Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions

BACKGROUND AND AIMS

The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models.

METHODS

A multicenter cohort study was performed in patients with nonpedunculated lesions ≥20 mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies.

RESULTS

DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets.

CONCLUSIONS

The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT03050333.).

Cholangitis secondary to afferent loop syndrome from a gastric stump adenocarcinoma

A clinical case of an 85-year-old patient with cholangitis secondary to afferent loop syndrome from gastric stump adenocarinoma. A brief review of the literature on it is made.

A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions

BACKGROUND & AIMS

After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk.

METHODS

We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding.

RESULTS

Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively.

CONCLUSIONS

The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.

Gastrointestinal endoscopy sedation and monitoring practices in Spain: a nationwide survey in the year 2014

BACKGROUND AND STUDY AIMS

The introduction of new sedative agents and a desire for improved patient care have encouraged the use of sedation for gastrointestinal (GI) endoscopy over the last decade. This survey aims to provide, within Spain, national and regional data on gastroenterologists' endoscopic sedation and monitoring practices, and on their attitudes concerning these practices.

METHODS

A 19-item survey covering the current practices of sedation and monitoring in GI endoscopy was electronically mailed to all members of the three nationwide scientific societies.

RESULTS

Of 2476 e-mailed questionnaires, a total of 569 (23 %) were returned, proportionally representing the structure of the Spanish health care system. Monitoring and resuscitation resources were universally available, as well as post-endoscopy recovery rooms. Endoscopy teams usually included a registered nurse (98.5 %), an auxiliary nurse (80.5 %), and other physicians (25.7 %), generally anesthesiologists. More than half of esophagogastroduodenoscopies (EGDs) are performed with the patient under sedation; in 25 % of centers, more than 95 % colonoscopies are performed with the patient sedated, but a wide variation was observed. Pre-endoscopic risk is assessed in the vast majority of procedures. Propofol is the most commonly used sedative, either alone (in 70 % of EGDs and 80 % of colonoscopies) or in combination with other drugs. Private funding of a clinic was the only predictor of a significant increase in the use of sedation; 57.7 % of the respondents stated having difficulties in implementing sedation, with the limited availability of anesthesiologists and resuscitation training for the auxiliary staff the most common complaints.

CONCLUSIONS

The use of sedation during GI endoscopy in Spain varies widely but is on the increase and is more common in private practice. Propofol is the preferred sedative in all procedures.

Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

Diverticular disease is the most frequent cause of lower gastrointestinal bleeding. Most of the times, bleeding stops without any intervention but in 10-20% of the cases it is necessary to treat the hemorrhage. Several modalities of endoscopic treatment have been described after purging the colon. We present five cases of severe diverticular bleeding treated with injection of epinephrine and hemoclips. All the colonoscopies were performed without purging of the colon in an emergency setting, with correct visualization of the point of bleeding. Patients recovered well avoiding other aggressive procedures such as angiography or surgery.

Acetic acid allows effective selection of areas for obtaining biopsy samples in Barrett's esophagus

OBJECTIVE

The aim of this study was to determine whether macroscopic changes resulting from acetic acid application on the surface of columnar-lined esophagus allow regular, nonmagnifying, endoscopic identification of areas presenting dysplasia and/or cancer in Barrett's esophagus.

PATIENTS AND METHODS

A total of 100 patients (mean age, 53 years; range, 27-86 years) under surveillance because of short-segment (n=71) and long-segment (n=29) Barrett's esophagus, with no alterations of columnar-lined esophagus on standard endoscopy, were enrolled. After endoscopic examination, 3% acetic acid was sprayed on columnar-lined esophagus. The subsequent appearance of the mucosa was classified as: (1) Normal pattern: uniform reticulum along the entire columnar-lined esophagus. (2) Abnormal pattern: reticulum presenting areas of rough or irregular appearance. Biopsy samples were obtained from areas of normal and abnormal patterns, and the results of the corresponding histological studies were compared. All endoscopies were performed by the same investigator.

RESULTS

The endoscopic appearance, after acetic acid application, corresponded to a normal pattern in 85% of cases and an abnormal pattern in 15%. The percentage of dysplasia and adenocarcinoma in biopsy specimens was significantly higher in patients with rough or irregular areas (86.7%) than in those with normal uniform reticulum (0%) (P< 0.001). Sensitivity for the identification of areas of dysplasia or adenocarcinoma was 100% (95% confidence interval: 71.7-100%). Specificity was 97.7% (95% confidence interval: 91.2-99.6%).

