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Trinh A, Tjandra D, Park YA, Sood S, Thomson B, Speer T, Buchanan D, Boussioutas A, Metz AJ. Searching for low phospholipid associated cholelithiasis among patients with post-cholecystectomy biliary pain. ANZ J Surg 2024. [PMID: 38361311 DOI: 10.1111/ans.18904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Low phospholipid associated cholelithiasis (LPAC) is associated with variants of the adenosine triphosphate-binding cassette subfamily B, member 4 (ABCB4) gene and is characterized by reduced phosphatidylcholine secretion into bile, impairing the formation of micelles and thus exposing bile ducts to toxic bile acids and increasing cholesterol saturation. LPAC is present in 1% of patients with gallstones and post-cholecystectomy pain is common in this group. LPAC is an under-appreciated cause of post-cholecystectomy pain. The aim of this study is to assess a cohort of patients with post-cholecystectomy pain to identify those with clinical features suggesting that further investigations for LPAC would be beneficial. METHODS A retrospective chart review was performed of the first 2 years of post-operative follow-up for all patients under 40 years of age undergoing cholecystectomy for symptomatic gallstones at a tertiary centre between January 2016 and December 2017. RESULTS 258 patients under the age of 40 underwent a cholecystectomy. 50 patients (19.4%) reported abdominal pain post-cholecystectomy. Five patients (1.9%) fulfilled the criteria for suspected LPAC. Family history of gallstones was documented in 33 of 258 (12.8%) of cases. Obstetric history was obtained in 69 of 197 (35%) female patients. None of the five patients identified above who satisfied the criteria of LPAC had the diagnosis of LPAC considered by their treating clinicians. CONCLUSION LPAC is an under-recognized cause of post-cholecystectomy pain. Treatment can avoid long-term symptoms and complications. Clinicians should take a family history and obstetric history to alert them to the diagnosis of LPAC.
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Affiliation(s)
- Andrew Trinh
- Department of Medicine, Royal Melbourne Hospital and The University of Melbourne, Parkville, Victoria, Australia
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Doug Tjandra
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Yeung-Ae Park
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Siddharth Sood
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Benjamin Thomson
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Tony Speer
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Daniel Buchanan
- Colorectal Oncogenomics Group, Genetic Epidemiology Laboratory, Department of Pathology, The University of Melbourne, Parkville, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
- University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
| | - Alex Boussioutas
- Department of Medicine, Royal Melbourne Hospital and The University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Gastroenterology, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Andrew J Metz
- Department of Medicine, Royal Melbourne Hospital and The University of Melbourne, Parkville, Victoria, Australia
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Mangira D, Raftopoulos S, Vogrin S, Hartley I, Mack A, Gazelakis K, Nalankilli K, Trinh A, Metz AJ, Appleyard M, Grimpen F, Elliott T, Brown G, Moss A. Effectiveness and safety of cold snare polypectomy and cold endoscopic mucosal resection for 10-19 mm non-pedunculated colorectal polyps: a multicenter observational cohort study. Endoscopy 2023. [PMID: 36750222 DOI: 10.1055/a-2029-9539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND AIMS CSP is standard of care for resecting small (<10mm) colonic polyps. Limited data exist for its efficacy for medium-sized (10-19mm) non-pedunculated polyps, especially conventional adenomas. This study evaluated the effectiveness and safety of CSP/C-EMR for medium-sized non-pedunculated colonic polyps. METHODS A prospective multicentre observational study was conducted between May-2018 and June-2021 of all morphologically suitable 10-19mm non-pedunculated colonic polyps removed by CSP/C-EMR. Once resection was complete, multiple biopsies were taken of the margins circumferentially and centrally. PRIMARY OUTCOME Incomplete resection rate (IRR) based on residual polyp in these biopsy specimens. SECONDARY OUTCOMES Recurrence rate at first surveillance colonoscopy and rates of adverse events. RESULTS CSP/C-EMR was performed for 350 polyps in 295 patients. Median polyp size: 15mm. 266 (76.0%) Paris 0-IIa classification. Submucosal injection used for 87.1%(n=305) of polyps. HISTOLOGY 68.5% adenomas, 26.2% SSL without dysplasia, 3.8% SSL with dysplasia and 1.4% hyperplastic. PRIMARY OUTCOME IRR based on margin or central biopsies being positive was 1.7%(n=6) and 0.3%(n=1) respectively. SECONDARY OUTCOMES Polyp recurrence rate was 1.7%(n=4) at first surveillance colonoscopy that was completed for 65.4%(n=229) of polyps at median interval of 9.7 months. Adverse events occurred in 3.4%(n=10) of patients: 1 intraprocedural bleed treated with clips, 3 self-limiting post-polypectomy bleeds, 4 post-polypectomy pain; 2 post-polypectomy-syndrome-like presentations. There were no perforations. CONCLUSION CSP/C-EMR for morphologically suitable 10-19mm non-pedunculated colonic polyps is effective and safe, including for conventional adenomas. Rates of incomplete resection and recurrence were low, with few adverse events. Studies directly comparing to hot snare resection are required.
