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Gupta S, Craciun A, Wang H, Whitfield A, Gauci J, O'Sullivan T, Cronin O, Abu Arisha M, Klein A, Lee EYT, Burgess NG, Bourke MJ. Hybrid resection versus conventional resection for laterally spreading lesions of the papilla. Gastrointest Endosc 2024; 99:428-436. [PMID: 37858758 DOI: 10.1016/j.gie.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 09/06/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS Although conventional hot snare resection (CR) of laterally spreading lesions of the major papilla (LSL-Ps) is effective, it can be associated with delayed bleeding in upward of 25% of cases. Given the excellent safety profile of cold snare polypectomy in the colorectum, we investigated the efficacy and safety of a novel hybrid resection (HR) technique for LSL-P management, consisting of hot snare papillectomy plus cold snare resection of the laterally spreading component. METHODS A prospective cohort of patients underwent HR in a tertiary referral center over 60 months until December 2022. This cohort was compared with a historical cohort of patients who underwent CR at the same institution over 120 months until August 2017. The primary outcomes were recurrence and bleeding. RESULTS Twenty patients underwent HR (14 female; mean age 65.2 ± 12.2 years). Median lesion size was 30 mm (interquartile range, 25.0-47.5 mm). Recurrent or residual adenoma (RRA) was greater with HR (58.8% [n = 10] vs 29.8% [n = 14]; P = .034). The odds ratio for recurrence was 3.6 times (95% CI, 1.2-11.0) higher with HR (P = .027). RRA was multifocal in 4 (40%) and had a composite RRA volume >10 mm in 7 (70%). The median number of procedures required to treat RRA was higher with HR (4 vs 1, P = .002). There was no difference between CR and HR for intraprocedural bleeding (41.1% [n = 23] vs 25% [n = 5]; P = .587) or delayed bleeding (25.0% vs 10.0%, P = .211). There were no perforations. CONCLUSIONS The novel HR technique for LSL-P management is associated with a high rate of RRA that is recalcitrant to treatment, without mitigating the risk of intraprocedural or delayed bleeding. Therefore, CR should remain the mainstay management option for treating patients with an LSL-P. (Clinical trial registration number: NCT02306603.).
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Ana Craciun
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Departamento de Gastrenterologia e Hepatologia, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Julia Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Muhammad Abu Arisha
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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Cronin O, Kirszenblat D, Forbes N, Gupta S, Whitfield A, O'Sullivan T, Gauci J, Abuarisha M, Wang H, Burgess NG, Lee EYT, Williams SJ, Bourke MJ. Geometry of cold snare polypectomy and risk of incomplete resection. Endoscopy 2024; 56:214-219. [PMID: 37774737 DOI: 10.1055/a-2184-1609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is safer than and equally efficacious as hot snare polypectomy (HSP) for the removal of small (<10mm) colorectal polyps. The maximum polyp size that can be effectively managed by piecemeal CSP (p-CSP) without an excessive burden of recurrence is unknown. METHODS Resection error risks (RERs), defined as the estimated likelihood of incomplete removal of adenomatous tissue for a single snare resection pass, for CSP and HSP were calculated, based on an incomplete resection rate. Polyp area, snare size, estimated number of resections, and optimal resection defect area were modeled. Overall risk of incomplete resection (RIR) was defined as RIR=1 - (1 - p)n, where p is the RER and n the number of resections. RESULTS A 40-mm polyp has a four times greater area than a 20-mm polyp (314.16mm2 vs. 1256.64mm2), and requires three times more resections (11 vs. 33, respectively, assuming 8-mm piecemeal resection pieces for p-CSP). RIRs for a 40-mm polyp by HSP and p-CSP were 15.1%-23% and 40.74%-60.60% respectively. CONCLUSION RER is more important with p-CSP than with HSP. The number of resections, n, and consequently RIR increases with increasing polyp size. Given the overwhelming safety of CSP, specific techniques to minimize the RER should be studied and developed.
