0%, respectively. The recurrence rate was 0% (median follow-up duration, 23 months), and perforation occurred in five cases (6.3%). Conclusions EMR-CI is an effective treatment modality for 20 to 30 mm-sized colorectal polyps, and may be considered as a second line therapeutic option if ESD is difficult.
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Affiliation(s)
- Young Mi Hong
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Abstract
Bleeding is a relatively rare complication occurring mainly after snare polypectomy. The majority of cases can be managed successfully by endoscopic means leaving very few cases which will ultimately need an operation. Colonic perforation, on the other hand is a serious complication that requires intensive and careful management. Prompt recognition of the perforation during the procedure allows, in selected cases, immediate endoscopic closure with an uneventful and full recovery followed by close monitoring and surgical management in case of clinical deterioration. The criteria for the right selection of perforation cases amenable to endoscopic treatment do still need to be confirmed by prospective studies and further experience is required before a standard algorithm on the endoscopic management of perforations is developed.
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15
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A prospective comparative study of blended and pure coagulation current in endoscopic mucosal resection of large sessile colorectal polyps. Surg Laparosc Endosc Percutan Tech 2014; 24:226-31. [PMID: 24887540 DOI: 10.1097/sle.0b013e31829ce99e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to compare pure coagulation and blended current in the resection of large colorectal sessile polyps (SPs). PATIENTS AND METHODS Between January 2009 and June 2012, 84 patients (45 men, 39 women; median age 66 y; range, 42 to 88 y) with large colorectal SPs (diameter ≥2 cm) were randomized in 1:1 ratio to undergo treatment by the "lift and cut" piecemeal resection technique. A total of 43 blended current subjects (group A) were well matched to 41 pure coagulation current subjects (group B), with a median lesion size of 3.9 cm (group A, 3.7 vs. group B, 4.2 cm; P=0.316), respectively. The rate of complications, the factors that predict complications, and the recurrence of adenoma were analyzed. RESULTS Complete macroscopic resection was achieved in 39 patients (90.7%) of group A and in 36 patients (87.6%) of group B (P=0.735). Argon plasma coagulation at resection's margins was performed in 10 patients (23.2%) of group A and in 14 patients (34.1%) of group B (P=0.269). Eight patients (9.5%) [group A, n=3 patients (7.1%) vs. group B, n=5 patients (12%); P=0.756] developed immediate (4) or delayed (4) bleeding. Four patients with bleeding were under treatment with selective serotonin reuptake inhibitors. All bleedings were successfully treated conservatively or with endoclipping and heater probe application. Perforation occurred in 1 patient of each group and was managed by clips closure and antibiotics and right hemicolectomy, respectively. Postpolypectomy syndrome was observed in 2 patients (4.6%) of group A and 3 patients (7.3%) of group B (P=0.834). In 3 patients, the histopathologic analysis of resected SPs revealed invasive carcinoma, and surgical resection was performed in 1 patient. Two patients refused operation. Among the patients who underwent follow-up surveillance colonoscopy, a total recurrence rate of 25.67% of adenomas with no difference was observed between the 2 groups [group A, n=8 patients (21.6%) vs. group B, n=11 patients (31.4%); P=0.345]. Recurrence of adenoma was observed in 12 patients (16.22%) without and in 7 patients (9.46%) with argon plasma coagulation treatment. CONCLUSIONS No difference was found in the rate of complications between the 2 types of current used in the resection of large colorectal SPs. However, an influence of selective serotonin reuptake inhibitors on postpolypectomy bleeding was observed, which deserves further investigation.