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Affiliation(s)
- Dileep Mangira
- Gastroenterology and Hepatology, Western Health, Footscray, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Sara Vogrin
- Australian Institute for Musculoskeletal Science, Melbourne, Australia, The Australian Institute of Musculoskeletal Sciences, St Albans, Australia
| | - Imogen Hartley
- Gastroenterology and Hepatology, Western Health, Footscray, Australia
| | - Alexandra Mack
- Gastroenterology and Hepatology, Western Health, Footscray, Australia
| | - Kathryn Gazelakis
- Gastroenterology and Hepatology, Western Health, Footscray, Australia
| | | | - Andrew Trinh
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew J Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | - Mark Appleyard
- Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Florian Grimpen
- Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Timothy Elliott
- Internal Medicine Services, Ballarat Health Services, Ballarat, Australia
| | - Gregor Brown
- Gastroenterology, The Alfred Hospital, Prahran, Australia
| | - Alan Moss
- Gastroenterology and Hepatology, Western Health, Footscray, Australia
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Ket S, Tjandra D, Hewett DG, Kheir AO, Metz AJ, Moss A, Ogra R, Tam W, Raftopoulos S, Reynolds J, Secomb R, Cavalieri L, Urquhart P, Gibson PR, Brown G. Erratum: Cold snare polypectomy of colorectal polyps ≤ 10 mm on clopidogrel: Australian and New Zealand randomized controlled trial. Endosc Int Open 2022; 10:C8. [PMID: 36388146 PMCID: PMC9652115 DOI: 10.1055/a-1969-9645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
[This corrects the article DOI: 10.1055/a-1813-1019.].
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Affiliation(s)
- Shara Ket
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia,Monash University, Central Clinical School, Melbourne, Victoria, Australia
| | - Douglas Tjandra
- Department of Gastroenterology, Melbourne Health, Victoria, Australia
| | - David G. Hewett
- Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Queensland
| | - Ammar O. Kheir
- Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Queensland,Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew J. Metz
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, 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
| | | | - William Tam
- Royal Adelaide Hospital, South Australia, Australia,University of Adelaide, South Australia, Australia,Calvary North Adelaide Hospital, South Australia, Australia
| | - Spiro Raftopoulos
- Sir Charles Gairdner Hospital, Western Australia,Peel Health Campus, Western Australia
| | - John Reynolds
- Biostatistics Consulting Platform, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Robyn Secomb
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - Peter R. Gibson
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia,Monash University, Central Clinical School, Melbourne, Victoria, Australia
| | - Gregor Brown
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia,Monash University, Central Clinical School, Melbourne, Victoria, Australia,Epworth Hospital, Richmond, Victoria, Australia
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Abujudeh S, Zeki SS, van Lanschot MCJ, Pusung M, Weaver JMJ, Li X, Noorani A, Metz AJ, Bornschein J, Bower L, Miremadi A, Fitzgerald RC, Morrissey ER, Lynch AG. Low-cost and clinically applicable copy number profiling using repeat DNA. BMC Genomics 2022; 23:599. [PMID: 35978291 PMCID: PMC9386984 DOI: 10.1186/s12864-022-08681-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Somatic copy number alterations (SCNAs) are an important class of genomic alteration in cancer. They are frequently observed in cancer samples, with studies showing that, on average, SCNAs affect 34% of a cancer cell's genome. Furthermore, SCNAs have been shown to be major drivers of tumour development and have been associated with response to therapy and prognosis. Large-scale cancer genome studies suggest that tumours are driven by somatic copy number alterations (SCNAs) or single-nucleotide variants (SNVs). Despite the frequency of SCNAs and their clinical relevance, the use of genomics assays in the clinic is biased towards targeted gene panels, which identify SNVs but provide limited scope to detect SCNAs throughout the genome. There is a need for a comparably low-cost and simple method for high-resolution SCNA profiling. RESULTS We present conliga, a fully probabilistic method that infers SCNA profiles from a low-cost, simple, and clinically-relevant assay (FAST-SeqS). When applied to 11 high-purity oesophageal adenocarcinoma samples, we obtain good agreement (Spearman's rank correlation coefficient, rs=0.94) between conliga's inferred SCNA profiles using FAST-SeqS data (approximately £14 per sample) and those inferred by ASCAT using high-coverage WGS (gold-standard). We find that conliga outperforms CNVkit (rs=0.89), also applied to FAST-SeqS data, and is comparable to QDNAseq (rs=0.96) applied to low-coverage WGS, which is approximately four-fold more expensive, more laborious and less clinically-relevant. By performing an in silico dilution series experiment, we find that conliga is particularly suited to detecting SCNAs in low tumour purity samples. At two million reads per sample, conliga is able to detect SCNAs in all nine samples at 3% tumour purity and as low as 0.5% purity in one sample. Crucially, we show that conliga's hidden state information can be used to decide when a sample is abnormal or normal, whereas CNVkit and QDNAseq cannot provide this critical information. CONCLUSIONS We show that conliga provides high-resolution SCNA profiles using a convenient, low-cost assay. We believe conliga makes FAST-SeqS a more clinically valuable assay as well as a useful research tool, enabling inexpensive and fast copy number profiling of pre-malignant and cancer samples.