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Affiliation(s)
- Oliver Cronin
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - David Kirszenblat
- Department of Mathematics and Statistics, University of Melbourne, Parkville, Australia
| | | | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Timothy O'Sullivan
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Julia Gauci
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Muhammad Abuarisha
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Hunter Wang
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Nicholas G Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Eric Y T Lee
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Stephen J Williams
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
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Cronin O, Gupta S, Gauci J, Whitfield A, O'Sullivan T, Abuarisha M, Wang H, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Endoscopic resection of large anastomotic polyps is safe and effective. Endoscopy 2024; 56:125-130. [PMID: 37699523 DOI: 10.1055/a-2174-2967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Large (≥20mm) adenomatous anastomotic polyps (LAAPs) are uncommon. Data pertaining to their prevalence, characteristics, and the efficacy of endoscopic resection (ER) are absent. A safe and effective strategy for ER would reduce morbidity and healthcare costs. METHODS Large nonpedunculated colorectal polyps of ≥20mm (LNPCPs) referred for ER were prospectively studied. Multiple data points were recorded including anastomotic location, polyp morphology, resection modality, complications, and technical success. RESULTS Over 7 years until November 2022, 2629 lesions were referred. Of these, 10 (0.4%) were LAAPs (median size 35 mm [interquartile range (IQR) 30-40mm]). All LAAPs were removed by piecemeal endoscopic mucosal resection (EMR), most (n=9; 90%) in combination with cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST). On comparison of the LAAP group with the conventional LNPCP group, CAST was more commonly used (90% vs. 9%; P<0.001) and deep mural injury (DMI) type II was more frequent (40% vs. 11%, P=0.003); however, significant DMI (III-V) did not occur. At 6 month (IQR 5.25-6 months) surveillance, there was no recurrence in any of the 10 cases. There were no serious adverse events. CONCLUSIONS LAAPs present unique challenges owing to their location overlying an anastomosis. Despite these challenges they can be safely and effectively managed endoscopically without recurrence at endoscopic follow-up.
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Affiliation(s)
- Oliver Cronin
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Julia Gauci
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Timothy O'Sullivan
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Muhammad Abuarisha
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Hunter Wang
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Eric Yong Tat Lee
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Stephen J Williams
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Nicholas Graeme Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
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Zammit SC, Cachia M, Sapiano K, Gauci J, Montefort S, Ellul P. Eosinophilic gastrointestinal disorder: is it what it seems to be? Ann Gastroenterol 2018; 31:475-479. [PMID: 29991893 PMCID: PMC6033761 DOI: 10.20524/aog.2018.0263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/13/2018] [Indexed: 12/14/2022] Open
Abstract
Background Eosinophilic gastroenteropathy is an uncommon condition whose causes can be numerous and non-specific. The aim of the study was to characterize the presence of gastrointestinal disorders in the adult Maltese population and assess the degree of association with atopic diseases. Methods Adult patients with gastrointestinal eosinophilia in the gastrointestinal tract on histology were identified and their clinical case notes were reviewed. Patients were interviewed and asked questions regarding asthma, allergic rhinitis, and eczema. Results Sixty-six patients (39 female) were recruited. The most common clinical symptoms were diarrhea (42.4%) and abdominal pain (33.3%). The sites involved were stomach (10.6%), colon (56.1%), small bowel (10.6%), small bowel and colon (18.2%), esophagus (1.5%), and esophagus and colon (1.5%). Forty percent had persistent lower gastrointestinal symptoms and a repeat ileocolonoscopy was performed within 12 months. These patients were diagnosed with ulcerative colitis (n=10; 47.6%), Crohn's disease (n=6; 28.6%), indeterminate colitis (n=1; 4.8%) or microscopic colitis (n=4; 19%). Allergic rhinitis was present in 39.4% of the study group, eczema in 26.1%, and asthma in 19.7%. These findings were compared with local data for atopic conditions and the study group was found to have a significantly higher prevalence of allergic rhinitis (P=0.002), but not of asthma (P=0.62) or eczema (P=0.19). Conclusions A high proportion of patients with eosinophilic gastrointestinal infiltration were subsequently diagnosed with inflammatory bowel disease. Patients persistently symptomatic or who do not respond to treatment should be reassessed to exclude inflammatory bowel disease, given its high prevalence in this group of patients.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Division of Gastroenterology, Department of Medicine (Stefania Chetcuti Zammit, Pierre Ellul), Mater Dei Hospital, Malta
| | - Monique Cachia
- Department of Medicine (Monique Cachia, Karen Sapiano, Julia Gauci), Mater Dei Hospital, Malta
| | - Karen Sapiano
- Department of Medicine (Monique Cachia, Karen Sapiano, Julia Gauci), Mater Dei Hospital, Malta
| | - Julia Gauci
- Department of Medicine (Monique Cachia, Karen Sapiano, Julia Gauci), Mater Dei Hospital, Malta
| | - Stephen Montefort
- Division of Respiratory Medicine, Department of Medicine (Stephen Montefort), Mater Dei Hospital, Malta
| | - Pierre Ellul
- Division of Gastroenterology, Department of Medicine (Stefania Chetcuti Zammit, Pierre Ellul), Mater Dei Hospital, Malta
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Affiliation(s)
| | - Julia Gauci
- Foundation Programme, Mater Dei Hospital, Msida, Malta
| | - Kelvin Cortis
- Department of Radiology, Mater Dei Hospital, Msida, Malta
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Fenech M, Abela R, Chetcuti Zammit S, Mercieca L, Gauci J, Edwards N, Carachi E, Mifsud M, Piscopo T. Wound swab use and misuse at a regional general hospital. J Wound Care 2014; 23:634-42. [DOI: 10.12968/jowc.2014.23.12.634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gauci J, Vella A. Improving outcomes by improving geriatric phlebotomy. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2013.07.559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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