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Maeshiro Y, Yamaji Y, Inoue S, Nakazato Y. Prerenal uremia induced by severe diarrhea due to colon adenoma: a case of McKittrick-Wheelock syndrome in an elderly patient. CEN Case Rep 2014; 3:75-79. [PMID: 28509250 PMCID: PMC5411540 DOI: 10.1007/s13730-013-0089-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/05/2013] [Indexed: 12/21/2022] Open
Abstract
McKittrick-Wheelock syndrome can be successfully treated by emergent dialysis, prescription of bicarbonate, and endoscopic submucosal dissection, which allow elderly people suffering from this syndrome to maintain their activities of daily living. In patients with this syndrome, a large colonic villous adenoma secretes excessive amounts of mucus and causes severe electrolyte depletion and dehydration. An 81-year-old man who had been suffering from chronic renal failure (creatinine 256.4 μmol/L), hypertension, and arrhythmia presented with frequent mucous diarrhea for a month. He was hospitalized for appetite loss, vomiting, general fatigue, and acute renal failure. His blood tests and blood gas analysis revealed urea nitrogen 58.9 mmol/L, creatinine 954.7 μmol/L, pH 7.13, and a base excess of -20.1 mmol/L. Although his symptoms were improved by the emergent dialysis and rehydration, he suffered a relapse only 4 days after he was discharged. At the second admission, a near-circumferential tumor was found in the rectum by the colonoscopy, which was pathologically confirmed as a villous adenoma. Considering his age and complications, endoscopic submucosal dissection was selected, and internal use of sodium bicarbonate was prescribed. Diarrhea and appetite loss were improved by these treatments, and the creatinine level was also improved to 168.0 μmol/L.
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Affiliation(s)
- Yuri Maeshiro
- Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan.
| | - Yasuyoshi Yamaji
- Kidney Disease Center and Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan
| | - Shuji Inoue
- Kidney Disease Center and Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan
| | - Yuichi Nakazato
- Kidney Disease Center and Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan
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Rüth S, Spatz J, Anthuber M. Is There an Indication for Surgical Resection in Colorectal Adenoma? VISZERALMEDIZIN 2014; 30:46-51. [PMID: 26288581 PMCID: PMC4513810 DOI: 10.1159/000358540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Due to the adenoma-carcinoma sequence, complete removal of colorectal polyps is essential. METHOD This article analyzes the role of surgery in the removal of colorectal adenoma. RESULTS Nowadays, most adenomas are removed properly by endoscopic methods. Also in the resection of giant polyps and recurrent adenoma endoscopic data is convincing. Therefore, surgical resection of colorectal adenomas is required in the case of endoscopic inaccessibility. Reasons for this may be the location of the polyp, incomplete endoscopic resection, or suspected malignancy. Endoscopic or limited surgical resection of malignant adenomas is acceptable only if 'low-risk' criteria are fulfilled. Otherwise oncologic radical resection is recommended. In general, radical resection is also necessary in the case of polyps that are not suitable for endoscopic removal, because here the rate of colorectal carcinoma is high. CONCLUSION If a surgical approach is necessary, minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas in the lower two thirds of the rectum are suitable for transanal full-thickness resection. This is done by conventional resection or transanal endoscopic microsurgery. The histopathological preparation of these specimens provides diagnostic and therapeutic benefits, particularly compared to piecemeal resection of early carcinoma.
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Affiliation(s)
- Stefan Rüth
- Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum Augsburg, Germany
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Belle S, Haase L, Pilz LR, Post S, Ebert M, Kaehler G. Recurrence after endoscopic mucosal resection-therapy failure? Int J Colorectal Dis 2014; 29:209-15. [PMID: 24146064 DOI: 10.1007/s00384-013-1783-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the success and complication rates of endoscopic mucosal resections (EMR) for large flat adenomas and to identify risk factors for adenoma recurrence. METHODS We evaluated all consecutive patients treated with EMR at our institution between 2003 and 2005 that fulfilled the following criteria: >10-mm diameter, Paris 0-Is and 0-IIa-c, and endoscopic follow-up. We conducted univariate analysis and multivariate analysis using a non-stratified logistic regression model to identify possible influencing factors. RESULT In a median follow-up period of 6 years, we analyzed 177 EMR procedures, with a mean size of 21 mm. The majority of the resections were in the right colon. Recurrence occurred in 29 patients. Further treatment of patients with recurrence was endoscopic in 27 patients, whereas 1 patient was treated with transanal endoscopic microsurgery and one underwent surgery. The variables influencing the multivariate model were resection technique, immediate complication age, and histology. CONCLUSIONS We show that EMR can achieve a long-term clearance of large flat adenomas. A recurrence after EMR does not equal to failed therapy. The possibility of recurrence has to be considered in the clinical implementation of EMR. An important part of the stratifying factors for follow-up is the procedural assessment of the effectiveness of the resection and the resection technique.
