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Meulen LW, Bogie RM, Winkens B, Masclee AA, Moons LM. Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E1127-E1135. [PMID: 36247075 PMCID: PMC9554920 DOI: 10.1055/a-1869-2446] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 01/04/2022] [Accepted: 05/31/2022] [Indexed: 12/01/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection of large non-pedunculated colorectal polyps is characterized by a high risk of recurrence. Thermal ablation of the mucosal defect margins may reduce recurrence in these lesions, but a systematic overview of the current evidence is lacking. Methods We searched PubMed, Embase and Cochrane until July 2021, for studies on thermal ablation of mucosal defect margins of large non-pedunculated colorectal polyps. Main goal of this meta-analysis was to identify pooled risk difference of recurrence between thermal ablation vs. no adjuvant treatment. Secondary goal was to identify pooled recurrence rate after snare tip soft coagulation (STSC) and argon plasma coagulation (APC). Results Ten studies on thermal ablation of mucosal defect margins were included, with three studies on argon plasma coagulation, six studies on snare tip soft coagulation and one study comparing both treatment modalities, representing a total of 316 APC cases and 1598 STSC cases. Overall pooled risk difference of recurrence was -0.17 (95 % confidence interval [CI] -0.22 to -0.12) as compared to no adjuvant treatment. Pooled risk difference was -0.16 (95 % CI -0.19 to -0.14) for STSC and -0.26 (95 % CI -0.80 to 0.28) for APC. Pooled recurrence rate was 4 % (95 % CI 2 % to 8 %) for STSC and 9 % (95 % CI 4 % to 19 %) for APC. Conclusions Thermal ablation of mucosal defect margins significantly reduces recurrence rate in large non-pedunculated colorectal lesions compared to no adjuvant treatment. While no evidence for superiority exists, STSC may be preferred over APC, because this method is the most evidence-based, and cost-effective modality.
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Affiliation(s)
- Lonne W.T. Meulen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Roel M.M. Bogie
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands,CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Ad A.M. Masclee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Schweitzer D, De Boer SW, Bogie RM, Keszthelyi D, Schweitzer DH, Bouwense SA. Immediate coiling of a gastroduodenal arterial bleeding in a case of haemorrhagic shock without haematemesis, a case report. Ann Med Surg (Lond) 2022; 80:104146. [PMID: 35846862 PMCID: PMC9283804 DOI: 10.1016/j.amsu.2022.104146] [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] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction and importance: Upper gastrointestinal (GI) bleeding is common in the clinic. In combination with haemorrhagic shock, morbidity is high. Rapid diagnosis and treatment can save lives. With the introduction of precision imaging several treatment options are feasible. Up-to-date diagnosis and treatment requires expertise from interventional radiology, gastroenterology and surgery to form a dedicated intervention team. This is illustrated by a typical case. Case presentation We report a 78-year-old otherwise healthy male with a severe diverticulum bleeding. He was initially diagnosed with acute pancreatitis. Approximately 60 minutes after CT scanning, he became haemodynamically instable. He also vomited coffee-like fluid but no clear blood or clots. A repeated CT scan showed active bleeding in the retroperitoneal space highly suspicious for a diverticular bleeding just outside the lumen of the duodenum. An acute multidisciplinary intervention team immediately decided not to perform endoscopy (according to the upper GI bleeding guidelines) but to extend the imaging procedure with digital subtraction angiography (DSA). By this time, active bleeding from a side branch of the gastroduodenal artery was noted and successfully coiled. Clinical discussion Guidelines determine day-to-day management in clinical medicine. Still, there is an exception to every rule. The case presented here was typical of upper GI bleeding with haemodynamic instability and signs of shock, but without haematemesis. This combination indicated a bleeding from somewhere outside the lumen of the GI tract. Instead of endoscopy, the acute intervention team decided to perform CT angiography (CTa) with subsequent DSA. On imaging, the bleeding focus was immediately identified and treated by coiling. Conclusion Performance of CTa immediately followed by DSA and no endoscopy was decided by an acute intervention team in a patient with upper GI bleeding and haemorrhagic shock. Swift coiling of the bleeding artery outside the GI tract lumen was successful. The team in charge relied on a hybrid multifunctional unit fully equipped to perform interventional radiologic as well as GI procedures. Direct computed tomography angiography could be an option in case the patient vomits no pure blood. Multidisciplinary revaluation is essential in an unstable patient with an upper GI bleeding until the situation is stabilized. The role of coiling is growing, with this important technic a laparotomy could be avoid.
