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Patel A, Treves G, Samreen I, Vaghani UP. The Effectiveness of Prophylactic Epinephrine Compared to No Prophylaxis for Postpolypectomy Bleeding in Endoscopic Colorectal Surgery: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e56778. [PMID: 38650798 PMCID: PMC11034620 DOI: 10.7759/cureus.56778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
Colorectal cancer prevention has seen significant advancements with colonoscopic polypectomy, a critical technique in clinical practice. However, postpolypectomy bleeding (PPB), particularly in the resection of large pedunculated polyps, remains a major complication. This systematic review and meta-analysis investigates the efficacy of prophylactic epinephrine injections in preventing PPB, addressing inconsistencies in the literature regarding its effectiveness. Employing a comprehensive search strategy, we rigorously selected studies for inclusion, focusing on those comparing prophylactic epinephrine with no intervention. The risk of bias was assessed using the Cochrane Risk of Bias assessment tool, ensuring a robust and reliable analysis. Our findings, based on an analysis of four studies involving 1,062 patients, indicate a significant reduction in early PPB with epinephrine use, with a marked decrease in bleeding incidence compared to the no-prophylaxis group. However, the impact on delayed bleeding was less conclusive, suggesting the need for further research in this area. Our study thus highlights the effectiveness of epinephrine as a preventive tool in colonoscopic polypectomy while underscoring the complexity of bleeding risks and the necessity for ongoing investigation in optimizing patient outcomes.
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Affiliation(s)
- Akash Patel
- Internal Medicine, Eisenhower Health, Rancho Mirage, USA
| | - Guy Treves
- Medicine and Surgery, St. George's University School of Medicine, Irvine, USA
| | - Isha Samreen
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | - Utsav P Vaghani
- Internal Medicine, Smt. N.H.L. Municipal Medical College, Ahmedabad, IND
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Hassanpour SE, Zirakzadeh H, Aghajani Y. The Effect of Subcutaneous Epinephrine Dosage on Blood Loss in Surgical Incisions. World J Plast Surg 2020; 9:309-312. [PMID: 33330008 PMCID: PMC7734936 DOI: 10.29252/wjps.9.3.309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Epinephrine is commonly used in plastic and reconstructive surgeries to reduce the blood loss, and to achieveing the lowest and the most effective dosage of epinephrine can improve the results of the surgery. METHODS Thirty two rats were divided in four groups. Local injection of epinephrine solution (3 mL) with concentrations of 1:200,000, 1:400,000 and 1:1,000,000 was undertaken in three different groups; and the fourth group was the control in which 3 mL of normal saline was administered 15 minutes before making the incision. The bleeding amount was compared in these groups. RESULTS A significant difference in blood loss was noted between the control and other groups, but no significant difference was present between epinephrine concentrations of 1:200,000, 1:400,000 and 1:1,000,000. CONCLUSION Local injection of epinephrine solution was shown to reduce bleeding from surgical incisions, but the difference between various pinephrine concentrations was not significant. The use of the lowest concentration (1:1,000,000) was suggested to decrease epinephrine side effects.