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Affiliation(s)
- Sam Abujudeh
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK.
| | - Sebastian S Zeki
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK. .,Department of Gastroenterology, Guy's and St Thomas' NHS Trust, London, SE1 7EH, UK.
| | | | - Mark Pusung
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Jamie M J Weaver
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK.,Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4TX, UK
| | - Xiaodun Li
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Ayesha Noorani
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Andrew J Metz
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Jan Bornschein
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Lawrence Bower
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK
| | - Ahmad Miremadi
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Rebecca C Fitzgerald
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK.
| | - Edward R Morrissey
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK. .,Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.
| | - Andy G Lynch
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK. .,School of Mathematics and Statistics/School of Medicine, University of St Andrews, St Andrews, UK.
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5
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Ket S, Tjandra D, Hewett DG, Kheir AO, Metz AJ, Moss A, Ogra R, Tam W, Raftopoulos S, Reynolds J, Secomb R, Cavalieri L, Urquhart P, Gibson PR, Brown G. Cold snare polypectomy of colorectal polyps ≤ 10 mm on clopidogrel: Australian and New Zealand randomized controlled trial. Endosc Int Open 2022; 10:E745-E752. [PMID: 35692915 PMCID: PMC9187418 DOI: 10.1055/a-1813-1019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/30/2022] [Indexed: 12/05/2022] Open
Abstract
Abstract
Background and study aims Optimal peri-colonoscopic management of clopidogrel remains unclear. Cold snare polypectomy is safe and effective for removing polyps ≤ 10 mm and clips can control intraprocedural bleeding. We conducted a randomized controlled trial to compare continuation of clopidogrel versus temporary replacement of clopidogrel with aspirin for routine colonoscopy using cold snare polypectomy for polyps ≤ 10 mm.
Patients and methods Between August 2016 and August 2019, consenting participants at 12 centers were randomized to continuation of clopidogrel as a single or dual antiplatelet agent, or to temporarily take aspirin alone from 7 days prior to 2 days after routine colonoscopy. Endoscopists were blinded to group allocation. Cold snare polypectomy was used to remove polyps ≤ 10 mm, with endoscopic clips applied if intraprocedural bleeding continued for > 2 minutes. Follow-up was performed on Day 30. The trial was stopped early due to delayed patient enrollment.
Results Two hundred seventy-six consecutive polyps ≤ 10 mm were removed from 107 patients. Of the patients, 61.7 % were male with a median age of 69 years (interquartile range [IQR] 63 to 76.75). Fifty-nine patients continued on clopidogrel and 48 temporarily took aspirin instead. One hundred thirty-four polyps were removed from 49 patients who continued on clopidogrel vs 142 from 43 patients temporarily took aspirin instead (P = 0.33). Intraprocedural bleeding requiring clips occurred in 11 of 49 patients who continued on clopidogrel and in two of 43 patients who temporarily took replacing with aspirin instead (P = 0.02). More post-procedural minor bleeding was seen in the aspirin arm (six of 43 vs one of 49; P = 0.03). One patient in each arm had acute coronary syndrome, which was medically managed. None of the patients had clinically significant post-procedural bleeding.