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Affiliation(s)
- S Belle
- University Medical Centre, Mannheim Heidelberg University, Mannheim, Germany,
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Cipolletta L, Rotondano G, Bianco MA, Buffoli F, Gizzi G, Tessari F. Endoscopic resection for superficial colorectal neoplasia in Italy: a prospective multicentre study. Dig Liver Dis 2014; 46:146-51. [PMID: 24183949 DOI: 10.1016/j.dld.2013.09.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/11/2013] [Accepted: 09/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients. METHODS Prospective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥10mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months. RESULTS Overall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. En bloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16-4.26]; p=0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56-4.87]; p=0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions<20mm, follow-up limited to 1 year. CONCLUSION In this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.
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Affiliation(s)
| | | | - Maria A Bianco
- Gastroenterology, Hospital Maresca, Torre del Greco, Italy
| | | | - Giuseppe Gizzi
- Department of Internal Medicine and Gastroenterology, University of Bologna, Italy
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Roriz-Silva R, Andrade AA, Ivankovics IG. Giant rectal villous adenoma: Surgical approach with rectal eversion and perianal coloanal anastomosis. Int J Surg Case Rep 2013; 5:97-9. [PMID: 24441716 PMCID: PMC3921655 DOI: 10.1016/j.ijscr.2013.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 11/20/2013] [Accepted: 12/02/2013] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Colorectal cancer is an important cause of death. Most cases of colon and rectal cancer arise from a preexisting adenomatous polyp. However, if colorectal polyps are very large or not accessible for endoscopic ablation, or if they cannot be removed without an increased risk of perforation, surgical procedures are required. PRESENTATION OF CASE The case of a patient with a giant villous adenoma of the rectum is described. The patient had diarrhea for 2 years associated with asthenia. Colonoscopy revealed a sessile lesion in the rectum measuring 14cm in the largest diameter. Rectal eversion technique was used, resecting the lesion under direct visibility and an external coloanal anastomosis was performed. Surgery was satisfactory and the resection margins were free. DISCUSSION Removal of these polyps should be performed aiming to reduce the incidence of colorectal cancer, as well as to control local and systemic symptoms, such as diarrhea and fluid and electrolyte disorders, mainly in villous adenomas. Various surgical techniques are proposed, but in extensive circumferential lesions of the rectum they are difficult to apply. The rectal stump eversion technique was described by Maunsell (1892), for rectal cancer. CONCLUSION Eversion of the rectal stump and external coloanal anastomosis may be a good surgical alternative for resecting giant rectal adenomas.
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Affiliation(s)
- Renato Roriz-Silva
- Division of General Surgery, Hospital de Base, Porto Velho City, Brazil.
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Desgrippes R, Beauchamp C, Henno S, Bouguen G, Siproudhis L, Bretagne JF. Prevalence and predictive factors of the need for surgery for advanced colorectal adenoma. Colorectal Dis 2013; 15:683-8. [PMID: 23398651 DOI: 10.1111/codi.12122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 11/11/2012] [Indexed: 12/11/2022]
Abstract
AIM Endoscopic resection is the primary treatment for colorectal adenoma, but in some cases surgery is necessary. The aim of this retrospective study was to define the prevalence and predictive factors for surgery in patients with advanced colorectal adenoma managed in a referral endoscopy centre. METHOD Consecutive patients diagnosed with advanced adenoma (Class 4 in the Vienna classification) during a colonoscopy from 2007 to 2009 in the endoscopy centre of the University Hospital of Rennes were included. Predictive factors of surgery were determined by univariate and multivariate analysis. RESULTS Two-hundred and twelve (135 male) patients with a mean age of 65.8 years were included. The reason for colonoscopy was for diagnosis in 63.2%, surveillance in 25.5% and screening in 11.3%. These referred patients amounted to 20.8% of all patients having colonoscopy. Surgery was performed in 13.7% of the 212 patients and in 16 (8.3%) of the 192 patients in whom endoscopic removal was attempted. In the subgroup of 192 patients, univariate analysis revealed that body mass index (P = 0.04), histology (P = 0.002), size (P = 0.03) and macroscopic appearance (P < 0.001) of the polyp were associated with surgery. Multivariate analysis revealed that the macroscopic appearance and histology only were significantly associated with surgery. CONCLUSION Surgery was needed in 13.7% of patients with an advanced adenoma, but in only 8.3% of the subgroup of 192 patients in whom endoscopic removal was attempted. Factors associated with surgery included macroscopic appearance and histology.