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Affiliation(s)
- Seyed Esmail Hassanpour
- Department of Plastic and Reconstructive Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hatef Zirakzadeh
- Department of Plastic and Reconstructive Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yasaman Aghajani
- Department of Anesthesiology; Khatam Al Anbia hospital, Tehran, Iran
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3
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Inoue S, Uedo N, Tabuchi T, Nakagawa K, Ohmori M, Iwagami H, Matsuno K, Iwatsubo T, Nakahira H, Matsuura N, Shichijo S, Maekawa A, Kanesaka T, Takeuchi Y, Higashino K, Ishihara R. Usefulness of epinephrine-added injection solution to reduce procedure time for gastric endoscopic submucosal dissection. Endosc Int Open 2020; 8:E1044-E1051. [PMID: 32743058 PMCID: PMC7373655 DOI: 10.1055/a-1192-4202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/18/2020] [Indexed: 11/25/2022] Open
Abstract
Background and study aims Epinephrine-added submucosal injection solution is used to facilitate hemostasis of non-variceal upper gastrointestinal bleeding and to prevent delayed bleeding of large pedunculated colorectal lesions. However, its benefit in gastric endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unclear. The effectiveness of epinephrine-added injection solution for outcomes of gastric ESD was examined using propensity score matching analysis. Patients and methods A total of 1,599 patients with solitary EGC (83 with non-epinephrine-added solution and 1,516 with epinephrine-added solution) between 2011 and 2018 were enrolled. Propensity scores were calculated to balance the distribution of baseline characteristics: age, sex, tumor location, specimen size, presence of ulcer scar, tumor depth, histological tumor type, and operators' experience, and 1:3 matching was performed. En bloc resection rate, mean procedure time, delayed bleeding rate, and perforation rate were compared between the non-epinephrine (n = 79) and epinephrine (n = 237) groups. Results Mean procedure time was significantly shorter in the epinephrine group than in the non-epinephrine group (60 vs. 78 min, P < 0.001). No significant difference was found in the rate of en bloc resection (both 99 %), incidence of delayed bleeding (both 6 %), or perforation (0 vs. 0.8 %) between the two groups. In multiple linear regression analysis, use of epinephrine-added solution was independently associated with short procedure time ( P < 0.001) after adjustment for other covariates. Conclusion The results suggest that epinephrine-added injection solution is useful for reduction of gastric ESD procedure time, warranting validation in a randomized controlled trial.
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Affiliation(s)
- Shuntaro Inoue
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takahiro Tabuchi
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Kentaro Nakagawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayasu Ohmori
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyoshi Iwagami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kenshi Matsuno
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Taro Iwatsubo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroko Nakahira
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Akira Maekawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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Mutlu IN, Kocak B, Baykara Ulusan M, Ulusan K, Cakir MS, Kilickesmez O. Regional anesthesia with epinephrine-containing lidocaine reduces pericatheter bleeding after tunneled hemodialysis catheter placement. Hemodial Int 2018; 23:26-32. [DOI: 10.1111/hdi.12686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/19/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ilhan Nahit Mutlu
- Department of Diagnostic and Interventional Radiology; Istanbul Training and Research Hospital; Istanbul Turkey
| | - Burak Kocak
- Department of Diagnostic and Interventional Radiology; Istanbul Training and Research Hospital; Istanbul Turkey
| | - Melis Baykara Ulusan
- Department of Diagnostic and Interventional Radiology; Istanbul Training and Research Hospital; Istanbul Turkey
| | - Kivilcim Ulusan
- Department of Diagnostic and Interventional Radiology; Istanbul Training and Research Hospital; Istanbul Turkey
| | - Mehmet Semih Cakir
- Department of Diagnostic and Interventional Radiology; Istanbul Training and Research Hospital; Istanbul Turkey
| | - Ozgur Kilickesmez
- Department of Diagnostic and Interventional Radiology; Istanbul Training and Research Hospital; Istanbul Turkey
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Facciorusso A, Muscatiello N. Submucosal Injection Solutions for Colon Polypectomy. COLON POLYPECTOMY 2018:89-106. [DOI: 10.1007/978-3-319-59457-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Electrochemical detection of Epinephrine using Polyaniline nanocomposite films doped with TiO 2 and RuO 2 Nanoparticles on Multi-walled Carbon Nanotube. Electrochim Acta 2017. [DOI: 10.1016/j.electacta.2017.05.031] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Park Y, Jeon TJ, Park JY, Park SJ, Cheon JH, Kim TI, Kim WH, Hong SP. Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps. J Gastroenterol Hepatol 2015; 30:1499-506. [PMID: 25973838 DOI: 10.1111/jgh.12994] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Post-polypectomy bleeding (PPB) is the most common adverse event of colonoscopic polypectomy, especially in cases with large pedunculated polyps. To minimize the risk of PPB, several endoscopic preventive methods have been performed. The aim of this prospective, randomized study was to compare the rates of PPB following single (clipping alone) and combined (clipping plus epinephrine-saline injection) methods in prevention of PPB in large pedunculated polyps. METHODS Adult patients with pedunculated colorectal polyps with heads ≥ 10 mm were prospectively enrolled from March 2011 to January 2013. Patients were randomized to receive treatment of either clips alone (group A) or clips plus injection of epinephrine-saline (group B) prior to a conventional polypectomy. PPB rate in both groups were compared. RESULTS A total of 148 patients with 173 pedunculated colorectal polyps were enrolled. Groups A and B each had 74 patients, with 83 and 90 polyps, respectively. The mean head diameters were 17.2 ± 6.6 and 17.5 ± 6.7 mm in groups A and B, respectively (P = 0.748). Immediate PPB (IPPB) occurred in 10 cases (12.0%) from group A and 13 cases (14.4%) from group B (P = 0.64). There were no cases of delayed PPB or perforation. Multivariate analysis showed that inadequate bowel preparation and large head diameter of polyp were independent risk factors for IPPB. CONCLUSIONS The rate of IPPB is relatively high in cases with large pedunculated polyps, but these polyps can be successfully resected by snare polypectomy following use of the single prophylactic clipping method.