Conclusions Continuation of clopidogrel in patients undergoing cold snare polypectomy for colorectal polyps ≤ 10 mm does not appear to increase the rate of clinically significant postpolypectomy bleeding. It is associated with an increase in intraprocedural bleeding, which can be successfully treated with clips.
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Affiliation(s)
- Shara Ket
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia,Monash University, Central Clinical School, Melbourne, Victoria, Australia
| | - Douglas Tjandra
- Department of Gastroenterology, Melbourne Health, Victoria, Australia
| | - David G. Hewett
- Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Queensland
| | - Ammar O. Kheir
- Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Queensland,Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew J. Metz
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, 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
| | | | - William Tam
- Royal Adelaide Hospital, South Australia, Australia,University of Adelaide, South Australia, Australia,Calvary North Adelaide Hospital, South Australia, Australia
| | - Spiro Raftopoulos
- Sir Charles Gairdner Hospital, Western Australia,Peel Health Campus, Western Australia
| | - John Reynolds
- Biostatistics Consulting Platform, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Robyn Secomb
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - Peter R. Gibson
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia,Monash University, Central Clinical School, Melbourne, Victoria, Australia
| | - Gregor Brown
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia,Monash University, Central Clinical School, Melbourne, Victoria, Australia,Epworth Hospital, Richmond, Victoria, Australia
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Khan S, Chandran S, Chin J, Karim S, Mangira D, Nasr M, Ermerak G, Trinh A, Kia CYH, Mules T, Zad M, Ang TL, Johns E, Tee D, Kaul A, Ratanachu-Ek T, Jirathan-Opas J, Fisher L, Cameron R, Welch C, Lim G, Metz AJ, Moss A, Bassan M, Saxena P, Kaffes A, St John A, Hourigan LF, Tagkalidis P, Weilert F, Vaughan R, Devereaux B. Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. J Gastroenterol Hepatol 2021; 36:3395-3401. [PMID: 34370869 DOI: 10.1111/jgh.15658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 06/05/2021] [Accepted: 07/25/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice. METHODS A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers. RESULTS Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion. CONCLUSIONS This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.
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Affiliation(s)
- Saad Khan
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Jerry Chin
- Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Shwan Karim
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Dileep Mangira
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Mohamad Nasr
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Goktug Ermerak
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Andrew Trinh
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher Y H Kia
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Thomas Mules
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Mohammadali Zad
- Department of Gastroenterology, Townsville Hospital, Townsville, Queensland, Australia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Estella Johns
- Department of Gastroenterology, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Derrick Tee
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Abha Kaul
- Department of Gastroenterology, Peninsula Health, Melbourne, Victoria, Australia
| | | | - Jirat Jirathan-Opas
- Department of Gastroenterology, Hatyai Hospital, Hat Yai, Songkhla Province, Thailand
| | - Leon Fisher
- Department of Gastroenterology, Peninsula Health, Melbourne, Victoria, Australia
| | - Rees Cameron
- Department of Gastroenterology, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Christine Welch
- Department of Gastroenterology, Townsville Hospital, Townsville, Queensland, Australia
| | - Gary Lim
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew J Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Milan Bassan
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Arthur Kaffes
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew St John
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Medicine, Toowoomba Hospital, Toowoomba, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Gallipoli Medical Research Institute, School of Medicine, University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Frank Weilert
- Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Rhys Vaughan
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Raine T, Thomas JP, Brais R, Godfrey E, Carroll NR, Metz AJ. Test performance and predictors of accuracy of endoscopic ultrasound-guided fine-needle aspiration for diagnosing biliary strictures or masses. Endosc Int Open 2020; 8:E1537-E1544. [PMID: 33140008 PMCID: PMC7577792 DOI: 10.1055/a-1231-4948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as an important method for obtaining a preoperative tissue diagnosis for suspected cholangiocarcinoma. However, doubts remain about test sensitivity. This study assessed the value and limitations of EUS-FNA in clinical practice. Patients and methods Patients undergoing EUS-FNA for biliary strictures/masses at a UK tertiary referral center from 2005 to 2014 were prospectively enrolled. Data on EUS-FNA findings, histology, and endoscopy and patient outcomes were collected to evaluate test performance and identify factors predictive of an inaccurate diagnostic result. Results Ninety-seven patients underwent a total of 112 EUS-FNA procedures. Overall test sensitivity for an initial EUS-FNA for suspected cholangiocarcinoma was 75 % (95 % CI 64 %-84 %), with specificity 100 % (95 % CI 85 %-100 %) and negative predictive value 0.62 (95 % CI 0.47-0.75). Hilar lesions, the presence of a biliary stent, and a diagnosis of PSC were significantly independently associated with an inaccurate result. For the most difficult cases, repeat sampling and use of the Papanicolaou cytopathology grading scale led to an increase in test sensitivity from 17 % to 100 % ( P = 0.015) with no loss of specificity. Conclusions EUS-FNA was found to be a useful method for obtaining a preoperative tissue diagnosis for patients with suspected cholangiocarcinoma. This study identified markers that can reduce test accuracy and measures that can improve test performance of EUS-FNA.
