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Argumánez V, Plumé G, Bustamante-Balén M. Periendoscopic management of antithrombotic drugs: Is cold snare polypectomy the answer? GASTROENTEROLOGIA Y HEPATOLOGIA 2025; 48:502286. [PMID: 39549819 DOI: 10.1016/j.gastrohep.2024.502286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 10/27/2024] [Accepted: 10/29/2024] [Indexed: 11/18/2024]
Abstract
Patients undergoing colonoscopy are increasingly taking antithrombotic medication. These patients, who are generally older, also have a higher prevalence of colon polyps. Therefore, it is general practice to modify or discontinue antithrombotic treatment before colonoscopy, to reduce the risk of post-polypectomy bleeding (PPB). However, this modification increases the risk of thrombotic events. Currently, the main clinical guidelines recommend cold-snare resection for polyps smaller than 10mm because of its better safety profile, especially in reducing post-polypectomy bleeding. This reduced PPB rate could open the door to maintaining antithrombotic drugs in patients undergoing colonoscopy. This review aims to evaluate the evidence available so far that may support a modification of current guidelines on the management of antithrombotic drugs in the periendoscopic period.
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Affiliation(s)
- Victor Argumánez
- Gastrointestinal Endoscopy Unit, Digestive Diseases Department, Hospital Universitari i Politècnic La Fe, Valencia 46026, Spain
| | - Gema Plumé
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia 46026, Spain
| | - Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit, Digestive Diseases Department, Hospital Universitari i Politècnic La Fe, La Fe Health Research Institute (IISLaFe), Valencia 46026, Spain.
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Kitagawa Y, Suzuki T, Miyakawa A, Okimoto K, Matsumura T, Shiratori T, Ishigami H, Mine T, Takashiro H, Saito H, Kato N. Comparison of endoscopic submucosal dissection and modified endoscopic mucosal resection for rectal neuroendocrine tumors. Sci Rep 2025; 15:5424. [PMID: 39948094 PMCID: PMC11825951 DOI: 10.1038/s41598-024-82082-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/02/2024] [Indexed: 02/16/2025] Open
Abstract
Although some studies have compared the treatment outcomes between modified endoscopic mucosal resection (m-EMR) and endoscopic submucosal dissection (ESD) for rectal neuroendocrine tumors (NETs), the results are based on the experience of experts from a single high-volume center. This multicenter study aimed to compare the outcomes between m-EMR and ESD for rectal NETs, with emphasis on the operator's level. Data of patients with rectal NETs treated using m-EMR or ESD at seven institutions that included general hospitals in Japan were retrospectively reviewed. Patients treated using m-EMR and those treated using ESD were matched for age, sex, lesion size, lesion location, and operator level through propensity score matching. The treatment outcomes were compared between the two groups. In total 304 patients (m-EMR = 178, ESD = 126) were included, with 218 in the matched groups (m-EMR = 109, ESD = 109). The R0 resection rate was not significantly different between the two groups (90.0% vs. 82.3%, P = .221). However, the procedural time was significantly shorter for the m-EMR group than that for the ESD group (6 vs. 26 min, P < .001). No significant difference in adverse events was observed between the two groups (postprocedure bleeding rate: 5.5% vs. 2.8%, P = .335; perforation rate: 0.9% vs. 0.9%, P = 1.00). Subgroup analysis revealed that the R0 resection rate for the trainees was significantly higher in the m-EMR group than in the ESD group (87.9% vs. 64.5%, P = .017). m-EMR is the preferred technique for the treatment of rectal NETs and should be considered, particularly for the trainees.
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Affiliation(s)
- Yoshiyasu Kitagawa
- Endoscopy Division, Chiba Cancer Center, 666-2 Nitonacho, Chuo-ku, Chiba, Japan.
| | - Takuto Suzuki
- Endoscopy Division, Chiba Cancer Center, 666-2 Nitonacho, Chuo-ku, Chiba, Japan
| | - Akihiro Miyakawa
- Department of Gastroenterology, Asahi General Hospital, Chiba, Japan
| | | | | | | | - Hideaki Ishigami
- Department of Gastroenterology, Chiba Rosai Hospital, Chiba, Japan
| | - Takeshi Mine
- Department of Gastroenterology, Kimitsu Chuo Hospital, Chiba, Japan
| | - Hideyuki Takashiro
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, Chiba, Japan
| | - Hirofumi Saito
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Chiba University, Chiba, Japan
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Chiang HC, Chen PJ, Yang EH, Kuo TL, Hsieh MT, Kang JW, Cheng HC, Chang WL, Chen WY, Chiu HC, Lin MY, Hong TC, Chiang CM, Chen WC, Huang KK, Lu MH, Wu MH, Chen CY, Lin XZ, Chuang CH. Clinical Trial: Precise Administration of Sucralfate Powder in Prevention of Delayed Postpolypectomy Bleeding. A Randomized Controlled Trial. Clin Transl Gastroenterol 2025:01720094-990000000-00365. [PMID: 39836033 DOI: 10.14309/ctg.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 01/03/2025] [Indexed: 01/22/2025] Open
Abstract
INTRODUCTION Delayed postpolypectomy bleeding occurs in approximately 1%-2% of all patients undergoing colonoscopic polypectomy, and this rate increases to 6% in patients with large (>2 cm) colon polyps. Sucralfate can protect the mucosa and promote its healing. This study was conducted to investigate whether colonoscopic spraying of sucralfate powder on polypectomy wounds can prevent delayed postoperative bleeding. METHODS This randomized controlled trial included patients with polyps (size ≥0.5 cm) who had undergone colonoscopic polypectomy at our hospital between May 2023 and January 2024. After polypectomy, the patients received standard treatment for immediate bleeding. Then, they were randomly allocated to either a sucralfate group (prophylactic spraying of sucralfate powder [3 g] on polypectomy wounds) or a control group. All patients were monitored for delayed bleeding within 28 days after colonoscopy. RESULTS A total of 160 patients were divided into the sucralfate and control groups (80 per group). The baseline characteristics were balanced between the groups. The rate of delayed postpolypectomy bleeding (0% vs 6.3%, respectively; P = 0.029) and postpolypectomy overt bloody stool (2.4% vs 18.8%, respectively; P = 0.001) were lower in the sucralfate group than in the control group. The duration of freedom from delayed bleeding was longer in the sucralfate group than in the control group ( P = 0.024). Multivariate Cox regression analysis confirmed the additional sucralfate spray as an independent factor against postpolypectomy overt bloody stool (relative risk, 0.03; 95% confidence interval, 0.003-0.43; P = 0.009). DISCUSSION Colonoscopic spraying of sucralfate powder is a safe approach with potential to reduce the risk of delayed postpolypectomy bleeding. Trial registration: NCT05817656.
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Affiliation(s)
- Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Jun Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Er-Hsiang Yang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Ling Kuo
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Tsung Hsieh
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jui-Wen Kang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chi Cheng
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Molecular Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Lun Chang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ying Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Molecular Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hung-Chih Chiu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Ying Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Chun Hong
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Ming Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Chih Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Kai Huang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Hsuan Lu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Hsuan Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiung-Yu Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Xi-Zhang Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Tseng CH, Chang LC, Wu JL, Chang CY, Chen CY, Chen PJ, Shun CT, Hsu WF, Chen YN, Chen CC, Huang TY, Tu CH, Chen MJ, Chou CK, Lee CT, Chen PY, Lin JT, Wu MS, Chiu HM. Bleeding Risk of Cold Versus Hot Snare Polypectomy for Pedunculated Colorectal Polyps Measuring 10 mm or Less: Subgroup Analysis of a Large Randomized Controlled Trial. Am J Gastroenterol 2024; 119:2233-2240. [PMID: 38775310 PMCID: PMC11524623 DOI: 10.14309/ajg.0000000000002847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/12/2024] [Indexed: 11/01/2024]
Abstract
INTRODUCTION Concerns regarding bleeding remain in cold snare polypectomy (CSP) for small pedunculated (0-Ip) polyps. The aim of this study was to compare the risk of CSP and hot snare polypectomy (HSP) for such lesions. METHODS Data on 0-Ip colorectal polyps ≤10 mm were extracted from a large, pragmatic, randomized trial. Immediate postpolypectomy bleeding (IPPB), defined as the perioperative use of a clip for bleeding, was evaluated through polyp-level analysis. Delayed postpolypectomy bleeding (DPPB), defined as bleeding occurring within 2 weeks postoperatively, was assessed at the patient-level among patients whose polyps were all ≤10 mm, including at least one 0-Ip polyp. RESULTS A total of 647 0-Ip polyps (CSP: 306; HSP: 341) were included for IPPB analysis and 386 patients (CSP: 192; HSP: 194) for DPPB analysis. CSP was associated with a higher incidence of IPPB (10.8% vs 3.2%, P < 0.001) but no adverse clinical events. The procedure time of all polypectomies was shorter for CSP than for HSP (123.0 ± 117.8 vs 166.0 ± 237.7 seconds, P = 0.003), while the procedure time of polypectomies with IPPB were similar (249.8 ± 140.2 vs 227.4 ± 125.9 seconds, P = 0.64). DPPB was observed in 3 patients (1.5%) in the HSP group, including one patient (0.5%) with severe bleeding, but not in the CSP group. DISCUSSION Despite CSP being associated with more IPPB events, it could be timely treated without adverse outcomes. Notably, no delayed bleeding occurred in the CSP group. Our findings support the use of CSP for 0-Ip polyps ≤ 10 mm.