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Affiliation(s)
- Yehyun Park
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Joo Jeon
- Division of Gastroenterology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Ji Young Park
- Division of Gastroenterology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Choi YS, Lee JB, Lee EJ, Lee SH, Suh JP, Lee DH, Kim DS, Youk EG. Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥ 30 mm) pedunculated colorectal polyp? Dis Colon Rectum 2013; 56:660-666. [PMID: 23575407 DOI: 10.1097/dcr.0b013e318276d2b9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Snare polypectomy of a giant pedunculated colorectal polyp is sometimes technically demanding, and, therefore, piecemeal resection is inevitable, despite the relative risk of invasive cancer and postpolypectomy bleeding. OBJECTIVE The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection in comparison with conventional snare polypectomy for giant pedunculated polyps DESIGN AND SETTINGS We retrospectively reviewed the clinical outcomes and complications of endoscopic polypectomy for giant pedunculated polyps from October 2006 to November 2011. PATIENTS All the patients who underwent endoscopic submucosal dissection (n = 23) or snare polypectomy (n = 20) for pedunculated polyps ≥ 3 cm were enrolled consecutively. In the case of a giant pedunculated polyp with 1) poor visualization of the stalk, 2) technical difficulties in snare positioning for en bloc resection, or 3) need for trimming of the head, we did not attempt piecemeal snare polypectomy, and we performed endoscopic submucosal dissection instead. (These were arbitrarily defined as "difficult" giant pedunculated polyps.) MAIN OUTCOME MEASURES Data on the patient's demography, endoscopic and histopathologic findings, clinical outcomes, and complications were analyzed. RESULTS Among the 43 giant pedunculated polyps, 23 polyps were defined as "difficult" polyps and were removed with endoscopic submucosal dissection. Subpedunculated (stalk <1 cm) type was more common in the "difficult" polyp group (p = 0.01). The overall incidence of cancer was 18.6% (8/43). En bloc resection rates were 100% (23/23) in the endoscopic submucosal dissection group and 90% (18/20) in the snare polypectomy group. The procedure times of snare polypectomy and endoscopic submucosal dissection group did not differ significantly (41.7 ± 13.7 minutes vs 44.9 ± 35.6 minutes, p = 0.70). Postpolypectomy bleeding was noted in 1 case (4.3%) in the endoscopic submucosal dissection group and in 3 cases (15%) in the snare polypectomy group. CONCLUSIONS Endoscopic submucosal dissection, as well as the snare polypectomy for giant pedunculated polyps, appeared to be effective without major complications and can be an alternative option to achieve en bloc resection, particularly for difficult cases, such as giant subpedunculated polyps.
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Affiliation(s)
- Yong Sung Choi
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
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Postpolypectomy bleeding: incidence, risk factors, prevention, and management. Surg Laparosc Endosc Percutan Tech 2012; 22:102-7. [PMID: 22487620 DOI: 10.1097/sle.0b013e318247c02e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.
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Matsui N, Akahoshi K, Nakamura K, Ihara E, Kita H. Endoscopic submucosal dissection for removal of superficial gastrointestinal neoplasms: A technical review. World J Gastrointest Endosc 2012; 4:123-36. [PMID: 22523613 PMCID: PMC3329612 DOI: 10.4253/wjge.v4.i4.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 11/13/2011] [Accepted: 03/30/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.
