Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice

BACKGROUND AND AIMS

Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice.

METHODS

We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy.

RESULTS

Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P < .001; RR = .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups.

CONCLUSION

TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.

Admission Hypocalcemia and the Need for Endoscopic and Clinical Interventions among Patients with Upper Gastrointestinal Bleeding

INTRODUCTION

Calcium is an essential co-factor in the coagulation cascade, and hypocalcemia is associated with adverse outcomes in bleeding patients, including trauma patients, women with postpartum hemorrhage, and patients with intracranial hemorrhage. In this retrospective, single-center, cohort study, we aimed to determine whether admission-ionized calcium (Ca++) is associated with higher rates of therapeutic interventions among patients presenting with acute nonvariceal upper gastrointestinal bleeding (NV-UGIB).

METHODS

Adult patients admitted due to NV-UGIB between January 2009 and April 2020 were identified. The primary outcome was defined as a need for clinical intervention (two or more packed cell transfusions, need for endoscopic, surgical, or angiographic intervention). Univariate and multivariable logistic regression analyses were performed to determine whether Ca++ was an independent predictor of the need for therapeutic interventions. Propensity score matching was performed to adjust the imbalances of covariates between the groups.

RESULTS

A total of 434 patients were included, of whom 148 (34.1%) had hypocalcemia (Ca++ <1.15 mmol/L). Patients with hypocalcemia were more likely to require therapeutic interventions than those without hypocalcemia (48.0% vs. 18.5%, p < 0.001). Specifically, patients with hypocalcemia were more likely to require endoscopic intervention for control of bleeding (25.0% vs. 15.7%, p = 0.03) and multiple packed cell transfusions (6.8% vs. 0.3%, p < 0.001). Additionally, they had significantly longer hospital stay (5.0 days [IQR 3.0-8.0] vs. 4.0 days [IQR 3.0-6.0], p = 0.01). After adjusting for multiple covariates, Ca++ was an independent predictor of the need for therapeutic intervention (aOR 1.62, 95% confidence interval [CI] 1.22-2.14, p < 0.001). The addition of Ca++ to the Modified Glasgow Blatchford score improved its accuracy in the prediction of therapeutic intervention from AUC of 0.68 (95% CI 0.63-0.72) to 0.72 (95% CI 0.67-0.76), p = 0.02. After incorporation of the propensity score, the results did not change significantly.

CONCLUSION

These findings suggest that hypocalcemia is common and is associated with an adverse clinical course in patients with NV-UGIB. Measurement of Ca++ on admission may facilitate risk stratification in these patients. Trials are needed to assess whether the correction of hypocalcemia will lead to improved outcomes.

Diagnostic Accuracy of Referral Biopsy Compared to Optical Biopsy in Large Non-pedunculated Colorectal Polyps

BACKGROUND

Endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) offers excellent efficacy and safety. Referral biopsies are commonly obtained prior to EMR despite their potential adverse effects. We aimed to assess the diagnostic accuracy of referral biopsy as compared with optical evaluations and the polyp's final pathology.

METHODS

We analyzed a cohort from two centers that included adult patients referred for EMR of LNPCPs between 2017 and 2022. The NICE classification system was used for optical classification. We compared procedural outcomes of lesions with or without a referral biopsy and diagnostic accuracy of referral biopsy and optical evaluation to the final histopathology of the resected polyp.

RESULTS

Of 605 EMR procedures, 398 (65.8%) had referral biopsies. Polyp size was larger in the biopsy group. No significant differences were observed in en-bloc resection rate, adequate lifting, procedural bleeding, or surveillance recurrence rates. Optical biopsies had higher diagnostic concordance with final histology (Cohen's Kappa 0.62 vs. 0.55) and enhanced sensitivity for sessile serrated polyps/hyperplastic polyps (SSP/HP) and cancer as compared to referral biopsies (0.75 vs. 0.72, p < 0.01, and 0.19 vs. 0.0, p < 0.01, respectively). Optical evaluation was more accurate in non-biopsied lesions.

CONCLUSION

Referral biopsies do not offer additional diagnostic accuracy and may reduce the accuracy of optical evaluation for LNPCPs.