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Affiliation(s)
- R Desgrippes
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Rennes, France
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Tanaka S, Terasaki M, Hayashi N, Oka S, Chayama K. Warning for unprincipled colorectal endoscopic submucosal dissection: accurate diagnosis and reasonable treatment strategy. Dig Endosc 2013; 25:107-16. [PMID: 23368854 PMCID: PMC3615179 DOI: 10.1111/den.12016] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 11/01/2012] [Indexed: 12/17/2022]
Abstract
Piecemeal endoscopic mucosal resection (EMR) is generally indicated for laterally spreading tumors (LST) >2 cm in diameter. However, the segmentation of adenomatous parts does not affect the histopathological diagnosis and completeness of cure. Thus, possible indications for piecemeal EMR are both adenomatous homogenous-type granular-type LST (LST-G) and LST-G as carcinoma in adenoma without segmentalizing the carcinomatous part. Diagnosis of the pit pattern using magnifying endoscopy is essential for determining the correct treatment and setting segmentation borders. In contrast, endoscopic submucosal dissection (ESD) is indicated for lesions requiring endoscopic en bloc excision, as it is difficult to use the snare technique for en bloc excisions such as in non-granular-type LST (LST-NG), especially for the pseudodepressed type, tumors with a type VI pit pattern, shallow invasive submucosal carcinoma, largedepressed tumors and large elevated lesions, which are often malignant (e.g. nodular mixed-type LST-G). Other lesions, such as intramucosal tumor accompanied by submucosal fibrosis, induced by biopsy or peristalsis of the lesion; sporadic localized tumors that occur due to chronic inflammation, including ulcerative colitis; and local residual early carcinoma after endoscopic treatment, are also indications for ESD. In clinical practice, an efficient endoscopic treatment with segregation of ESD from piecemeal EMR should be carried out after a comprehensive evaluation of the completeness of cure, safety, clinical simplicity, and cost-benefit, based on an accurate preoperative diagnosis.
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Affiliation(s)
- Shinji Tanaka
- Department of Endoscopy, Hiroshima University HospitalHiroshima, Japan
| | - Motomi Terasaki
- Department of Gastroenterology and Metabolism, Hiroshima University HospitalHiroshima, Japan
| | - Nana Hayashi
- Department of Endoscopy, Hiroshima University HospitalHiroshima, Japan
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University HospitalHiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University HospitalHiroshima, Japan
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Dior M, Coriat R, Tarabichi S, Leblanc S, Polin V, Perkins G, Dhooge M, Prat F, Chaussade S. Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management? Surg Endosc 2013; 27:2775-81. [PMID: 23404147 DOI: 10.1007/s00464-013-2807-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 12/28/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management. METHODS Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study. RESULTS A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding. CONCLUSIONS The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.
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Affiliation(s)
- Marie Dior
- Department of Gastroenterology, Cochin Teaching Hospital AP-HP, Paris, France
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Tholoor S, Tsagkournis O, Basford P, Bhandari P. Managing difficult polyps: techniques and pitfalls. Ann Gastroenterol 2013; 26:114-121. [PMID: 24714799 PMCID: PMC3959925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 11/28/2012] [Indexed: 11/10/2022] Open
Abstract
There is no standardized definition of difficult polyps. However, polyps become difficult and challenging to remove endoscopically when they are large in size, flat in nature, situated in a high-risk location and when access to them is very awkward. Recently, an SMSA (Size, Morphology, Site, Access) classification has been proposed that helps to qualify the degree of difficulty by scoring on the above parameters. This article reviews the features that make polyps difficult to remove and provides some practical tips in managing these difficult polyps. We believe that 'difficult polyp' is a relative term and each endoscopist should define their own level of difficulty and what they would be able to handle safely. However, in expert trained hands, most difficult polyps can be safely removed by an endoscopic approach.