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Affiliation(s)
- Noriaki Matsui
- Noriaki Matsui, Department of Gastroenterology and Hepatology, National Hospital Organization Fukuoka Higashi Medical Center, Koga 811-3195, Japan
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Prophylactic argon plasma coagulation ablation does not decrease delayed postpolypectomy bleeding. Gastrointest Endosc 2009; 70:353-61. [PMID: 19386307 DOI: 10.1016/j.gie.2008.11.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 11/12/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most common complication of colonoscopic polypectomy is postpolypectomy bleeding (PPB). However, there are no established guidelines for the prevention of delayed PPB. It is possible that submucosal vessels of an artificial ulcer are a potential source of delayed bleeding that occurs several days after polypectomy. OBJECTIVE The aim of this randomized, controlled study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) of nonbleeding visible vessels in preventing delayed PPB. DESIGN A prospective, randomized, controlled study. SETTING A tertiary referral center. PATIENTS A total of 987 polyps in 600 consecutive patients were resected by colonoscopic polypectomy. INTERVENTION In patients who underwent APC (APC group), all nonbleeding visible vessels on the ulcer crater were targeted and were then coagulated by APC ablation until they disappeared, but not in patients who did not undergo APC (control group). MAIN OUTCOME MEASUREMENT The incidence of delayed PPB in the APC group was compared with that in the control group. RESULTS Delayed PPB occurred in 3.3% (16/475) of all the patients, including 2.5% (6/240) in the APC group and 4.3% (10/235) in the control group. No significant differences were observed between the 2 groups in the rates of delayed PPB, irrespective of the type of delayed bleeding (significant bleeding: 0.8% [2/240] vs 1.3% [3/235], P = .638; minor bleeding: 1.7% [4/240] vs 3% [7/235], P = .378). There were no significant APC-related complications. LIMITATION Single-center study. CONCLUSION Prophylactic APC ablation does not appear to have an additional advantage in the prevention of delayed PPB.
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Kouklakis G, Mpoumponaris A, Gatopoulou A, Efraimidou E, Manolas K, Lirantzopoulos N. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 2009; 23:2732-7. [PMID: 19430833 DOI: 10.1007/s00464-009-0478-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 02/08/2009] [Accepted: 03/16/2009] [Indexed: 01/05/2023]
Abstract
BACKGROUND Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods. MATERIALS AND METHODS Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions. RESULTS Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04). CONCLUSION Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.
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Affiliation(s)
- George Kouklakis
- Endoscopy Unit, Demokritus University of Thrace, Draganaa, 68100 Alexandroupolis, Greece.
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Kouklakis G, Mpoumponaris A, Gatopoulou A, Efraimidou E, Manolas K, Lirantzopoulos N. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 2009. [PMID: 19430833 DOI: 10.1007/s00464-009- 0478-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods. MATERIALS AND METHODS Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions. RESULTS Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04). CONCLUSION Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.
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Affiliation(s)
- George Kouklakis
- Endoscopy Unit, Demokritus University of Thrace, Draganaa, 68100 Alexandroupolis, Greece.
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Uraoka T, Saito Y, Yamamoto K, Fujii T. Submucosal injection solution for gastrointestinal tract endoscopic mucosal resection and endoscopic submucosal dissection. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 2:131-8. [PMID: 19920900 PMCID: PMC2761197 DOI: 10.2147/dddt.s3219] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have provided new alternatives for minimally invasive treatment of gastrointestinal adenomas and early-stage cancers that involve a minimum risk of lymph-node metastasis. The use of submucosal injections is essential to the success of these endoscopic resection techniques. The “ideal” submucosal injection solution should provide a sufficiently high submucosal fluid cushion for safe and effective EMRs and ESDs while also preserving lesion tissue for accurate histopathological assessment. In the past, normal saline (NS) solution was commonly used for this purpose, but it is difficult to achieve the proper submucosal elevation and maintain the desired height with NS. Therefore, other safe and effective facilitative submucosal injection solutions have been developed that also take into account relevant cost-benefit considerations. This review examines recent advances in the development of effective submucosal injection solutions for use during endoscopic resections.