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Affiliation(s)
- Cheng-Hao Tseng
- Department of Gastroenterology and Hepatology, E-Da Cancer Hospital, Kaohsiung, Taiwan
- Department of Gastroenterology and Hepatology, I-Shou University, Kaohsiung, Taiwan
| | - Li-Chun Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Ling Wu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Yang Chang
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei, Taiwan
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Chi-Yi Chen
- Department of Internal Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Peng-Jen Chen
- Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Feng Hsu
- Department of Internal Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Yen-Nien Chen
- Department of Internal Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chieh-Chang Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Jyh Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Kuang Chou
- Department of Internal Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Ching-Tai Lee
- Department of Gastroenterology and Hepatology, I-Shou University, Kaohsiung, Taiwan
- Department of Gastroenterology and Hepatology, E-Da Hospital, Kaohsiung, Taiwan
| | - Po-Yueh Chen
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Jaw-Town Lin
- Department of Gastroenterology and Hepatology, E-Da Cancer Hospital, Kaohsiung, Taiwan
- Department of Gastroenterology and Hepatology, I-Shou University, Kaohsiung, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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5
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Gweon TG, Kim HG, Jung Y, Jeon SR, Na SY, Lee YJ, Kim TH. Safety of cold snare resection techniques for removal of polyps in the small colon in patients taking clopidogrel and aspirin: a Korean Association for the Study of Intestinal Diseases prospective multicenter study. Gastrointest Endosc 2024:S0016-5107(24)03597-1. [PMID: 39424007 DOI: 10.1016/j.gie.2024.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/28/2024] [Accepted: 10/08/2024] [Indexed: 10/21/2024]
Abstract
BACKGROUND AND AIMS Polypectomy is a procedure associated with a high risk of bleeding. Guidelines recommend uninterrupted aspirin use during polypectomy, whereas cessation of clopidogrel 5 to 7 days before polypectomy is recommended. The cold snare resection (CSR) technique, with or without submucosal injection, is considered safer than conventional polypectomy using electrocoagulation for postpolypectomy bleeding. In this study, we compared the bleeding adverse events associated with CSR between clopidogrel and aspirin users. METHODS This multicenter prospective cohort study was conducted in 5 academic hospitals in Korea and included clopidogrel and aspirin users who underwent polypectomy. Antiplatelet agents were used without interruption, with ≤3 days of interruption defined as continuous use. The primary endpoint was delayed bleeding, which was defined as bleeding occurring several hours after polypectomy, whereas immediate bleeding was defined as bleeding requiring hemostasis 2 minutes after polypectomy. Risk factors for immediate bleeding were investigated for each polyp. RESULTS Among the 263 patients (clopidogrel, 129; aspirin, 134), 509 underwent polypectomies. The rates of delayed bleeding per patient in the clopidogrel and aspirin groups were .8% and .7%, respectively, meeting noninferiority (rate difference, .03%; 95% confidence interval, -2.07 to 2.13). Hemostasis was achieved in 100 patients who underwent polypectomy (19.8%). Immediate bleeding risk factors were female sex, end-stage renal disease, submucosal injection before resection, and polyp size ≥5 mm. CONCLUSIONS This multicenter prospective study demonstrated the safety of CSR in patients treated with uninterrupted clopidogrel and aspirin. (Clinical trial registration number: NCT04328987.).
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Affiliation(s)
- Tae-Geun Gweon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Gun Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Soo-Young Na
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Tae Ho Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Gerald A, na ayuddhaya KP, McCandless M, Hsu P, Pang J, Mankad A, Chu A, Aihara H, Russo S. Ex Vivo Evaluation of a Soft Optical Blood Sensor for Colonoscopy. DEVICE 2024; 2:100422. [PMID: 39678941 PMCID: PMC11637413 DOI: 10.1016/j.device.2024.100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2024]
Abstract
Colonoscopies are vital procedures allowing diagnosis of colorectal cancer and other gastrointestinal diseases. However, excessive forces may be applied to the colon during navigation. This can cause bleeding, especially in patients presenting inflammatory bowel diseases. The endoscopist is often unable to detect bleeding as visualization is limited to the distal tip camera of the endoscope. Thus, there is a need to have bleeding detection capabilities behind the device tip. This work presents a soft optical blood sensor that can be mounted onto a colonoscope. The presence of blood in the sensor's microchannel causes a reduction in optical transmission, and the endoscopist is alerted. We evaluate the sensor safety and performance ex vivo with a cohort of 10 endoscopists (novices and experts). We demonstrate the ability of the sensor to rapidly identify bleeding and easily integrate into the clinical workflow, without significantly affecting navigation time and the users' learning curve.
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Affiliation(s)
- Arincheyan Gerald
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | | | - Max McCandless
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Patra Hsu
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Johann Pang
- Department of Biomedical Engineering, Boston University, Boston, MA 02215, USA
| | - Arnav Mankad
- Department of Biomedical Engineering, Boston University, Boston, MA 02215, USA
| | - Addison Chu
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Hiroyuki Aihara
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sheila Russo
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
- Division of Materials Science and Engineering, Boston University, Boston, MA 02215, USA
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality indicators for colonoscopy. Gastrointest Endosc 2024; 100:352-381. [PMID: 39177519 DOI: 10.1016/j.gie.2024.04.2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/25/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Department of Medicine/Division of Gastroenterology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine/Division of Gastroenterology, White River Junction VAMC, White River Junction, Vermont, USA; University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco; Chief Medical Officer, University of California San Francisco Health System
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA; VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality Indicators for Colonoscopy. Am J Gastroenterol 2024:00000434-990000000-01296. [PMID: 39167112 DOI: 10.14309/ajg.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Chief Medical Officer, University of California San Francisco Health System, San Francisco, California, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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9
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Chiang HC, Chiang CM, Lin XZ, Chen PJ. Effect of Cold Versus Hot Snare Polypectomy on Colon Postpolypectomy Bleeding in Patients with End-Stage Renal Disease: A Retrospective Cohort Study. Dig Dis Sci 2024; 69:2381-2389. [PMID: 38722411 DOI: 10.1007/s10620-024-08405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/24/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) who undergo polypectomy may experience postpolypectomy bleeding. To reduce the risk of delayed postpolypectomy bleeding among the general population, cold snare polypectomy (CSP) is recommended for removing colon polyps smaller than 1 cm. Nevertheless, only few studies have examined the effect of CSP on patients with ESRD. METHODS We retrospectively analyzed the data of patients with ESRD who underwent colonoscopic polypectomy for polyps larger than 5 mm at a Taiwanese university hospital from January 2014 to January 2023. The main outcome was delayed postpolypectomy bleeding within 30 days. Multivariate analysis was conducted to adjust for major confounders. RESULTS A total of 557 patients with ESRD underwent colonoscopic polypectomy during the study period: 201 underwent CSP and 356 underwent hot snare polypectomy (HSP). Delayed postpolypectomy bleeding occurred in 27 patients (4.8%). The rate of delayed postpolypectomy bleeding was lower in patients with ESRD who underwent CSP than in those who underwent HSP (1.9% vs. 6.4%, P = 0.022). The percentage of patients who did not experience postpolypectomy bleeding within 30 days after CSP remained lower than that observed after HSP (P = 0.019, log-rank test). Multivariate analysis demonstrated immediate postpolypectomy bleeding and HSP to be independent risk factors for delayed postpolypectomy bleeding. A nomogram prognostic model was used to predict the potential of delayed postpolypectomy bleeding within 30 days in patients with ESRD. CONCLUSIONS Compared with HSP, CSP is more effective in mitigating the risk of delayed postpolypectomy bleeding in patients with ESRD.
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Affiliation(s)
- Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, 704, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Ming Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, 704, Taiwan
| | - Xi-Zhang Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, 704, Taiwan
| | - Po-Jun Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, 704, Taiwan.
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10
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Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, Paspatis GA, Moss A, Libânio D, Lorenzo-Zúñiga V, Voiosu AM, Rutter MD, Pellisé M, Moons LMG, Probst A, Awadie H, Amato A, Takeuchi Y, Repici A, Rahmi G, Koecklin HU, Albéniz E, Rockenbauer LM, Waldmann E, Messmann H, Triantafyllou K, Jover R, Gralnek IM, Dekker E, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024; 56:516-545. [PMID: 38670139 DOI: 10.1055/a-2304-3219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
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Affiliation(s)
- Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Gastroenterology, Evangelical Hospital, Vienna, Austria
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Mauro Risio
- Department of Pathology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy
| | - Gregorios A Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Vincente Lorenzo-Zúñiga
- Endoscopy Unit, La Fe University and Polytechnic Hospital / IISLaFe, Valencia, Spain
- Department of Medicine, Catholic University of Valencia, Valencia, Spain
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthew D Rutter
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
- Department of Gastroenterology, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Leon M G Moons
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, Ospedale A. Manzoni, Lecco, Italy
| | - Yoji Takeuchi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Gabriel Rahmi
- Hepatogastroenterology and Endoscopy Department, Hôpital européen Georges Pompidou, Paris, France
- Laboratoire de Recherches Biochirurgicales, APHP-Centre Université de Paris, Paris, France
| | - Hugo U Koecklin
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Teknon Medical Center, Barcelona, Spain
| | - Eduardo Albéniz
- Gastroenterology Department, Hospital Universitario de Navarra (HUN); Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lisa-Maria Rockenbauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Helmut Messmann
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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11
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Wehbe H, Gutta A, Gromski MA. Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon. Gastrointest Endosc Clin N Am 2024; 34:363-381. [PMID: 38395489 DOI: 10.1016/j.giec.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.