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Affiliation(s)
- Shareef Tholoor
- Dept of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Orestis Tsagkournis
- Dept of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Peter Basford
- Dept of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Pradeep Bhandari
- Dept of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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25
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Abstract
Rectal cancer is a distinct subset of colorectal cancer where specialized disease-specific management of the primary tumor is required. There have been significant developments in rectal cancer surgery at all stages of disease in particular the introduction of local excision strategies for preinvasive and early cancers, standardized total mesorectal excision for resectable cancers incorporating preoperative short- or long-course chemoradiation to the multimodality sequencing of treatment. Laparoscopic surgery is also increasingly being adopted as the standard rectal cancer surgery approach following expertise of colorectal surgeons in minimally invasive surgery gained from laparoscopic colon resections. In locally advanced and metastatic disease, combining chemoradiation with radical surgery may achieve total eradication of disease and disease control in the pelvis. Evidence for resection of metastases to the liver and lung have been extensively reported in the literature. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases is showing promise in achieving locoregional control of peritoneal dissemination. This paper summarizes the recent developments in approaches to rectal cancer surgery at all these time points of the disease natural history.
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Belle S, Collet PH, Szyrach M, Ströbel P, Post S, Enderle MD, Kähler G. Selective tissue elevation by pressure for endoscopic mucosal resection of colorectal adenoma: first clinical trial. Surg Endosc 2011; 26:343-9. [PMID: 21993928 DOI: 10.1007/s00464-011-1873-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 08/01/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection of large lateral spreading tumors currently are technically limited by complications such as bleeding, perforation, and disturbed large procedural sites, leading to incomplete resection and secondary surgery. Further technical improvements are necessary. The authors previously demonstrated the effectiveness of a focused water jet for elevation of the lamina submucosa in animal studies. For the first time, the clinical application of selective tissue elevation by pressure (STEP) for the treatment of colorectal adenomas as a prospective single-arm human trial is presented. METHODS This trial evaluated 59 patients who had primary colorectal adenomas with diameters exceeding 12 mm classified as 0-IIa or 0-IIb according to Paris classification. A submucosal cushion was created with a flexible water jet applicator using the Helix HydroJet. The adenoma was subsequently resected with a mucosal resection snare. All results were recorded. The resected specimens were assessed histologically. RESULTS A total of 59 patients underwent resection of 70 lesions with a maximum diameter of 80 mm (mean, 27 mm). Submucosal elevation with the water jet dissector was possible in all cases and locations from the pectinate line to the ileocecal valve. Of the 70 lesions, 64 (91%) were resected completely in one session. Histologically, the resected specimens were found to be adenocarcinomas (n = 2, 3%), adenomas with high-grade intraepithelial neoplasia (n = 24, 34%), adenomas with low-grade intraepithelial neoplasia (n = 38, 54%), and hyperplastic polyps (n = 6, 9%). Hemostasis during the resection was necessary in 24 cases (34%). No perforation required surgical intervention. CONCLUSION This first clinical trial to analyze STEP technique demonstrated that STEP used to elevate large mucosal lesions in any location is feasible and facilitates EMR for colorectal adenoma.
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Affiliation(s)
- S Belle
- Medical Center Mannheim, Medical Department, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Wood JJ, Lord AC, Wheeler JMD, Borley NR. Laparo-endoscopic resection for extensive and inaccessible colorectal polyps: a feasible and safe procedure. Ann R Coll Surg Engl 2011; 93:241-5. [PMID: 21477440 DOI: 10.1308/003588411x565978] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Polypectomy at colonoscopy may be difficult or dangerous. In such instances colonic resection may be indicated. Novel combined laparoscopic-endoscopic procedures have the potential to allow safe extensive extramucosal resection, thus avoiding resection. Laparoscopic colon mobilisation provides a more favourable orientation for endoscopic mucosal resection and facilitates identification of possible perforation sites with immediate laparoscopic repair or resection if necessary. This study aimed to assess the efficacy and safety of laparo-endoscopic resection (LER) of colonic polyps. PATIENTS AND METHODS Data were collected prospectively on consecutive patients undergoing LER. The mode of presentation, referral pattern, lesion site and size, hospital stay, procedural details, complications, histology and further treatment were recorded. RESULTS A total of 13 patients underwent attempted LER (16 polyps in total) and this was completed for 10, with a median hospital stay of 2 days. Five polyps were removed whole and eight piecemeal. Excision was clinically complete in all cases. Three procedures were converted to colonic resection. One lesion appeared malignant, indicating a conversion to laparoscopic right hemicolectomy. Two polyps were not amenable to LER and resection was performed. One patient underwent subsequent colonic resection based on the histological findings. There were no perforations or serious complications. CONCLUSIONS LER is a safe and effective treatment for large and inaccessible colonic polyps that would otherwise be treated by colonic resection.