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Affiliation(s)
- Toshio Uraoka
- Department of Gastroenterology and Hepatology, Okayama University, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Abstract
BACKGROUND The use of endoclipping may minimize the risk of bleeding after endoscopic polypectomy of large pedunculated polyps. The aim of this study was to assess the safety and efficacy of endoclipping of the stalk before resection of large pedunculated colorectal polyps, drawing particular attention to the cases in which the use of this method could be very useful. PATIENTS AND METHODS This retrospective study included 17 patients [10 men, 7 women; median age: 62 y (range 38 to 79)] with 18 large pedunculated colorectal polyps, who underwent endoclipping-assisted endoscopic polypectomy between March 2003 and May 2006. The outcome of the technique and the technique-related complications were evaluated. RESULTS Application of the clips was possible in all patients. In 4 patients (23.5%), the endoclipping was performed via the more flexible gastroscope. En bloc resection of colon polyps was achieved in all patients. No immediate or late bleeding or perforation occurred. One patient (5.9%) developed postcoagulation syndrome and was successfully treated conservatively. Histologic examination showed in situ carcinoma in 6 polyps (33.3%). Follow-up colonoscopy demonstrated no recurrence of polyps or cancer development. CONCLUSIONS Endoclipping, followed by snare transection, may be safer than conventional polypectomy in large pedunculated colorectal polyps. Special attention is needed not to cut very close to clips to avoid thermal injury of colonic wall.
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Klebl FH, Schölmerich J. Future expectations in the prophylaxis of intestinal bleeding. Best Pract Res Clin Gastroenterol 2008; 22:373-87. [PMID: 18346690 DOI: 10.1016/j.bpg.2007.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Prophylaxis of gastrointestinal bleeding is attempted in widely varying situations. In NSAID-induced peptic ulcer, the advantage of selective cyclooxygenase 2 inhibitors with regard to gastrointestinal damage has yet to be translated into an advantage in overall morbidity. Strategies for primary and secondary prevention of variceal bleeding have been established. Therapy tailored to hepatic venous pressure gradient has the potential to achieve clinical relevance. Several methods have been developed to prevent postpolypectomy bleeding, but their optimal risk-tailored application has yet to be demonstrated. Although octreotide treatment seems to be beneficial in reducing the blood loss from angiodysplasias, controlled studies to determine its optimal use are awaited. Stress-ulcer prophylaxis is commonly applied in critically ill patients. Although data indicate that H2-receptor antagonists and omeprazole are effective in preventing clinically significant bleeding, evidence for an advantage with respect to length of hospital or intensive-care-unit stay, as well as mortality, is still lacking. Since there is misuse of acid-suppressing drugs on regular wards, in-house guidelines may offer the potential for saving costs and reducing inappropriate prescription.
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Affiliation(s)
- F H Klebl
- Department of Internal Medicine I, University of Regensburg, D-93042 Regensburg, Germany.
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Charoniti I, Theodoropoulou A, Vardas E, Oustamanolakis P, Manolaraki M, Ieromonachou P, Anastasiadou A, Paspatis GA. Combination of adrenaline injection and detachable snare application as haemostatic preventive measures, before polypectomy of large colonic polyps in children. Dig Dis Sci 2007; 52:3381-2. [PMID: 17415643 DOI: 10.1007/s10620-006-9456-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 05/17/2006] [Indexed: 01/15/2023]
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for nonvariceal bleeding disorders of the GI tract. Gastrointest Endosc 2007; 66:343-54. [PMID: 17643711 DOI: 10.1016/j.gie.2006.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 11/09/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California 94305, USA
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Lee SH, Chung IK, Kim SJ, Kim JO, Ko BM, Kim WH, Kim HS, Park DI, Kim HJ, Byeon JS, Yang SK, Jang BI, Jung SA, Jeen YT, Choi JH, Choi H, Han DS, Song JS. Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy: A prospective randomized, multicenter study. World J Gastroenterol 2007; 13:2973-7. [PMID: 17589949 PMCID: PMC4171151 DOI: 10.3748/wjg.v13.i21.2973] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate and compare the clinical outcomes of prophylactic submucosal saline-epinephrine injection and saline injection alone for large colon polyps by conventional polypectomy.