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Affiliation(s)
- Hisham Wehbe
- Department of Internal Medicine, Indiana University School of Medicine, 550 University Boulevard, UH 3533, Indianapolis, IN 46202, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA
| | - Mark A Gromski
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA.
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12
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Taghiakbari M, Kim DHD, Djinbachian R, von Renteln D. Endoscopic resection of large non-pedunculated colorectal polyps: current standards of treatment. EGASTROENTEROLOGY 2024; 2:e100025. [DOI: 10.1136/egastro-2023-100025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2025]
Abstract
Colorectal cancer is a significant public health concern, and large non-pedunculated colorectal polyps pose a substantial risk for malignancy and incomplete resection, which may lead to interval cancer. The choice of resection technique is influenced by various factors, including polyp size, morphology, location, submucosal invasion depth and endoscopist expertise. For non-cancerous superficial large non-pedunculated polyps, conventional hot or cold snare polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection are common techniques for non-surgical therapeutic endoscopic resection of these polyps. This manuscript provides a comprehensive review of literature on current endoscopic resection techniques for large non-pedunculated colorectal polyps, emphasising indications, advantages, limitations and outcomes.
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13
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Copland AP, Kahi CJ, Ko CW, Ginsberg GG. AGA Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review. Clin Gastroenterol Hepatol 2024; 22:470-479.e5. [PMID: 38032585 DOI: 10.1016/j.cgh.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
DESCRIPTION In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.
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Affiliation(s)
- Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Charles J Kahi
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Cynthia W Ko
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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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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15
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Ji JH, Kim HW, Park J, Park SJ, Cheon JH, Kim TI, Park JJ. Risk factors for post-polypectomy bleeding in patients with end-stage renal disease undergoing colonoscopic polypectomy. Surg Endosc 2024; 38:846-856. [PMID: 38082006 DOI: 10.1007/s00464-023-10626-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND AIMS Little is known about the risk factors of bleeding after colonoscopic polypectomy in patients with end-stage renal disease (ESRD). This study investigated the incidence and risk factors of post-polypectomy bleeding (PPB), including immediate and delayed bleeding, in patients with ESRD. METHODS Ninety-two patients with ESRD who underwent colonoscopic polypectomy between September 2005 and June 2020 at a single tertiary referral center were included. The patients' medical records were retrospectively reviewed. Patient- and polyp-related factors associated with immediate PPB (IPPB) were analyzed using logistic regression analysis. Additionally, the optimal cutoff polyp size related to a significant increase in the risk of IPPB was determined by performing receiver operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC). RESULTS In total, 286 polyps were removed. IPPB occurred in 24 (26.1%) patients and 46 (16.1%) polyps and delayed PPB occurred in 2 (2.2%) patients. According to multivariate analysis, the polyp size (> 7 mm), old age (> 70), and endoscopic mucosal resection (EMR) as the polypectomy method (EMR versus non-EMR) were found to be independent risk factors for IPPB. According to the Youden index method, the optimal cutoff polyp size to identify high-risk polyps for IPPB was 7 mm (AUC = 0.755; sensitivity, 76.1%; specificity, 69.6%). CONCLUSIONS Colonoscopic polypectomy should be performed with caution in patients with ESRD, especially in those with the following risk factors: advanced age (> 70 years), polyp size > 7 mm, and EMR as the polypectomy method.
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Affiliation(s)
- Jung Hyun Ji
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jihye Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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16
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Keating E, Leyden J, O'Connor DB, Lahiff C. Unlocking quality in endoscopic mucosal resection. World J Gastrointest Endosc 2023; 15:338-353. [PMID: 37274555 PMCID: PMC10236981 DOI: 10.4253/wjge.v15.i5.338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.
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Affiliation(s)
- Eoin Keating
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Jan Leyden
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Donal B O'Connor
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Conor Lahiff
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
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17
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Lau LHS, Jiang W, Guo CLT, Lui RN, Tang RSY, Chan FKL. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in aspirin users: a propensity-score analysis. Gastrointest Endosc 2023; 97:517-527.e1. [PMID: 36209766 DOI: 10.1016/j.gie.2022.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Antithrombotic use is a significant risk factor of postpolypectomy bleeding (PPB). Evidence of prophylactic clipping is only available for proximal and large colonic lesions in the general population. Dedicated studies to examine the benefit of prophylactic clipping in patients on aspirin remain scarce. METHODS A propensity score-weighted retrospective cohort study was performed in a tertiary referral center from January 2018 to September 2021. Patients who received aspirin and underwent colonoscopic polypectomy, EMR, or endoscopic submucosal dissection were included. Data on baseline demographics, medications, and endoscopic factors (polyp number, size, location, and morphology; resection method; and prophylactic clipping) were captured. Propensity score-weighted models were developed between prophylactic clipping and no clipping groups. The primary outcome was delayed PPB within 30 days, with a composite endpoint consisting of repeated colonoscopy for hemostasis, requirement of blood transfusion, or hemoglobin drop >2 g/dL. RESULTS A total of 1373 patients with 3952 polyps were included. Baseline characteristics were balanced between the 2 groups. In the multivariate analysis, the largest polyp size was a significant risk factor for PPB (odds ratio, 1.07; 95% confidence interval, 1.02-1.11; P = .002). Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio, 1.34; 95% confidence interval, .83-2.18; P = .240) and did not show any risk reduction in subgroups with different polyp sizes and locations and endoscopic resection techniques. CONCLUSIONS Prophylactic clipping was not associated with a lower risk of PPB in aspirin users after endoscopic resection of colorectal polyps. Aspirin use should not be regarded as the only factor for the routine use of prophylactic clips.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Wei Jiang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Rashid N Lui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong SAR
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18
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Lau LHS, Guo CLT, Lee JKK, Chan CST, Mak JWY, Wong SH, Yip TCF, Wong GLH, Wong VWS, Chan FKL, Tang RSY. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in oral anticoagulant users: a propensity-score analysis. Gastrointest Endosc 2022; 96:530-542.e1. [PMID: 35413329 DOI: 10.1016/j.gie.2022.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Evidence of prophylactic clipping is inconsistent except for proximal and large colonic lesions in the general population. Although warfarin and direct oral anticoagulants (DOACs) are significant risk factors of postpolypectomy bleeding (PPB), dedicated studies to examine the benefit of prophylactic clipping in these high-risk patients remain limited. METHODS We performed a propensity score-weighted retrospective cohort study from 2012 to 2020. Patients who received an oral anticoagulant and underwent colonoscopic polypectomy were included. Data were collected on baseline demographics, medications (anticoagulant, antiplatelet, and heparin bridging), and endoscopies (polyp number, location, size, morphology, histopathology, resection method and prophylactic clipping). Propensity-score models with inverse probability of treatment weighting were developed between prophylactic clipping and no clipping groups. Unbalanced variables were included in a doubly robust model with multivariate analysis. The primary outcome was clinically significant delayed PPB, defined as a composite endpoint of hemoglobin drop ≥2 g/dL, blood transfusion, or repeat colonoscopy for hemostasis within 30 days. RESULTS Five hundred forty-seven patients with 1485 polyps were included. Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio [OR], 1.19; 95% confidence interval [CI], .73-1.95; P = .497). The hot resection method was associated with a significantly higher risk of PPB (OR, 9.76; 95% CI, 3.94-32.60; P < .001) compared with cold biopsy or snare polypectomy. In a subgroup analysis, prophylactic clipping was associated with a lower PPB risk in patients on DOACs (OR, .36; 95% CI, .16-.82; P = .015). CONCLUSIONS Prophylactic clipping was not associated with an overall reduced risk of PPB in patients on oral anticoagulants. The use of cold snare polypectomy should be maximized in anticoagulated patients.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Joyce K K Lee
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Clive S T Chan
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Sunny H Wong
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Terry C F Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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19
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Auriemma F, Sferrazza S, Bianchetti M, Savarese MF, Lamonaca L, Paduano D, Piazza N, Giuffrida E, Mete LS, Tucci A, Milluzzo SM, Iannelli C, Repici A, Mangiavillano B. From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s. World J Gastrointest Surg 2022; 14:632-655. [PMID: 36158280 PMCID: PMC9353749 DOI: 10.4240/wjgs.v14.i7.632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/02/2021] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.
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Affiliation(s)
- Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38014, Italy
| | - Mario Bianchetti
- Digestive Endoscopy Unit, San Giuseppe Hospital - Multimedica, Milan 20123, Italy
| | - Maria Flavia Savarese
- Department of Gastroenterology and Gastrointestinal Endoscopy, General Hospital, Sanremo 18038, Italy
| | - Laura Lamonaca
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Nicole Piazza
- Gastroenterology Unit, IRCCS Policlinico San Donato, San Donato Milanese; Department of Biomedical Sciences for Health, University of Milan, Milan 20122, Italy
| | - Enrica Giuffrida
- Gastroenterology and Hepatology Unit, A.O.U. Policlinico “G. Giaccone", Palermo 90127, Italy
| | - Lupe Sanchez Mete
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Alessandra Tucci
- Department of Gastroenterology, Molinette Hospital, Città della salute e della Scienza di Torino, Turin 10126, Italy
| | | | - Chiara Iannelli
- Department of Health Sciences, Magna Graecia University, Catanzaro 88100, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit and Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano 20089, Italy
| | - Benedetto Mangiavillano
- Biomedical Science, Hunimed, Pieve Emanuele 20090, Italy
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Varese 21053, Italy
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20
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Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions. Am J Gastroenterol 2022; 117:1080-1088. [PMID: 35765907 DOI: 10.14309/ajg.0000000000001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/27/2022] [Indexed: 12/11/2022]
Abstract
The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.