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Affiliation(s)
- Tim Raine
- Division of Gastroenterology, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - John P. Thomas
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Rebecca Brais
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Endoscopy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nicholas R. Carroll
- Department of Endoscopy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J. Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
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Keane MG, Wehnert N, Perez-Machado M, Fusai GK, Thorburn D, Oppong KW, Carroll N, Metz AJ, Pereira SP. A prospective trial of CONfocal endomicroscopy in CYSTic lesions of the pancreas: CONCYST-01. Endosc Int Open 2019; 7:E1117-E1122. [PMID: 31475228 PMCID: PMC6715431 DOI: 10.1055/a-0957-2976] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Pancreatic cystic lesions (PCL) are common. While some harbor malignant potential, accurate preoperative diagnosis remains challenging. Needle-based confocal laser endomicroscopy (nCLE) via a 19G FNA needle enables real-time imaging of the cyst wall. This study evaluated the safety and utility of nCLE in patients with an indeterminate PCL undergoing EUS-FNA. Patients and methods The CONCYST study prospectively recruited patients with indeterminate PCL attending three hepatopancreaticobiliary (HPB) referral centers in the UK, with indeterminate PCL, who required EUS-FNA between July 2014 and October 2016. Following the procedure, all patients were followed up in telephone clinic for at least 12 months. Ethical approval for the study was granted by the National Research Ethics Service (14/LO/0040). Results Sixty-seven patient were recruited, 11 excluded and 56 included in the final analysis: 35 male, 21 female; median age 68 (range 28 - 80). Recognizable confocal images were obtained in 48 of 56 cases. Median nCLE scanning time was 5 minutes and did not exceed 10 minutes in any case. EUS-nCLE findings correlated with final diagnosis (based on imaging, cytology and multidisciplinary team review) in 43/56 (77 %) of cases, compared with 37/56 (66 %) for cytology alone ( P = 0.12). One patient experienced mild pruritus following the procedure and another developed an infected pseudocyst, which resolved with antibiotics. Conclusions EUS-nCLE under conscious sedation in the day case setting is safe and provides additional information to standard EUS-FNA for diagnosing indeterminate PCL.
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Affiliation(s)
- Margaret G. Keane
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Pond St, London, UK
| | - Natascha Wehnert
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Pond St, London, UK
| | - Miguel Perez-Machado
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Pond St, London, UK
| | - Giuseppe K. Fusai
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Pond St, London, UK
| | - Douglas Thorburn
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Pond St, London, UK
| | - Kofi W. Oppong
- Department of Gastroenterology and HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK & Institute of Cellular Medicine Newcastle University, Newcastle upon Tyne, UK
| | - Nicholas Carroll
- Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew J. Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville VIC, Australia
| | - Stephen P. Pereira
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Pond St, London, UK,Corresponding author Professor Stephen Pereira UCL Institute for Liver and Digestive HealthRoyal Free CampusPond St, London, NW3 2PFUK+442079356826
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Keung CYY, Metz AJ, Sood S. Rapid large pulmonary embolism after prothrombin complex concentrate for warfarin reversal during colonoscopy. Intern Med J 2018; 47:710-711. [PMID: 28580741 DOI: 10.1111/imj.13435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/09/2016] [Accepted: 11/15/2016] [Indexed: 12/28/2022]
Affiliation(s)
- Charlotte Y Y Keung
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew J Metz
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Siddharth Sood
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Metz AJ, Klein SD, Scholkmann F, Wolf U. Continuous coloured light altered human brain haemodynamics and oxygenation assessed by systemic physiology augmented functional near-infrared spectroscopy. Sci Rep 2017; 7:10027. [PMID: 28855556 PMCID: PMC5577215 DOI: 10.1038/s41598-017-09970-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 08/02/2017] [Indexed: 11/12/2022] Open
Abstract
Exposure to artificial coloured light is unavoidable in our modern life, but we are only just beginning to understand the impact of coloured light on human physiology. The aim of the present study was to determine effects of coloured light exposure on human systemic and brain physiology using systemic physiology augmented functional near-infrared spectroscopy (SPA-fNIRS). We measured changes in haemoglobin concentrations and tissue oxygen saturation in the left and right prefrontal cortices (L-PFC, R-PFC) by fNIRS, and also recorded skin conductance (SC), partial pressure of end-tidal CO2 (PETCO2), and heart-rate variability variables. 17 healthy adults (median age: 29 years, range: 25–65 years, 6 women) were exposed to blue, red, green, or yellow light for 10 minutes. Pre-light and post-light conditions were in darkness. In the L-PFC the yellow evoked a brain activation. SC and PETCO2 did not change during any of the coloured light exposures, but SC increased and PETCO2 decreased for all colours (except green) in the post-light period. Changes in L-PFC haemoglobin concentration were also observed during the post-light period but have to be interpreted with care, because heart rate and SC increased while PETCO2 decreased. The detected effects are potentially of high relevance for choosing room lighting and may possibly be applied therapeutically.