METHODS: A prospective study was conducted from July 2003 to July 2004 at 11 tertiary endoscopic centers. Large colon polyps (> 10 mm in diameter) were randomized to undergo endoscopic polypectomy with submucosal saline-epinephrine injection (epinephrine group) or normal saline injection (saline group). Endoscopic polypectomy was performed by the conventional snare method, and early (< 12 h) and late bleeding complications (12 h-30 d) were observed.
RESULTS: A total of 561 polyps in 486 patients were resected by endoscopic polypectomy. Overall, bleeding complications occurred in 7.6% (37/486) of the patients, including 4.9% (12/244) in the epinephrine group, and 10.3% (25/242) in the saline group. Early and late postpolypectomy bleeding (PPB) occurred in 6.6% (32/486) and 1% (5/486) of the patients, respectively, including 4.5% (11/244), 0.4% (1/244) in the epinephrine group, and 8.7% (21/242), 1.7% (4/242) in the saline group. No significant differences in the rates of overall, early and late PPB were observed between the 2 groups. Multivariate stepwise logistic regression analysis revealed that large size (> 2 cm) and neoplastic polyps were independently and significantly associated with the presence of PPB.
CONCLUSION: The prophylactic submucosal injection of diluted epinephrine does not appear to provide an additional advantage over the saline injection alone for the prevention of PPB.
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Affiliation(s)
- Suck-Ho Lee
- Department of Internal Medicine, University of Soonchunhyang at Cheonan, Cheonan & Seoul & Bucheon, Republic of Korea.
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Paspatis GA, Paraskeva K, Theodoropoulou A, Mathou N, Vardas E, Oustamanolakis P, Chlouverakis G, Karagiannis I. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 2006; 101:2805; quiz 2913. [PMID: 17026560 DOI: 10.1111/j.1572-0241.2006.00855.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Our study sought to compare the efficacy of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. METHODS At the time of colonoscopy, patients with at least one colonic polyp > or =2 cm were randomized to receive treatment either by the injection of a 1:10.000 solution of adrenaline and the position of a detachable snare followed by a conventional snare polypectomy (group A) or injection of adrenaline followed by a conventional snare polypectomy (group B). A total of 159 consecutive patients were randomly assigned to one of the above groups. Out of them, 84 patients (47 men, 37 women, mean age 61 yr) were assigned to group A and 75 (37 men, 38 women, mean age 64 yr) to group B. Early (<24 h) and late (>24 h-30 days) bleeding complications were assessed. RESULTS Overall bleeding complications occurred in 10/159 (6.2%) of the patients. There were two cases of bleeding in group A (2.3%), and eight in group B (10.6%) (P= 0.04). The number of early bleeding episodes was significantly reduced in group A patients (1 case) compared to that of group B (7 cases) (P= 0.02). In contrast, there was no significant difference between group A and B as far as late bleeding is concerned. CONCLUSIONS Our data suggest that the use of adrenaline injection in combination with detachable snare may significantly decrease the number of early postpolypectomy bleeding episodes in patients with large colonic polyps.