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21
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Keraliya A, Yu HS, Uyeda JW. CT imaging findings of complications of optical colonoscopy. Emerg Radiol 2022; 29:915-923. [PMID: 35710648 DOI: 10.1007/s10140-022-02058-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/06/2022] [Indexed: 10/18/2022]
Abstract
Colonoscopy is one of the most commonly performed endoscopic procedures and remains the most commonly used screening modality method for colorectal cancer (CRC) screening in the USA. Although serious complications of fiberoptic colonoscopy are uncommon due to technical advances, due to increasing number of colonoscopy procedures, post-procedural complications are not uncommonly encountered in the routine clinical practice. Also, as some of the post-colonoscopy complications are life threatening, it is important to diagnose them early so that timely treatment measures can be taken to decrease mortality and morbidity. In this review, we present a case-based illustration of the utility of CT to detect complications of colonoscopy including bowel perforation, hemorrhage, splenic injury, and postpolypectomy syndrome.
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Affiliation(s)
- Abhishek Keraliya
- Department of Radiology, Emergency Radiology Division, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Hei Shun Yu
- Department of Radiology, Emergency Radiology Division, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Jennifer W Uyeda
- Department of Radiology, Emergency Radiology Division, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
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22
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Jagtap N, Reddy DN, Tandan M. Lower Gastrointestinal Bleeding. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1742694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractLower gastrointestinal (LGI) bleeding indicates bleeding from colon or anorectum. Typically, patients with LGI bleeding present with bright red blood per rectum or hematochezia, although rarely they can present with melena as well. Alternatively, LGI bleeding is also defined as bleeding from a source within potential reach of a colonoscope, that is, colon and terminal ileum. LGI bleedings have more favorable outcomes than upper GI (UGI) bleeding and less common than UGI bleeding. Any patient presenting with GI bleeding should undergo a detailed history and physical examination for clues that may suggest source and possible etiology. Colonoscopy remains the most widely used and preferred instrument of choice for both diagnosis and therapy. This review will discuss in brief the causes, triaging, and role of colonoscopy in the management of LGI bleeding.
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Affiliation(s)
- Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D. Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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23
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Gerald A, McCandless M, Sheth A, Aihara H, Russo S. A Soft Sensor for Bleeding Detection in Colonoscopies. ADVANCED INTELLIGENT SYSTEMS (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2022; 4:2100254. [PMID: 35757581 PMCID: PMC9216226 DOI: 10.1002/aisy.202100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Indexed: 06/15/2023]
Abstract
Colonoscopies allow surgeons to detect common diseases i.e. colorectal cancer, ulcers and other ailments. However, there is a risk of bleeding in the lower gastrointestinal (GI) tract while maneuvering endoscopes. This may be due to perforations, hemorrhaging, polyps, diverticuli or post-biopsy complications. Thus, it is essential for the surgeon to be able to detect bleeding at the site and evaluate the severity of blood leakage. This paper presents a soft sensor that can detect the presence of blood at the bleeding site during colonoscopies. The sensor consists of optical waveguides that interface with a microfluidic channel. Blood flow causes absorption and scattering of incident light that can be picked up by the optical sensing apparatus via light transmission through the waveguide. The surgeon can be alerted when bleeding occurs through a graphical user interface. The device is compact and measures only 1 mm thick. This allows the sensor to be circumferentially mounted onto a colonoscope at different locations. The sensor is able to record the presence of blood as an optical loss, rapidly detect the presence of blood in under 100 milliseconds as it enters the microchannel, and differentiate between gastric fluid and blood through changes in measured optical loss.
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Affiliation(s)
- Arincheyan Gerald
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Max McCandless
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Avani Sheth
- Department of Biomedical Engineering, Boston University, Boston, MA 02215, USA
| | - Hiroyuki Aihara
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sheila Russo
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
- Materials Science & Engineering Division, Boston University, Boston, MA 02215, USA
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24
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Patient Selection, Risks, and Long-Term Outcomes Associated with Colorectal Polyp Resection. Gastrointest Endosc Clin N Am 2022; 32:351-370. [PMID: 35361340 DOI: 10.1016/j.giec.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Although the incidence rates are generally low (<1%), these can be avoided by recognizing pertinent risk factors, which can be patient, polyp, and technique/device related. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques to achieve hemostasis and manage colon perforations are reviewed.
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25
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Arimoto J, Chiba H, Tachikawa J, Yamaoka K, Yamazaki D, Higa A, Okada N, Suto T, Kawano N, Niikura T, Kuwabara H, Nakaoka M, Ida T, Morohashi T, Goto T. Evaluation of cold snare polypectomy for small pedunculated (Ip) polyps with thin stalks: a prospective clinical feasibility study. Scand J Gastroenterol 2022; 57:253-259. [PMID: 34727817 DOI: 10.1080/00365521.2021.1998603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the use of cold snare polypectomy (CSP) has spread rapidly, no prospective studies evaluating the safety of CSP for pedunculated (Ip) polyps have been carried out. AIM We performed this study to provide an accurate evaluation of the safety of CSP for Ip polyps. METHODS This is a prospective study (UMIN000035687). From January 2019 to February 2021, the safety of CSP for use on Ip polyps <10 mm with thin stalks was evaluated at our hospital. The primary outcome measure was the incidence of bleeding (delayed post-polypectomy bleeding (DPPB) and immediate bleeding). RESULTS During the study period, 89 consecutive patients (including 92 colonoscopies and 114 polyps) were prospectively enrolled. The en-bloc resection rate was 100%. The rate of DPPB after CSP was 0%, however, DPPB after conversion to HSP occurred in 1 case (33.3% (1/3)). The rate of immediate bleeding during CSP was 28.9% (33/114). Polyps with diameters ≥6 mm (OR (95% CI): 2.77 (1.041-7.376); p = .041) were extracted as independent risk factors for immediate bleeding during CSP for Ip polyps. In all, 104 (91.2%) polyps were low-grade adenomas, and the percentage of cases with negative pathological margins was 96.5% (110/114). CONCLUSIONS CSP for Ip polyps was safe and had good outcomes. We believe that Ip polyps could be included as an indication for CSP, and that CSP may become the next step in the 'cold revolution.' To confirm our results and verify CSP's inclusion in future guidelines, prospective, randomized studies are necessary.
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Affiliation(s)
- Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Kenji Yamaoka
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Dai Yamazaki
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Airi Higa
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Naoya Okada
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Takuma Suto
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Naoya Kawano
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Toshihiro Niikura
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Tomonori Ida
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Taiki Morohashi
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Tohru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
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26
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Bai Y, Yang F, Liu C, Li DF, Wang S, Lin R, Ding Z, Meng WB, Li ZS, Linghu EQ. Expert consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy (2020, Shanghai). J Dig Dis 2022; 23:2-12. [PMID: 34953023 DOI: 10.1111/1751-2980.13074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/11/2022]
Abstract
High-frequency electrosurgery has been widely applied in digestive endoscopy with constantly expanding indications. However, high-frequency electrosurgery may cause possible complications such as hemorrhage or perforation during or after the procedure, of which endoscopists must be cautious. Digestive endoscopists must have a firm grasp of the principles of high-frequency electrosurgery as well as its safety issues so as to improve the safety of its clinical application. To this end, experts in gastroenterology and hepatology, digestive endoscopy, surgery, nursing and other related fields were invited to draft a consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy based on relevant domestic and international literatures and their experiences.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Fan Yang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Cui Liu
- Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - De Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong Province, China
| | - Shi Wang
- Endoscopy Center, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, Zhejiang Province, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Wen Bo Meng
- Department of General Surgery, First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - En Qiang Linghu
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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27
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Lau LH, Guo CL, Yip TC, Mak JW, Wong SH, Lam KL, Wong GL, Ng SC, Chan FK. Risks of post-colonoscopic polypectomy bleeding and thromboembolism with warfarin and direct oral anticoagulants: a population-based analysis. Gut 2022; 71:100-110. [PMID: 33619167 DOI: 10.1136/gutjnl-2020-323600] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND There were limited data on the risk of post-polypectomy bleeding (PPB) in patients on direct oral anticoagulants (DOAC). We aimed to evaluate the PPB and thromboembolic risks among DOAC and warfarin users in a population-based cohort. METHODS We performed a territory-wide retrospective cohort study involving patients in Hong Kong from 2012 to 2020. Patients who received an oral anticoagulant and had undergone colonoscopy with polypectomy were identified. Propensity-score models with inverse probability of treatment weighting were developed for the warfarin-DOAC and between-DOAC comparisons. The primary outcome was clinically significant delayed PPB, defined as repeat colonoscopy requiring haemostasis within 30 days. The secondary outcomes were 30-day blood transfusion requirement and new thromboembolic event. RESULTS Apixaban was associated with lower PPB risk than warfarin (adjusted HR (aHR) 0.39, 95% CI 0.24 to 0.63, p<0.001). Dabigatran (aHR 2.23, 95% CI 1.04 to 4.77, adjusted p (ap)=0.035) and rivaroxaban (aHR 2.72, 95% CI 1.35 to 5.48, ap=0.002) were associated with higher PPB risk than apixaban. In subgroup analysis, apixaban was associated with lower PPB risk in patients aged ≥70 years and patients with right-sided colonic polyps.For thromboembolic events, apixaban was associated with lower risk than warfarin (aHR 0.22, 95% CI 0.11 to 0.45, p<0.001). Dabigatran (aHR 2.60, 95% CI 1.06 to 6.41, ap=0.033) and rivaroxaban (aHR 2.96, 95% CI 1.19 to 7.37, ap =0.013) were associated with higher thromboembolic risk than apixaban. CONCLUSIONS Apixaban was associated with a significantly lower risk of PPB and thromboembolism than warfarin, dabigatran and rivaroxaban, particularly in older patients with right-sided polyps.