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Affiliation(s)
- A J Metz
- University of Bern, Institute of Complementary Medicine, Bern, Switzerland
| | - S D Klein
- University of Bern, Institute of Complementary Medicine, Bern, Switzerland
| | - F Scholkmann
- University of Bern, Institute of Complementary Medicine, Bern, Switzerland.,University Hospital Zurich, University of Zurich, Department of Neonatology, Biomedical Optics Research Laboratory, Zurich, Switzerland
| | - U Wolf
- University of Bern, Institute of Complementary Medicine, Bern, Switzerland.
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11
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Shetty D, Godfrey EM, Metz AJ, Carroll NR. Re: squamous-lined cysts of the pancreas: radiological-pathological correlation. Clin Radiol 2014; 70:112-3. [PMID: 25468635 DOI: 10.1016/j.crad.2014.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/15/2014] [Indexed: 11/25/2022]
Affiliation(s)
- D Shetty
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - E M Godfrey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A J Metz
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - N R Carroll
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Burgess NG, Metz AJ, Williams SJ, Singh R, Tam W, Hourigan LF, Zanati SA, Brown GJ, Sonson R, Bourke MJ. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12:651-61.e1-3. [PMID: 24090728 DOI: 10.1016/j.cgh.2013.09.049] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 09/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Wide-field endoscopic mucosal resection (WF-EMR) of large sessile colonic polyps is a safe and cost-effective outpatient treatment. Bleeding is the main complication. Few studies have examined risk factors for bleeding during the procedure (intraprocedural bleeding [IPB]) or after it (clinically significant post-endoscopic bleeding [CSPEB]). We investigated factors associated with IPB and CSPEB in a large prospective study. METHODS We analyzed data from WF-EMRs of sessile colorectal polyps ≥ 20 mm in size (mean size, 35.5 mm), which were performed on 1172 patients (mean age, 67.8 years) from June 2008-March 2013 at 7 tertiary hospitals as part of the Australian Colonic Endoscopic Resection Study. Data were collected on characteristics of patients and lesions, along with outcomes of procedures and clinical and histologic analyses. Independent predictors of IPB and CSPEB were identified by multiple logistic regression analysis. RESULTS Of the patients studied, 133 (11.3%) had IPB. Independent predictors included increasing lesion size (odds ratio, 1.24/10 mm; P < .001), Paris endoscopic classification of 0-IIa + Is (odds ratio, 2.12; P = .004), tubulovillous or villous histology (odds ratio, 1.84; P = .007), and study institutions that performed the procedure on fewer than 75 patients (odds ratio, 3.78; P < .001). All IPB was successfully controlled endoscopically. IPB prolonged procedures and was associated with early recurrence (relative risk, 1.68; P = .011). Seventy-three patients (6.2%) had CSPEB. On multivariable analysis, CSPEB was associated with proximal colon location (odds ratio, 3.72; P < .001), use of an electrosurgical current not controlled by a microprocessor (odds ratio, 2.03; P = .038), and IPB (odds ratio, 2.16; P = .016). Lesion size and comorbidities did not predict CSPEB. CONCLUSIONS In a prospective study of patients undergoing WF-EMR of large sessile colonic polyps, IPB is associated with larger lesions, lesion histology, and Paris endoscopic classification of type 0-IIa + Is. IPB prolongs the duration of the procedure, is a marker for recurrence, and is associated with CSPEB. CSPEB occurs most frequently in the proximal colon and less when current is controlled by a microprocessor.