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Affiliation(s)
- Donald Schweitzer
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Corresponding author. Departement of Surgery, Maastricht UMC+, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
| | - Sanne W. De Boer
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Roel M.M. Bogie
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Daniel Keszthelyi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Dave H. Schweitzer
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Stefan A.W. Bouwense
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
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van de Wetering AJ, Meulen LW, Bogie RM, van der Zander QE, Reumkens A, Winkens B, Cheng HR, Straathof JWA, Dekker E, Keulen E, Bakker CM, Hoge C, de Ridder R, Masclee AA, Sanduleanu-Dascalescu S. Optical diagnosis of diminutive polyps in the Dutch Bowel Cancer Screening Program: Are we ready to start? Endosc Int Open 2020; 8:E257-E265. [PMID: 32118099 PMCID: PMC7043968 DOI: 10.1055/a-1072-4853] [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: 08/05/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Implementation of optical diagnosis of diminutive polyps may potentially increase the efficacy and cost-effectiveness of colonoscopies. To adopt such strategy in clinical practice, the Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) thresholds provide the basis to be met: ≥ 90 % negative predictive value (NPV) for diagnosis of adenomatous histology and ≥ 90 % agreement on surveillance intervals. We evaluated this within the Dutch Bowel Cancer Screening Program (BCSP). Patients and methods Endoscopic and histological data were collected from participants of the national bowel cancer screening program with an unfavorable fecal immunochemical test referred for colonoscopy between February 2014 and August 2015 at four endoscopy centers. The "resect and discard" scenario was studied, resecting diminutive polyps without histological evaluation. Agreement between optical diagnosis and histological diagnosis was measured for surveillance intervals according to Dutch, European and American post-polypectomy surveillance guideline. Results Fifteen certified endoscopists participated in this study and included 3028 diminutive polyps. In 2,330 patients both optical and histological diagnosis were available. Optical diagnosis of diminutive polyps showed NPV of 84 % (95 % CI 80-87) for adenomatous histology in the rectosigmoid. Applying the 'resect and discard' strategy resulted in 90.6 %, 91.2 %, 90.9 % agreement on surveillance intervals for the Dutch, European and American guideline respectively. Conclusion Our data representing current clinical practice in the Dutch BCSP practice on optical diagnosis of diminutive polyps showed that accuracy of predicting histology remains challenging, and risk of incorrect optical diagnosis is still significant. Therefore, it is too early to safely implement these strategies.
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Affiliation(s)
- Alouisa J.P. van de Wetering
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands,Corresponding author Alouisa J.P. van de Wetering, MD Maastricht University Medical Center+Division of Gastroenterology and HepatologyPO Box 5800, 6202 AZ MaastrichtThe Netherlands+31-43-387 5006
| | - Lonne W.T. Meulen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roel M.M. Bogie
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Quirine E.W. van der Zander
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ankie Reumkens
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands,Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University,CAPHRI, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hao Ran Cheng
- Department of Gastroenterology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Jan-Willem A. Straathof
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,Department of Gastroenterology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, The Netherlands
| | - Eric Keulen
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - C. M. Bakker
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Chantal Hoge
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rogier de Ridder
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ad A.M. Masclee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Silvia Sanduleanu-Dascalescu
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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