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Affiliation(s)
- Louis Hs Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Cosmos Lt Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Terry Cf Yip
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Joyce Wy Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Kelvin Ly Lam
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Grace Lh Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Siew C Ng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Francis Kl Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR .,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
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28
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Markarian E, Fung BM, Girotra M, Tabibian JH. Large polyps: Pearls for the referring and receiving endoscopist. World J Gastrointest Endosc 2021; 13:638-648. [PMID: 35070025 PMCID: PMC8716985 DOI: 10.4253/wjge.v13.i12.638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/04/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Polyps are precursors to colorectal cancer, the third most common cancer in the United States. Large polyps, i.e.,, those with a size ≥ 20 mm, are more likely to harbor cancer. Colonic polyps can be removed through various techniques, with the goal to completely resect and prevent colorectal cancer; however, the management of large polyps can be relatively complex and challenging. Such polyps are generally more difficult to remove en bloc with conventional methods, and depending on level of expertise, may consequently be resected piecemeal, leading to an increased rate of incomplete removal and thus polyp recurrence. To effectively manage large polyps, endoscopists should be able to: (1) Evaluate the polyp for characteristics which predict high difficulty of resection or incomplete removal; (2) Determine the optimal resection technique (e.g., snare polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, etc.); and (3) Recognize when to refer to colleagues with greater expertise. This review covers important considerations in this regard for referring and receiving endoscopists and methods to best manage large colonic polyps.
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Affiliation(s)
- Eric Markarian
- Academy of Science and Medicine, Crescenta Valley High School, Los Angeles, CA 91214, United States
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ 85006, United States
- Division of Gastroenterology, Banner - University Medical Center Phoenix, Phoenix, AZ 85006, United States
| | - Mohit Girotra
- Section of Gastroenterology and Therapeutic Endoscopy, Digestive Health Institute, Swedish Medical Center, Seattle, WA 98104, United States
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
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29
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Oh CK, Choi HS, Cho YS. Comparison of cold snare polypectomy and endoscopic mucosal resection for 3-10-mm colorectal polyps in end-stage renal disease patients. Saudi J Gastroenterol 2021; 28:67-73. [PMID: 34755710 PMCID: PMC8919930 DOI: 10.4103/sjg.sjg_371_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND : Patients with end-stage renal disease (ESRD) have a higher incidence of clinically relevant complications, such as bleeding and perforation after polyp resection, compared to patients without underlying diseases. Cold snare polypectomy (CSP) is increasingly used for the removal of small polyps and diminutive polyps due to its shorter procedure time and low risk of bleeding and perforation. However, there have been few studies on the effectiveness and safety of CSP in patients with ESRD. The aim of this study was to compare the efficacy and safety of CSP and endoscopic mucosal resection (EMR) in ESRD patients. METHODS : This study was a retrospective study. We performed propensity score-matched analysis in patients with ESRD who underwent endoscopic resection for 3-10-mm-sized colorectal polyps at Seoul St. Mary's Hospital, from January 2014 to December 2019. RESULTS : After 1:1 ratio matching, 406 polyps were included: 203 polyps were resected with CSP and 203 polyps with EMR. There was no difference between the CSP group and EMR group in incomplete resection rate (4.43% vs. 1.97%, P = 0.16). There were no differences between the CSP and EMR group for immediate bleeding (5.42% vs. 7.88%, P = 0.32) and delayed bleeding (0% vs. 0.49%, P = 1.00). No perforation occurred in either group. CONCLUSIONS : There were no differences between the CSP and EMR group in terms of efficacy and safety. CSP can be one of the standard methods for the removal of 3-10-mm-sized colorectal polyps in patients with ESRD.
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Affiliation(s)
- Chang Kyo Oh
- Division of Gastroenterology, Department of Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Soon Choi
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,Address for correspondence: Prof. Young-Seok Cho, Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul - 06591, Korea. E-mail:
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30
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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Soh H, Chun J, Hong SW, Park S, Lee YB, Lee HJ, Cho EJ, Lee JH, Yu SJ, Im JP, Kim YJ, Kim JS, Yoon JH. Child-Pugh B or C Cirrhosis Increases the Risk for Bleeding Following Colonoscopic Polypectomy. Gut Liver 2021; 14:755-764. [PMID: 31816672 PMCID: PMC7667933 DOI: 10.5009/gnl19131] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 09/22/2019] [Accepted: 10/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims The risk for colonoscopic postpolypectomy bleeding (PPB) in patients with chronic liver disease (CLD) remains unclear. We determined the incidence and risk factors for colonoscopic PPB in patients with CLD, especially those with liver cirrhosis. Methods We retrospectively reviewed the medical records of patients with CLD who underwent colonoscopic polypectomy at Seoul National University Hospital between 2011 and 2014. The study endpoints were immediate and delayed PPB. Results A total of 1,267 consecutive patients with CLD were included in the study. Immediate PPB occurred significantly more often in the Child-Pugh (CP) B or C cirrhosis group (17.5%) than in the CP-A (6.3%) and chronic hepatitis (4.6%) groups (p<0.001). Moreover, the incidence of delayed PPB in the CP-B or C cirrhosis group (4.4%) was significantly higher than that in the CP-A (0.7%) and chronic hepatitis (0.2%) groups (p<0.001). The independent risk factors for immediate PPB were CP-B or C cirrhosis (p=0.011), a platelet count <50,000/μL (p<0.001), 3 or more polyps (p=0.017), endoscopic mucosal resection or submucosal dissection (p<0.001), and polypectomy performed by trainees (p<0.001). The independent risk factors for delayed PPB were CP-B or C cirrhosis (p=0.009), and polyps >10 mm in size (p=0.010). Conclusions Patients with CP-B or C cirrhosis had an increased risk for bleeding following colonoscopic polypectomy.
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Affiliation(s)
- Hosim Soh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Wook Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seona Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Jung Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Gangwani MK, Ahuja P, Aziz A, Rani A, Lee-Smith W, Aziz M. Role of prophylactic hemoclip placement in prevention of delayed post-polypectomy bleeding for large colon polyps: a meta-analysis of randomized controlled trials. Ann Gastroenterol 2021; 34:392-398. [PMID: 33948065 PMCID: PMC8079868 DOI: 10.20524/aog.2021.0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022] Open
Abstract
Background Polypectomy is a widely used and effective procedure to treat precancerous polyps. Delayed post-polypectomy bleeding (DPPB), a common complication of polypectomy, may diminish the utility of this procedure. Previous data on the efficacy of hemoclips has been conflicting, therefore we aimed to collectively evaluate and analyze the data to reach a definitive conclusion on the efficacy of using hemoclips to prevent incidences of DPPB in patients with large polyps (≥10 mm). Methods We identified a total of 261 studies based on our previously defined search strategy. After screening, we included 6 randomized controlled trials. A meta-analysis was performed comparing the use of prophylactic application of hemoclips to a standard group without prophylactic clip placement for large polyps. Results We found a statistically significant reduction in the incidence of DPPB when using hemoclips for large polyps. The overall incidence of DPPB was lower in the hemoclip group compared to the standard group for all large polyps ≥10 mm (relative risk 0.51, 95% confidence interval 0.35-0.75; P=0.01; I 2=0%). Conclusions The use of hemoclips in achieving hemostasis for large polyps has a beneficial effect and appears to prevent DPPB. This reinforces the routine clinical practice of using hemoclips in polypectomy procedures.
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Affiliation(s)
- Manesh Kumar Gangwani
- Department of Internal Medicine, Mercy Hospital St. Louis, MO, USA (Manesh Kumar Gangwani)
| | - Priyanka Ahuja
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto University, Larkana, Pakistan (Priyanka Ahuja)
| | - Abeer Aziz
- Department of Medicine, Aga Khan University, Karachi, Pakistan (Abeer Aziz)
| | - Anooja Rani
- Department of Medicine, Dow University of Health Sciences, Pakistan (Anooja Rani)
| | - Wade Lee-Smith
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio, USA (Wade Lee-Smith)
| | - Muhammad Aziz
- Department of Gastroenterology, University of Toledo Medical Center, Ohio, USA (Muhammad Aziz)
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Song JH, Friedland S. Is Submucosal Injection Helpful in Cold Snare Polypectomy for Small Colorectal Polyps? Clin Endosc 2021; 54:397-403. [PMID: 33557513 PMCID: PMC8182251 DOI: 10.5946/ce.2020.226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/27/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Cold snare polypectomy (CSP) is an effective method of polyp removal for small colorectal polyps. However, the effect of submucosal injection in cold snare endoscopic mucosal resection (CS-EMR) for small polyps is unclear. Therefore, this study aimed to evaluate the effect of submucosal injection in CS-EMR for small polyps. METHODS Between 2018 and 2019, 100 consecutive small colorectal polyps (5-10 mm) were identified in 58 patients. The first 50 consecutive polyps were removed by CS-EMR, and the remaining 50 were removed by CSP. Demographic data, clinical data, endoscopic findings, procedure times, complication rates, and pathology data were collected. RESULTS No difference in the complete resection rate was observed between the CS-EMR and CSP groups. A total of 9 polyps showed post-polypectomy bleeding (7 had immediate bleeding, 1 had delayed bleeding, and 1 had both immediate and delayed bleeding). No difference in the bleeding rate was observed between the two groups. In multivariate analysis, warfarin (odds ratio [OR], 42.334; 95% confidence interval [CI], 1.006-1,781.758) and direct-acting oral anticoagulants (OR, 35.244; 95% CI, 3.853-322.397) showed a significantly increased risk of bleeding. CONCLUSION The effect of submucosal injection in CSP was not significant for small colorectal polyps.