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Affiliation(s)
- J J Wood
- Department of Colorectal Surgery, Cheltenham General Hospital, Cheltenham, UK.
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Abstract
The knowledge that due to the adenoma-cancer sequence polyps will develop sooner or later into invasive cancer demands the complete removal of colorectal polyps. The majority of polyps can be endoscopically removed. The indications for surgical removal of polyps are a previous incomplete endoscopic resection, location not amenable to endoscopic removal and lesions which are macroscopically highly suspicious for malignancy and cannot be detached by submucosal saline injection. If a surgical approach is indicated minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas suspicious for malignancy in the lower two thirds of the rectum should not be treated by time-consuming endoscopic submucosal dissection (ESD) and can be quickly and safely removed transanally, conventionally or by transanal endoscopic microsurgery (TEM) by a full thickness én bloc resection. This allows the pathologist to determine the depth of invasion and the completeness of resection in terms of the circumferential margin and a definitive radical surgical approach is only necessary in high risk situations.
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Affiliation(s)
- S Rüth
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum Augsburg, Deutschland.
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Endoscopic mucosal resection with the grasp-and-snare technique through a double-channel endoscope in humans. Gastrointest Endosc 2011; 73:349-52. [PMID: 21295646 DOI: 10.1016/j.gie.2010.10.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 10/19/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND EMR is being used to manage premalignant lesions of the GI tract. Lifting of the lesion is required to perform EMR. Earlier biopsy or snare may cause scarring and preclude adequate lifting. OBJECTIVE We report our experience with a novel grasp-and-snare EMR technique that can be used when a good lifting is not achieved or the location of the lesion is challenging for standard EMR, such as in a fold. DESIGN Single-center case series. SETTING Tertiary referral academic gastroenterology unit. PATIENTS Patients referred for endoscopic treatment of flat gastrointestinal polyps. INTERVENTIONS Single-session EMR performed with a grasp-and-snare technique through a double-channel gastroscope or colonoscope. MAIN OUTCOME MEASUREMENTS Technical success, complication rates, and recurrence rates. RESULTS Seventeen patients with flat gastrointestinal polyps were referred: mean age 70 years, 11 (65%) male, polyp size 0.8 to 6 cm; 13 colonic, 2 duodenal, 1 gastric, and 1 esophageal EMR performed with grasp-and-snare technique in single sessions. Six polyps (35%) did not lift after injection of hydroxypropylmethylcellulose. Fourteen polyps (82%) were resected completely. Two complications occurred (12%): 1 bleeding treated medically and 1 perforation treated surgically. Residual disease at 1 year was 18%, but 8 patients (47%) had not yet had their 1-year follow-up. LIMITATIONS Single-center, uncontrolled, not randomized. Limited follow-up. CONCLUSIONS The grasp-and-snare technique can be used to perform EMR with good outcomes and low complication rates in areas where poor lifting and accessibility are problems.
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Abstract
PURPOSE OF REVIEW Colorectal cancer screening and prevention is a pivotal element in every gastroenterologist practice. Recent advances in imaging technology and treatment opened the field for endoscopic management of large flat colorectal polyps and early cancer. RECENT FINDINGS High-definition white light colonoscopy allowed for better characterization of colon polyps, particularly flat lesions. Chromoendoscopy facilitated the identification of colon polyps as well as better endoscopic polyp characterization, with strong correlation with final pathological diagnosis, opening the field of 'virtual' biopsy. One particular technology, confocal endomicroscopy can magnify an image approximately 1000 times resembling optical microscopy with very good correlation with histology. Endoscopic mucosal resection has gained great acceptance to manage flat colorectal polyps with the two major complications being bleeding and perforation, both now under 5% in experienced hands. Endoscopic submucosal resection was developed to increase en-bloc resection (less residual disease) of a flat colorectal lesion but one has to accept a higher perforation rate around 10%. SUMMARY Current technology allows for better polyp identification and characterization, which can be managed endoscopically.
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