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Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Andrew J Metz
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - William Tam
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, QLD, Australia
| | - Simon A Zanati
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, VIC, Australia
| | - Gregor J Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne VIC, Australia
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW, Australia.
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Metz AJ, Moss A, McLeod D, Tran K, Godfrey C, Chandra A, Bourke MJ. A blinded comparison of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy in a porcine model. Gastrointest Endosc 2013. [PMID: 23199650 DOI: 10.1016/j.gie.2012.09.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although linked with perforation, serositis, delayed bleeding, and incomplete resection, hot biopsy forceps electrocauterization (HBF) is still widely used for diminutive colonic polypectomy. OBJECTIVE To evaluate the safety and efficacy of HBF in comparison with conventional snare polypectomy (CSP). DESIGN Randomized, blinded, controlled trial. SETTING Academic endoscopy unit. SUBJECTS Ten swine. INTERVENTION Eighty-two paired polypectomies (41 HBF, 41 CSP) of small, minimally elevated, artificial lesions. Standardized technique using coagulating current at 25 W. HBF: the tissue was avulsed after 1 to 2 seconds of current caused blanching of the artificial pedicle. CSP: the polyp was removed by snare diathermy. MAIN OUTCOME MEASUREMENTS Histopathology of resected specimens and polypectomy sites in colectomy specimens at necropsy (lateral mucosal and depth of ulceration, necrosis and inflammation). RESULTS Some (21%) of the HBF specimens were ablated and uninterpretable. All CSP specimens yielded interpretable specimens. Mucosal necrosis adjacent to HBF resection sites varied widely, between 1.5 and 9 mm (mean 5.7 mm, standard deviation ± 2). There was visible mucosa under the HBF ulcer in 14% of cases. The depth of necrosis in the colon wall was significantly different between the two techniques, with partial muscularis propria (MP) necrosis in 14 of 41 lesions (34%) with HBF, compared with 1 of 41 (2%) of CSP (P < .001), and full-thickness MP necrosis in 9 of 41 lesions (22%) with HBF, compared with 1 of 41 (2%) of CSP (P = .014). There was full-thickness MP inflammation in 13 of 41 lesions (32%) with HBF compared with 5 of 41 (12%) of CSP (P = .06). Transmural subserosal inflammation was seen in 13 of 41 lesions (32%) with HBF compared with 4 of 41 (10%) of CSP (P = .027). There was no relationship between visible lateral mucosal injury and depth of injury (rs = -0.07). LIMITATIONS Animal study. CONCLUSION Despite use of the standardized HBF technique, there is a wide range of lateral mucosal and deep thermal injury as well as residual target mucosa. HBF also results in a significantly greater depth of tissue injury, with a high proportion of transmural necrosis. Ensuring minimal blanching of the mucosa during the procedure does not protect from deep injury. In comparison to conventional snare polypectomy, HBF is imprecise, potentially ineffective, and hazardous.
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Affiliation(s)
- Andrew J Metz
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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Moss A, Bourke MJ, Metz AJ, McLeod D, Tran K, Godfrey C, McKay G, Chandra AP, Pasupathy A. Beyond the snare: technically accessible large en bloc colonic resection in the West: an animal study. Dig Endosc 2012; 24:21-9. [PMID: 22211408 DOI: 10.1111/j.1443-1661.2011.01154.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) and circumferential submucosal incision endoscopic mucosal resection (CSI-EMR) are techniques for en bloc excision of large sessile colonic lesions. Our aims were to compare the efficacy, safety and learning curve of colonic hybrid knife (HK) ESD versus CSI-EMR for en bloc excision of 50 mm diameter hemi-circumferential artificial lesions in a porcine model. PATIENTS AND METHODS Two separate 50 mm diameter areas of normal recto-sigmoid mucosa were marked out in each of ten pigs. One was excised with HK-ESD using succinylated gelatin (SG) submucosal injection. The other was isolated with CSI with the Insulated Tip Knife 2 followed by SG submucosal injection then EMR with a large snare. Euthanasia and colectomy was performed at 72 h followed by blinded histopathology assessment. RESULTS En bloc excision rates were: HK-ESD 100% versus CSI-EMR 20% (P = 0.008). The mean number of resections per lesion was HK-ESD 1 versus CSI-EMR 3 (P = 0.001). The mean dimensions of the largest specimen per technique were HK-ESD 63 × 54 mm versus CSI-EMR 49 × 41 mm (P = 0.005). Procedure duration mean was HK-ESD 54 min versus CSI-EMR 22 min (P < 0.001). When procedure duration was adjusted for the size of the resected en bloc specimen, a statistically significant and accelerated learning effect was noted for HK-ESD (r = -0.83, P = 0.003). There were no perforations and no significant bleeding. CONCLUSIONS HK-ESD with SG submucosal injection is superior to CSI-EMR for en bloc excision of 50 mm diameter lesions in a porcine model. The technique is rapidly learnt. This novel approach may lower the barrier to colonic ESD for Western endoscopists.