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Affiliation(s)
- Ji Hyun Song
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Division of Gastroenterology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Inoue T, Ishihara R, Nishida T, Akasaka T, Hayashi Y, Nakamatsu D, Ogiyama H, Yamaguchi S, Yamamoto K, Mukai A, Kinoshita K, Yakushijin T, Iijima H, Takehara T. Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial. J Gastroenterol Hepatol 2021; 36:383-390. [PMID: 32511792 DOI: 10.1111/jgh.15134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Prophylactic clipping (PC) after polypectomy has the potential to prevent post-polypectomy bleeding (PPB). We aimed to evaluate the effectiveness of PC in preventing PPB for < 20-mm polyps. METHODS This multicenter, open-label, randomized controlled trial conducted from December 2013 to June 2017 at 10 institutions randomly assigned 1080 patients with < 20-mm colon polyps to the non-PC and PC groups. Allocation factors were institution, antiplatelet drug use, and polyp number. The primary endpoint was differences in PPB rates between the groups. The severity of PPB and post-procedural abdominal symptoms were also investigated. These endpoints in intention-to-treat and per-protocol (PP) analyses were evaluated. RESULTS We investigated 1039 patients with 2960 lesions. There was no significant difference between the groups in characteristics including age, sex, hypertension, diabetes, hyperlipidemia, antiplatelet drug use, and lesion characteristics such as type and size. Excluding the clip used in the non-PC group, intraoperative bleeding, and deviation of protocol, 903 patients were investigated in PP analysis. There was no significant difference in the PPB rate between the non-PC and PC groups (2.7% vs 2.3%, P = 0.6973 [intention-to-treat analysis]; 3.0 vs 2.4%, P = 0.7353 [PP analysis]). Severe PPB (≥ grade 3) was similar between the groups. Total procedure time was significantly shorter in the non-PC group than in the PC group (31 vs 36 min, P = 0.0002). Post-procedural abdominal fullness was less common in the non-PC group than in the PC group (20.8% vs 25.6%, P = 0.0833). CONCLUSION Prophylactic clipping is not effective in preventing PBB for < 20-mm colon polyps (UMIN000012163).
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Affiliation(s)
- Takuya Inoue
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan.,Department of Gastroenterology and Hepatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterology, Kaizuka City Hospital, Kaizuka, Japan
| | - Hideharu Ogiyama
- Department of Gastroenterology, Itami City Hospital, Itami, Japan
| | | | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Akira Mukai
- Department of Gastroenterology, Sumitomo Hospital, Osaka, Japan
| | - Kazuo Kinoshita
- Department of Gastroenterology, Otemae Hospital, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Osaka Gut Forum, Osaka, Japan
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36
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Kishino T, Oyama T, Hotta K, Ishii E, Momoi T, Shimizu T, Kunieda K, Takeda S, Komatsu H. Risk of colonoscopic post-polypectomy bleeding in patients after the discontinuation of antithrombotic therapy. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:752-759. [PMID: 33361037 DOI: 10.5152/tjg.2020.19428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Few studies have examined the incidence of post-polypectomy bleeding (PPB) after discontinuation of antithrombotic therapies. Therefore, this study aimed to evaluate the incidence of PPB and thromboembolic events in patients whose antithrombotic agents were discontinued before colonoscopy. MATERIALS AND METHODS We retrospectively selected all patients who underwent colon polypectomy at a community hospital. A total of 282 patients (540 polypectomies) discontinued antithrombotic agents (group 1), and 1,648 patients (2,827 polypectomies) did not take antithrombotic agents (group 2). The cessation periods before and after polypectomies were 4 and 3 days for warfarin, 5 and 3 days for anti-platelet agents, and 7 and 5 days of combination therapy, respectively. Main outcome measurements were the incidence of PPB and thromboembolic events. RESULTS Immediate PPB rates were 3.9% (11/282) in group 1 and 4.6% (76/1648) in group 2 (adjusted odds ratio [OR], 0.85; 95% confidence interval [CI], 0.42-1.72; p=0.65). Delayed PPB rates were 1.4% (4/282) in group 1 and 1.1% (18/1648) in group 2 (adjusted OR, 1.24; 95% CI, 0.36-4.24; p=0.732). No thromboembolic events were observed in either group. CONCLUSION Our cessation periods were appropriate, and further shortening of these periods is possible.
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Affiliation(s)
- Takaaki Kishino
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan; Department of Gastroenterology, Nara City Hospital, Nara, Japan
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Kinichi Hotta
- Division of Endoscopy and Gastrointestinal Oncology, Shizuoka Cancer Center, Nagaizumi, Japan
| | | | - Tamaki Momoi
- Department of Gastroenterology, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Takehiro Shimizu
- Department of Gastroenterology, Isesaki Municipal Hospital, Isesaki, Japan
| | - Kenji Kunieda
- Department of Medical Oncology, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Shinichiro Takeda
- Department of Gastroenterology, Matsudo City Hospital, Matsudo, Japan
| | - Hirokazu Komatsu
- Department of Community Care, Saku Central Hospital, Saku, Japan
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Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis. Clin Transl Gastroenterol 2020; 11:e00288. [PMID: 33337822 PMCID: PMC7748214 DOI: 10.14309/ctg.0000000000000288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/06/2020] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION: Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients. METHODS: A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality. RESULTS: A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics. DISCUSSION: In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.
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Furuhashi H, Dobashi A, Tamai N, Shimamoto N, Kobayashi M, Ono S, Hara Y, Matsui H, Kamba S, Horiuchi H, Koizumi A, Ohya TR, Kato M, Ikeda K, Arakawa H, Sumiyama K. Blood group O is a risk factor for delayed post-polypectomy bleeding. Surg Endosc 2020; 35:6882-6891. [PMID: 33258034 DOI: 10.1007/s00464-020-08195-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/17/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Blood group O of ABO blood group system is considered as a risk factor for various bleeding events, but the relationship with endoscopic treatment-associated bleeding has yet to be investigated. This study aimed to evaluate whether blood group O is associated with delayed bleeding after colorectal endoscopic resection. METHODS This was a retrospective observational study based on medical records at four university hospitals in Japan. We reviewed the records for consecutive patients who underwent colorectal endoscopic resection from January 2014 through December 2017. The primary outcome was the incidence of delayed bleeding, defined as hematochezia or melena, requiring endoscopy, transfusion, or any hemostatic intervention up to 28 days after endoscopic resection. Multivariate logistic regression analysis was performed to adjust the impact of blood group O on the delayed bleeding. RESULTS Among 10,253 consecutive patients who underwent colorectal endoscopic resection during the study period, 8625 patients met the criteria. In total, delayed bleeding occurred in 255 patients (2.96%). The O group had significantly more bleeding events compared with the non-O group (A, B, and AB) (relative risk, 1.62 [95% confidence interval, 1.24-2.10]; P < 0.001). In multivariate logistic regression analysis, blood group O remained an independent risk factor for the bleeding (adjusted odds ratio, 1.60 [95% confidence interval, 1.18-2.17]; P = 0.002). CONCLUSIONS Blood group O was associated with an increased risk of delayed bleeding in patients undergoing colorectal endoscopic resection. Preoperative screening for ABO blood group could improve risk assessments.
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Affiliation(s)
- Hiroto Furuhashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Naoto Tamai
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Nana Shimamoto
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shingo Ono
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuko Hara
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroaki Matsui
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Kamba
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hideka Horiuchi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akio Koizumi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Tomohiko R Ohya
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keiichi Ikeda
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroshi Arakawa
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Rutter MD, Jover R. Personalizing Polypectomy Techniques Based on Polyp Characteristics. Clin Gastroenterol Hepatol 2020; 18:2859-2867. [PMID: 31563558 DOI: 10.1016/j.cgh.2019.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/20/2019] [Indexed: 12/18/2022]
Abstract
Polypectomy is an essential skill for all endoscopists performing lower gastrointestinal endoscopy. Different polypectomy tools and techniques have evolved and it is important that endoscopists are familiar with these so they can select the most appropriate technique for each polyp. This narrative review updates the different concepts in tailoring polypectomy technique to the characteristics of polyps. Effective polypectomy requires different components, including the following: careful evaluation of the polyp; decision making about optimal polyp management; actual polypectomy, which includes careful positioning of the endoscope and polyp; and postpolypectomy evaluation of the results (for completeness of resection and prophylaxis of complications).
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Affiliation(s)
- Matthew D Rutter
- University Hospital of North Tees, Stockton on Tees, United Kingdom; Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Rodrigo Jover
- Servicio de Medina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain.
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Abstract
Gastrointestinal surgery is increasingly being performed. Despite improving technology and outcomes, complications are not completely avoidable. Frequently, surgical complications require invasive procedures for management. However, with increasing availability of flexible endoscopy and a wider array of tools, more often these complications can be managed with an endolumenal approach. This article is an in-depth review of endoscopic management of surgical complications.