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Affiliation(s)
- Gregorios A Paspatis
- Department of Gastroenterology, Benizelion General Hospital, Heraklion-Crete, Greece
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Efthymiou A, Markoglou C, Michalopoulou F, Viazis N, Vlachogiannakos J, Avgerinos A. Intracerebral hemorrhage after therapeutic upper-GI endoscopy: report of a case. Gastrointest Endosc 2006; 63:522-5. [PMID: 16500416 DOI: 10.1016/j.gie.2005.09.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Accepted: 09/19/2005] [Indexed: 12/12/2022]
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Dobrowolski S, Dobosz M, Babicki A, Dymecki D, Hać S. Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 2004; 18:990-3. [PMID: 15108107 DOI: 10.1007/s00464-003-9214-6] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Accepted: 01/04/2004] [Indexed: 01/01/2023]
Abstract
BACKGROUND Endoscopic polypectomy is a standard method of treatment of gastrointestinal polyps, but is associated with substantial risk of complications. The most common is hemorrhage, the rate of which varied between 0.3%, and 6%. Various prophylactic techniques have been used to reduce this incidence. The aim of this study was to establish whether the prophylactic injection of adrenaline-saline solution reduces the risk of postpolypectomy bleeding in colonoscopic polypectomy. METHODS Between May 2000 and June 2002, patients with colorectal polyps of size > or =1 cm were randomized to receive submucosal epinephrine injection (group A) or no injection (group B). The polypectomies were carried out using the conventional method. In group A, epinephrine (1/10,000) was injected into the stalk or base of the polyp. The patients were observed for complications. RESULTS A total of 69 patients with 100 polyps were enrolled in this study: n = 50 in group A, and n = 50 in group B, according to randomization. There were a total of nine episodes of postpolypectomy hemorrhage, one in the epinephrine group and eight in the control group (1/50 vs 8/50, p < 0.05). The bleeding correlated with the size of the polyps and the diameter of the stalks. CONCLUSIONS Epinephrine injection prior to colonoscopic polypectomy is effective in preventing bleeding.
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Affiliation(s)
- S Dobrowolski
- Department of General, Gastroenterological and Endocrinological Surgery, Medical University of Gdansk, Ul. Kieturakisa 1, 80-742, Gdansk, Poland.
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Dominitz JA, Eisen GM, Baron TH, Goldstein JL, Hirota WK, Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Raddawi HM, Vargo JJ, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO. Complications of colonoscopy. Gastrointest Endosc 2003; 57:441-5. [PMID: 12665750 DOI: 10.1016/s0016-5107(03)80005-6] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 2000; 51:690-6. [PMID: 10840301 DOI: 10.1067/mge.2000.105773] [Citation(s) in RCA: 171] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postpolypectomy hemorrhage may warrant intensive care monitoring, transfusions, and surgery. We sought factors predicting significant bleeding requiring blood transfusion and the benefits of critical care monitoring. METHODS Patients with postpolypectomy bleeding between April 1989 and November 1996 were identified from a comprehensive GI bleeding database. Data included age, gender, medical history, medications, polyp characteristics, and polypectomy technique. Outcomes assessed included bleeding cessation, transfusion requirements, recurrent bleeding, length of stay, and death. RESULTS There were 83 patients with a median age of 73 years (range 18 to 88 years; 56 men, 27 women). Comorbid conditions were common (71.1% cardiovascular, 43.4% musculoskeletal, 14.5% hematologic, 6.0% renal). Within 3 days of presentation, 32.5% had taken aspirin, 10.8% nonsteroidal anti-inflammatory drugs, 12.0% warfarin, and 12.0% corticosteroids; and within 1 day, 10.8% intravenous heparin, 7.2% subcutaneous heparin, and 7.2% dipyridamole. Fifty-seven percent of patients were hemodynamically stable. Sessile cecal polyps greater than 2 cm in diameter bled more commonly. The median number of units transfused was equal between critical care and noncritical care patients. Using age in the logistic regression model, no other variable was predictive of transfusion. Eighty patients (96.4%) received endoscopic therapy, 1 required embolization and 2 hemicolectomy. There was no significant difference in outcomes for patients managed in an intensive care unit versus a general medical floor. CONCLUSIONS Postpolypectomy bleeding appears to have a predictable presentation and outcome. Advanced age seems to be predictive of transfusion requirement. Patient monitoring in an intensive care setting is not absolutely necessary.
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Affiliation(s)
- D Sorbi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Cappell MS, Abdullah M. Management of gastrointestinal bleeding induced by gastrointestinal endoscopy. Gastroenterol Clin North Am 2000; 29:125-vii. [PMID: 10752020 DOI: 10.1016/s0889-8553(05)70110-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.
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Affiliation(s)
- M S Cappell
- Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA
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Nelson DB, Bosco JJ, Curtis WD, Faigel DO, Kelsey PB, Leung JW, Mills MR, Smith P, Tarnasky PR, VanDam J, Wassef WY. ASGE technology status evaluation report. Injection needles. February 1999. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1999; 50:928-31. [PMID: 10644194 DOI: 10.1016/s0016-5107(99)70198-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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