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Affiliation(s)
- Alan Moss
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
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Abstract
BACKGROUND AND STUDY AIMS Endoscopic mucosal resection (EMR) for large colonic laterally spreading tumors (LSTs) is a safe, efficacious, and cost-effective treatment. The most common serious complication is delayed bleeding, which reduces these advantages, but consensus guidelines for large-polyp EMR do not exist. PATIENTS AND METHODS Data from two large prospective intention-to-treat studies of EMR for colonic LSTs 20 mm or greater in size were analyzed. Data collection was comprehensive, and included patient and lesion characteristics. EMR technique and cessation of anticoagulant and antiplatelet therapy was standardized. Clinically significant delayed bleeding was defined as that requiring hospital admission. RESULTS EMR was performed on 302 lesions in 288 patients. There was clinically significant delayed bleeding in 21 cases (7 %). Ten underwent colonoscopy. One required angiography. One required surgery after perforation following hemostatic clip placement. There were no deaths. Risk factors for bleeding on multivariate analysis were right colon location [adjusted odds ratio (OR) 4.4, P = 0.01], use of aspirin (OR 6.3, P = 0.005), and age (OR per decade of age 1.70). All bleeds occurred before aspirin was restarted. Patient characteristics, including ASA grade and co-morbidity type, were not predictive. Despite requiring more complex EMR, larger lesion size ( P = 0.2), multiple excisions rather than en bloc resection ( P = 0.1), polyp morphology ( P = 0.2), and previous attempts ( P = 0.5), were not associated with increased risk. CONCLUSIONS Proximal lesion location is a highly significant risk for clinically significant delayed bleeding following colonic EMR, and this knowledge could form the basis of a targeted therapeutic trial. Recent aspirin use also increases bleeding risk--specific consensus guidelines in this area are required for colonic EMR.
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Affiliation(s)
- A J Metz
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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Moss A, Bourke MJ, Metz AJ. A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. Am J Gastroenterol 2010; 105:2375-82. [PMID: 20717108 DOI: 10.1038/ajg.2010.319] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Succinylated gelatin (SG) is an inexpensive, safe, colloidal solution. It was superior to normal saline (NS) in a porcine colon endoscopic resection (ER) model. Our aim was to compare the efficacy, efficiency, and safety of ER with SG vs. NS. METHODS A randomized double-blind trial of submucosal injection with SG vs. NS was conducted for patients undergoing colonoscopy and ER for sessile lesions ≥20 mm in size at an Australian academic hospital endoscopy unit. The primary end point was the "Sydney Resection Quotient" (SRQ), defined as "lesion size in mm divided by the number of pieces to resect." This allows a comparison of technical outcomes for lesions of various sizes. A large lesion removed in fewer pieces gives a greater value. RESULTS Eighty patients (45 men, mean age 69) with lesions sized 20-100 mm were randomized. A total of 41 SG subjects were well matched to 39 NS subjects, with median (interquartile range) lesion size 40 mm (25-45) vs. 35 mm (30-50), respectively (P=0.382). Complete single-session lesion excision was 90% in both groups. There were no adverse events attributable to SG. The SRQ (median (interquartile range)) was SG 10.0 (7.5-20.0) vs. NS 5.9 (4.4-11.7), P=0.004. Other end points (median (interquartile range)) included fewer resections per lesion in the SG group: 3.0 (1.0-6.0) vs. NS 5.5 (3.0-10.0), P=0.028; fewer injections per lesion with SG: 2.0 (1.0-3.0) vs. NS 3.0 (2.0-11.0), P=0.002; lower injection volume: 14.5 ml (8.5-23.0) vs. NS 20.0 ml (16.0-46.0), P=0.009; and shorter procedure duration with SG: 12.0 min (8.0-28.0) vs. NS 24.5 min (15.0-36.0), P=0.006. CONCLUSIONS SG significantly improves SRQ by almost halving the number of resections for piecemeal ER. SG also safely halves procedure duration.
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Affiliation(s)
- Alan Moss
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
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