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Maida M, Sferrazza S, Maida C, Morreale GC, Vitello A, Longo G, Garofalo V, Sinagra E. Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature. World J Gastrointest Endosc 2020; 12:172-192. [PMID: 32843928 PMCID: PMC7415229 DOI: 10.4253/wjge.v12.i6.172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/09/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients’ comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential.
This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.
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Affiliation(s)
- Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38123, Italy
| | - Carlo Maida
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Palermo 93100, Italy
| | | | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Giovanni Longo
- Cardiology Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Vincenzo Garofalo
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Istituto San Raffaele Giglio, Cefalù 90015, Italy
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Albéniz E, Gimeno-García AZ, Fraile M, Ibáñez B, Guarner-Argente C, Alonso-Aguirre P, Álvarez MA, Gargallo CJ, Pellisé M, Ramos Zabala F, Herreros de Tejada A, Nogales Ó, Martínez-Ares D, Múgica F, de la Peña J, Espinós J, Huerta A, Álvarez A, Gonzalez-Santiago JM, Navajas F, Martínez-Cara JG, Redondo-Cerezo E, Merlo Mas J, Sábado F, Rivero L, Saperas E, Soto S, Rodríguez-Sánchez J, López-Roses L, Rodríguez-Téllez M, Rullán Iriarte M, Elosua González A, Pardeiro R, Valdivielso Cortázar E, Concepción-Martín M, Huelin Álvarez P, Colán Hernández J, Cobian J, Santiago J, Jiménez A, Remedios D, López-Viedma B, García O, Martínez-Alcalá F, Pérez-Roldán F, Carbó J, Enguita M. Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions. Gastrointest Endosc 2020; 91:868-878.e3. [PMID: 31655045 DOI: 10.1016/j.gie.2019.10.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/03/2019] [Indexed: 02/08/2023]
Abstract
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.).
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Affiliation(s)
| | | | | | - Berta Ibáñez
- Navarrabiomed-Complejo Hospitalario de Navarra-UPNA and REDISSEC, Pamplona, Spain
| | - Carlos Guarner-Argente
- Hospital de la Santa Creu y Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | - Óscar Nogales
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Múgica
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | | | | | | | - Alberto Álvarez
- Complejo Asistencial Universitario de Salamanca, IBSAL, Salamanca, Spain
| | | | | | | | | | | | - Fernando Sábado
- Consorcio Hospitalario Provincial Castellón, Castellón, Spain
| | | | | | | | | | | | | | | | | | | | | | - Mar Concepción-Martín
- Hospital de la Santa Creu y Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | - Juan Colán Hernández
- Hospital de la Santa Creu y Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Julyssa Cobian
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - José Santiago
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | | | | | | | | | - Jorge Carbó
- Hospital Universitario La Paz, Madrid, Spain
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Ham NS, Kim J, Oh EH, Hwang SW, Park SH, Yang DH, Ye BD, Myung SJ, Yang SK, Byeon JS. Cost of Endoscopic Submucosal Dissection Versus Endoscopic Piecemeal Mucosal Resection in the Colorectum. Dig Dis Sci 2020; 65:969-977. [PMID: 31493041 DOI: 10.1007/s10620-019-05822-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies have compared the costs of colorectal endoscopic submucosal dissection (ESD) and endoscopic piecemeal mucosal resection (EPMR). AIMS Here, we aimed to investigate the cost-effectiveness of these approaches by analyzing clinical outcomes and costs. METHODS Data from patients undergoing colorectal ESD and EPMR were retrospectively reviewed. Clinical outcomes (procedure time, complete resection, and recurrence) were compared, and total direct costs (procedural and follow-up) were assessed. RESULTS Data from 429 ESD and 115 EPMR patients were included in the analysis. The complete resection rate was significantly higher (83.9% vs. 32.2%, p < 0.001), recurrence rate was lower (0.5% vs. 7.1%, p < 0.001), procedure time was longer (55.4 ± 47.0 vs. 25.6 ± 32.7 min, p < 0.001), and total direct procedural costs at the initial resection were higher (1480.0 ± 728.0 vs. 729.8 ± 299.7 USD, p < 0.001) in the ESD group than in the EPMR group. The total number of surveillance endoscopies was higher in the EPMR group (1.7 ± 1.5 vs. 1.3 ± 1.1, p = 0.003). The cumulative total costs of ESD and EPMR were comparable at 3 and 2 years' follow-up in the adenoma and mucosal/superficial submucosal cancer subgroups, respectively. CONCLUSIONS Colorectal ESD was associated with higher complete resection and lower recurrence rates. EPMR showed shorter procedure times and similar cumulative total direct costs. ESD or EPMR should be chosen based on both clinical outcomes and cost-effectiveness.
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Affiliation(s)
- Nam Seok Ham
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeongseok Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Eun Hye Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Li DF, Chang X, Fang X, Wang JY, Yu ZC, Wei C, Xiong F, Xu ZL, Zhang DG, Liu TT, Luo MH, Wang LS, Yao J. Colonoscopic post-polypectomy bleeding in patients on uninterruptedclopidogrel therapy: A systematic review and meta-analysis. Exp Ther Med 2020; 19:3211-3218. [PMID: 32266017 PMCID: PMC7132234 DOI: 10.3892/etm.2020.8597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Current guidelines recommend temporary cessation of clopidogrel for 7-10 days for patients on clopidogrel undergoing colonoscopy with polypectomy. However, recent prospective randomized controlled trials have advocated for uninterrupted clopidogrel, due to similar post-polypectomy bleeding (PPB) rates with and without continued clopidogrel therapy. Thus, a meta-analysis was conducted to assess the risk of PPB rate in patients on continued clopidogrel therapy. Systemically identified publications were used to compare the rate of PPB in patients on continued clopidogrel therapy with those who had interrupted clopidogrel therapy. The primary outcome was the incidence of PPB. The secondary outcomes were immediate PPB, delayed PPB and serious cardio-thrombotic events. This study has been registered in PROSPERO (no. CRD42018118325). A total of five studies were identified, which included 655 patients in the continued clopidogrel group and 6620 patients in the control group. There was an increased risk of PPB with continued clopidogrel [P=0.0003; risk ratio (RR), 1.96; 95% confidence interval (CI), 1.36-2.83). The rate of immediate PPB was slightly higher in the continued clopidogrel group (5.77% vs. 1.77%, respectively), but was not statistically significant (P=0.06; RR, 1.57; 95%CI, 0.98-2.51). The rate of delayed PPB was increased in the continued clopidogrel group (P=0.0008; RR, 3.10; 95%CI, 1.60-5.98). However, no significant difference in serious cardio-thrombotic events was observed within 30 days (P=0.74; RR, 0.78; 95%CI, 0.18-3.40). Although continued clopidogrel therapy decreased the incidence of serious cardio-thrombotic events, the risk of delayed PPB was increased. Therefore, endoscopists should make all preparations to prevent bleeding in the perioperative period for patients at high thrombotic risk and on continued clopidogrel therapy, if polypectomy cannot be reasonably postponed.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Xin Chang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Xue Fang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Jian-Yao Wang
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Zhi-Chao Yu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Cheng Wei
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Feng Xiong
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Zheng-Lei Xu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ding-Guo Zhang
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ting-Ting Liu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ming-Han Luo
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Li-Sheng Wang
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Jun Yao
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
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Soh JS, Seo M, Kim KJ. Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding. BMC Gastroenterol 2020; 20:68. [PMID: 32164613 PMCID: PMC7069010 DOI: 10.1186/s12876-020-01210-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although prophylactic clip application before polypectomy may prevent postpolypectomy bleeding (PPB), the usefulness of prophylactic clipping in the treatment of large pedunculated polyps is controversial in some prospective randomized studies. This study was conducted to evaluate the efficacy of prophylactic clip application and to investigate the predictors of PPB in large pedunculated colorectal polyps. METHODS A total of 137 pedunculated polyps (size ≥1 cm) in 116 patients were prospectively included and randomized into group A (with clipping) and group B (without clipping), and resected. The occurrences of immediate PPB (graded 1-4) and delayed PPB were compared. RESULTS Sixty-seven polyps were allocated in group A and 70 polyps in group B. In both groups, the median polyp diameter was 15 mm (P = 0.173) and the median stalk diameter was 3 mm (P = 0.362). Twenty-eight (20.4%) immediate PPB episodes in 137 polyps occurred, 6 (9.0%) in group A and 22 (31.4%) in group B (P = 0.001). However, the occurrence of delayed PPB was not different between the groups (P = 0.943). Prophylactic clip application decreased the occurrence of immediate PPB (odds ratio 0.215, 95% confidence interval 0.081-0.571). Moreover, polyp size ≥20 mm and stalk diameter ≥ 4 mm increased the risk of immediate PPB. CONCLUSIONS Clip application before polypectomy of ≥1 cm pedunculated polyps is effective in decreasing the occurrence of immediate PPB. Thus, clip application should be considered before performing snare polypectomy, especially for large polyps with a thick stalk. TRIAL REGISTRATION This research was studied a prospective maneuver and enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT01437631). This study was registered on September 19, 2011.