CONCLUSIONS

This prospective study shows that acetic acid test is useful for standard, nonmagnifying, endoscopic detection of dysplasia and cancer in Barrett's esophagus.

Self-expandable stents in malignant colonic obstruction: insertion assisted with a sphincterotome in technically difficult cases

BACKGROUND

Stent placement is effective in relieving malignant colonic obstruction. Nevertheless, the technique may offer difficulties in sharply angulated lesions.

METHODS

Guidewire insertion assisted with a sphincterotome was performed in 4 patients with intestinal obstruction caused by malignant colonic strictures. The manipulation of the sphincterotome by turning and bending its tip allows the cannulation of the lesion with the guidewire and, as a consequence, the stent insertion.

OBSERVATIONS

The procedure was successfully performed in 4 technically difficult cases in which it had been impossible to pass the guidewire with the standard catheter.

CONCLUSIONS

In technically difficult cases, with the use of a sphincterotome, insertion of the guidewire appears to be easier. This new method may improve technical success rates in stent placement.

Self-expandable stents in malignant colonic obstruction: insertion assisted with a sphincterotome in technically difficult cases

BACKGROUND

Stent placement is effective in relieving malignant colonic obstruction. Nevertheless, the technique may offer difficulties in sharply angulated lesions.

METHODS

Guidewire insertion assisted with a sphincterotome was performed in 4 patients with intestinal obstruction caused by malignant colonic strictures. The manipulation of the sphincterotome by turning and bending its tip allows the cannulation of the lesion with the guidewire and, as a consequence, the stent insertion.

OBSERVATIONS

The procedure was successfully performed in 4 technically difficult cases in which it had been impossible to pass the guidewire with the standard catheter.

CONCLUSIONS

In technically difficult cases, with the use of a sphincterotome, insertion of the guidewire appears to be easier. This new method may improve technical success rates in stent placement.

Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients

BACKGROUND

Endoscopic sphincterotomy without cholecystectomy is a therapeutic option in selected patients after acute biliary pancreatitis. We conducted a prospective evaluation of the long-term effects of sphincterotomy in terms of the need for of subsequent cholecystectomy and the recurrence of gallstone pancreatitis.

METHODS

We studied 88 patients with acute biliary pancreatitis and an intact gallbladder who, underwent endoscopic sphincterotomy either because they were high-risk candidates for surgery or because they had refused of cholecystectomy. The median follow-up was 51 months (range, 5-86).

RESULTS

Only two patients (2.2%) experienced recurrent pancreatitis. Subsequent cholecystectomy was performed in 10 patients because of acute cholecystitis in eight cases and biliary colic in two cases. Sixty-six patients (75%) remained asymptomatic.

CONCLUSIONS

Endoscopic sphincterotomy is a safe and acceptable alternative to cholecystectomy for the prevention of recurring attacks of gallstone pancreatitis. As a result of this procedure, 75% of patients remained free of symptoms in the long term.

Treatment of achalasia with the Witzel dilator: a prospective randomized study of two methods

BACKGROUND AND STUDY AIMS

Several studies have shown that the use of the Witzel dilator is an effective and safe treatment for achalasia. However, the optimal values for pressure, number of dilations, and duration of application have not yet been established. The aim of this study was to determine these three parameters.

PATIENTS AND METHODS

43 patients with a diagnosis of achalasia (based on clinical, radiological, manometric and endoscopic evaluation) were randomly allocated to one of two treatment groups. Patients in group A (n=21) underwent three consecutive 1-minute dilations per session at 1-minute intervals, at 200 mmHg for the first dilation and 300 mmHg for the second and third. In group B patients (n=22) only one dilation was done, at 200 mmHg for 2 minutes. Before and after treatment, the clinical score, the maximum esophageal diameter (obtained using barium contrast studies) and the basal pressure of the lower esophageal sphincter were evaluated in each patient. The need for further treatment and the presence of complications were also determined.

RESULTS

Both methods led to clinical, radiological, and manometric benefits. No differences were observed between the methods (satisfactory results in 86%; one perforation in each group). Six patients underwent operation; five for an incomplete response and one for a perforation.

CONCLUSIONS

There were no differences between the two groups investigated, suggesting that only one 2-minute dilation at 200 mmHg is sufficient.