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Affiliation(s)
- Jae Seung Soh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea
| | - Myeongsook Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Rebello D, Bakhit M, McCarty TR, Machan JT, Nagar A, Moss SF. Heparin bridge is associated with more post-polypectomy bleeding and emergency department visits among anticoagulated patients. Ann Gastroenterol 2020; 33:73-79. [PMID: 31892801 PMCID: PMC6928471 DOI: 10.20524/aog.2019.0430] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/07/2019] [Indexed: 01/23/2023] Open
Abstract
Background: Among patients undergoing colonoscopy, anticoagulants are usually stopped and are sometimes substituted by a heparin bridge (hep-bridge). We aimed to assess adverse events associated with hep-bridge compared to temporary cessation of anticoagulants (no-bridge). Methods: This was a single-center, retrospective cohort study that included anticoagulated patients undergoing colonoscopy between 2013 and 2016 at a Veterans Affairs Medical Center. In the no-bridge cohort, warfarin was stopped for 5 days and novel anticoagulants for 2 days pre-procedure. In the hep-bridge cohort, anticoagulants were stopped and were substituted by subcutaneous enoxaparin. The primary outcome was post-polypectomy bleeding. Secondary outcomes included cardiovascular events, all-cause adverse events and emergency department or unscheduled ambulatory office visits within 30 days. The predictive values of the HAS-BLED and CHADS2 scores were evaluated. Results: A total of 662 patients were included, of whom 551 underwent polypectomy (mean age 68.6 years; 97.6% male). Four hundred seventy colonoscopies were performed with no-bridge and 192 with hep-bridge. Post-polypectomy bleeding occurred in 6.0% of procedures: 5.7% in the no-bridge cohort compared to 13.0% of hep-bridge procedures (P=0.0038). Cardiovascular or thrombotic events occurred after 2.6% of the no-bridge and 5.2% of the hep-bridge procedures (P=0.1176). Emergency department or unscheduled office visits within 30 days were reported after 18.7% of the no-bridge procedures and 29.7% of the hep-bridge procedures (P<0.0001). Neither CHADS2 nor HASBLED scores predicted bleeding. Conclusion: The use of hep-bridge was associated with a greater incidence of post-polypectomy bleeding and more emergency department and unscheduled office visits compared with cessation of all anticoagulants.
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Affiliation(s)
- Dionne Rebello
- Department of Internal Medicine, Brown University, Providence, RI (Dionne Rebello)
| | - Mena Bakhit
- Division of Gastroenterology, Brown University, Providence, RI (Mena Bakhit, Steven F. Moss)
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA (Thomas R. McCarty).,Harvard Medical School, Boston, MA (Thomas R. McCarty)
| | - Jason T Machan
- Biostatistics and Research, RI Hospital, Providence, RI (Jason T. Machan)
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT (Anil Nagar).,West Haven Veteran Affairs Medical Center, West Haven, CT (Anil Nagar)
| | - Steven F Moss
- Division of Gastroenterology, Brown University, Providence, RI (Mena Bakhit, Steven F. Moss).,Providence Veteran Affairs Medical Center, Providence, RI (Steven F. Moss), USA
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Periprocedural adverse events after endoscopic resection of T1 colorectal carcinomas. Gastrointest Endosc 2020; 91:142-152.e3. [PMID: 31525362 DOI: 10.1016/j.gie.2019.08.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS In contrast to the adverse event (AE) risk of endoscopic resection (ER) of adenomas, the intra- and postprocedural AE risks of ER of T1 colorectal cancer (CRC) are scarcely reported in the literature. It is unclear whether ER of early CRCs, which grow into the submucosal layer and sometimes show incomplete lifting, is associated with an increased AE risk. We aimed to identify the AE rate after ER of T1 CRCs and to identify the risk factors associated with these AEs. METHODS Medical records of patients with T1 CRCs diagnosed between 2000 and 2014 in 15 hospitals in the Netherlands were reviewed. Patients who underwent primary ER were selected. The primary outcome was the occurrence of endoscopy-related AEs. The secondary outcome was the identification of risk factors. Multivariate logistic regression was performed. RESULTS Endoscopic AEs occurred in 59 of 1069 (5.5%) patients, among which 37.3% were classified as mild, 59.3% as moderate, and 3.4% as severe. AEs were postprocedural bleeding (n = 40, 3.7%), perforation (n = 13, 1.2%), and postpolypectomy electrocoagulation syndrome (n = 6, 0.6%). No fatal AEs were observed. Independent predictors for AEs were age >70 years (odds ratio, 2.11; 95% confidence interval, 1.12-3.96) and tumor size >20 mm (odds ratio, 2.22; 95% confidence interval, 1.05-4.69). CONCLUSIONS In this large multicenter retrospective cohort study, AE rates of ER of T1 CRC (5.5%) are comparable with reported AE rates for adenomas. Larger tumor size and age >70 years are independent predictors for AEs. This study suggests that endoscopic treatment of T1 CRCs is not associated with an increased periprocedural AE risk.
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Yu JX, Lin JL, Oliver M, Soetikno R, Chang MS, Kwong AJ, Limketkai BN, Bhattacharya J, Kaltenbach T. Trends in EMR for nonmalignant colorectal polyps in the United States. Gastrointest Endosc 2020; 91:124-131.e4. [PMID: 31437455 PMCID: PMC11044222 DOI: 10.1016/j.gie.2019.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although most large nonpedunculated colorectal lesions can be safely and efficaciously removed using EMR, the use of colectomy for benign colorectal lesions appears to be increasing. The reason(s) is unclear. We aimed to determine the use and adverse events of EMR in the United States. METHODS We used Optum's de-identified Clinformatics Data Mart Database (2003-2016), a database from a large national insurance provider, to identify all colonoscopies performed with either EMR or simple polypectomy on adult patients from January 1, 2011 to December 31, 2015. We measured time trends, regional variation, and adverse event rates. We assessed risk factors for adverse events using multivariate logistic regression. RESULTS The rate of EMR use in the US increased from 1.62% of all colonoscopies in 2011 to 2.48% of colonoscopies in 2015 (P < .001). There were, however, significant regional differences in the use of EMRs, from 2.4% of colonoscopies in the western United States to 2.0% of colonoscopies in the southern United States. Between 2011 and 2015, we found stable rates of perforation, GI bleeding (GIB), infections, and cardiac adverse events and decreasing rates of admissions after EMR. In our multivariate model, EMR was an independent risk factor for adverse events, albeit the rates of adverse events were low (1.35% GIB, .22% perforation). CONCLUSIONS Use of EMR is rising in the United States, although there is significant regional variation. The rates of adverse events after EMR and polypectomies were low and stable, confirming the continued safety of EMR procedures. A better understanding of the regional barriers and facilitators may improve the use of EMR as the standard management for benign colorectal lesions throughout the United States.
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Affiliation(s)
- Jessica X. Yu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jody L. Lin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Melissa Oliver
- Department of Pediatric Rheumatology, Riley Hospital for Children, IU School of Medicine, Indianapolis, IN, United States
| | - Roy Soetikno
- Advanced Gastrointestinal Endoscopy, Mountain View, CA, United States
| | - Matthew S. Chang
- Department of Gastroenterology, Kaiser Permanente - San Francisco, San Francisco, CA, United States
| | - Allison J. Kwong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Berkeley N. Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, United States
| | - Tonya Kaltenbach
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA, United States
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Jung Y. [Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 73:315-321. [PMID: 31234621 DOI: 10.4166/kjg.2019.73.6.315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022]
Abstract
Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.
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Affiliation(s)
- Yunho Jung
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Ono S, Ishikawa M, Matsuda K, Tsuda M, Yamamoto K, Shimizu Y, Sakamoto N. Clinical impact of the perioperative management of oral anticoagulants in bleeding after colonic endoscopic mucosal resection. BMC Gastroenterol 2019; 19:206. [PMID: 31791254 PMCID: PMC6889536 DOI: 10.1186/s12876-019-1124-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/21/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Heparin bridging therapy (HBT) is indeed related to a high frequency of bleeding after endoscopic mucosal resection (EMR). In this study, our aim was to investigate clinical impact of management of oral anticoagulants without HBT in bleeding after colonic EMR. METHODS From data for patients who underwent consecutive colonic EMR, the relationships of patient factors and procedural factors with the risk of bleeding were analysed. Our management of antithrombotic agents was based on the shortest cessation as follows: the administration of warfarin was generally continued within the therapeutic range, and direct oral anticoagulants (DOACs) were not administered on the day of the procedure. We calculated bleeding risks after EMR in patients who used antithrombotic agents and evaluated whether perioperative management of anticoagulants without HBT was beneficial for bleeding. RESULTS A total of 1734 polyps in 825 EMRs were analysed. Bleeding occurred in 4.0% of the patients and 1.9% of the polyps. The odds ratios for bleeding using multivariate logistic regression analysis were 3.67 in patients who used anticoagulants and 4.95 in patients who used both anticoagulants and antiplatelet agents. In patients with one-day skip of DOACs, bleeding occurred in 6.5% of the polyps, and there were no significant differences in bleeding risk between HBT and continuous warfarin or one-day skip DOACs. CONCLUSIONS The use of oral anticoagulants was related to bleeding after colonic EMR, and perioperative management of oral anticoagulants based on the shortest cessation without HBT would be clinically acceptable.
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Affiliation(s)
- Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan.
| | - Marin Ishikawa
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Kana Matsuda
- Department of Gastroenterology, Graduate School of Medicine and Faculty of Medicine Hokkaido University, Sapporo, Japan
| | - Momoko Tsuda
- Department of Gastroenterology, Graduate School of Medicine and Faculty of Medicine Hokkaido University, Sapporo, Japan
| | - Keiko Yamamoto
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuichi Shimizu
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology, Graduate School of Medicine and Faculty of Medicine Hokkaido University, Sapporo, Japan
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