|
1
|
Paspatis G, Fragaki M, Arna DE, Velegraki M, Psistakis A, Nicolaou P, Psaroudakis I, Tribonias G, Voudoukis E, Karmiris K, Theodoropoulou A, Chlouverakis G, Vardas E. Long-term adenoma recurrence and development of colorectal cancer following endoscopic mucosal resection in large non-pedunculated colonic polyps ≥4 cm. Dig Liver Dis 2025; 57:44-50. [PMID: 39013709 DOI: 10.1016/j.dld.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/21/2024] [Accepted: 06/26/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES Data of long-term follow up for large non pedunculated colorectal polyps (LNPCPs) ≥4 cm removed with piecemeal wide field endoscopic mucosal resection (PWF-EMR) are limited. We primarily evaluated the recurrence rates and secondarily the rates of post colonoscopic polypectomy colorectal cancer (PCPCRC) on a long-term basis. METHODS We retrospectively reviewed a prospectively-stored electronic database of all patients who underwent PWF-EMR for LNPCPs at the Venizeleion General Hospital, between 2009 and 2020. Eligible patients were those with LNPCPs ≥4 cm, deemed completely removed by endoscopic means and followed-up for a minimum of 36 months with at least two surveillance colonoscopies, the first one (SC1) (4-6) months after the initial PWF-EMR procedure and the second one (SC2) after (12-18) months. In 2023, all cases were checked for PCPCRC development. RESULTS Residual/early recurrent tissue was detected in 44 (31 %) cases among the 142 (82 males, 60 females) assessed during SC1. Late recurrent tissue was detected in 9 (6.6 %) cases among the 137 surveyed during SC2. Investigation did not reveal any case of PCPCRC . CONCLUSIONS This historical cohort shows that the PWF-EMR for LNPCPs ≥4 cm is a safe and definitive removal method while it is not associated with the appearance of PCPCRC.
Collapse
Affiliation(s)
- Gregorios Paspatis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece.
| | - Maria Fragaki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Despoina-Eleni Arna
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Magdalini Velegraki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Andreas Psistakis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Pinelopi Nicolaou
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Ioannis Psaroudakis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - George Tribonias
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Evangelos Voudoukis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Konstantinos Karmiris
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | | | - Gregorios Chlouverakis
- Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Greece
| | - Emmanouil Vardas
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| |
Collapse
|
|
2
|
Cronin O, Mandarino FV, Bourke MJ. Selection of endoscopic resection technique for large colorectal lesion treatment. Curr Opin Gastroenterol 2024; 40:355-362. [PMID: 39110099 DOI: 10.1097/mog.0000000000001041] [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: 01/04/2025]
Abstract
PURPOSE OF REVIEW Large nonpedunculated colorectal polyps ≥ 20 mm (LNPCPs) comprise 1% of all colorectal lesions. LNPCPs are more likely to contain advanced histology such as high-grade dysplasia and submucosal invasive cancer (SMIC). Endoscopic resection is the first-line approach for management of these lesions. Endoscopic resection options include endoscopic mucosal resection (EMR), cold-snare EMR (EMR), endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). This review aimed to critically evaluate current endoscopic resection techniques. RECENT FINDINGS Evidence-based selective resection algorithms should inform the most appropriate endoscopic resection technique. Most LNPCPs are removed by conventional EMR but there has been a trend toward C-EMR for endoscopic resection of LNPCPs. More high-quality trials are required to better define the limitations of C-EMR. Advances in our understanding of ESD technique, has clarified its role within the colorectum. More recently, the development of a full thickness resection device (FTRD) has allowed the curative endoscopic resection of select lesions. SUMMARY Endoscopic resection should be regarded as the principle approach for all LNPCPs. Underpinned by high-quality research, endoscopic resection has become more nuanced, leading to improved patient outcomes.
Collapse
Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital
- Department of Gastroenterology, Northern Health
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Hepatology, Westmead Hospital
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
|
3
|
Dhorajiya P, Mahmood S, Fabrizio A, Deshpande V, Vyas M. Gone but not forgotten: expanding the spectrum of ORISE (submucosal lifting agent) associated diagnostic pitfalls and complications. J Clin Pathol 2024:jcp-2024-209419. [PMID: 39025488 DOI: 10.1136/jcp-2024-209419] [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: 02/15/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024]
Abstract
AIMS A synthetic lifting agent, ORISE, used for endoscopic mucosal resections, has been recalled from the market since November 2022 due to clinical complications. Despite this, the impact of ORISE-associated complications is expected to persist in the foreseeable future. We present a large single institutional series of therapeutic resections from patients for whom ORISE was used for initial endoscopic procedures, highlighting the pitfalls and complications associated with its use. METHODS All specimens showing lifting agent granulomata (LAGs) associated with the use of ORISE were identified. The H&E slides were reviewed to define the morphological characteristics and extent of LAG in the intestinal wall and other organs. The clinical impression and gross findings were compared with the final pathological diagnosis. RESULTS 34 cases (28 resections and 6 repeat endoscopic mucosal resection specimens) showed LAG. On microscopy, 20.5% showed no residual disease, 64.7% also showed residual precursor lesion and 14.7% also showed malignancy. In 64.2% of cases, a mass lesion was seen grossly but no malignancy was identified microscopically. ORISE was present in vascular spaces (n=9), lymph nodes (n=2), other organs such as appendix (n=1) and omentum/peritoneum (n=1). The major discordance between clinical impression (mass/neoplasm) and final pathology (no residual malignancy) was seen in 4/34 (11.8%) cases. LAGs were seen up to 10 months after the use of ORISE in the prior endoscopic procedure. CONCLUSION ORISE deposits may mimic residual/disseminated neoplasm and prompt inadvertent changes in surgical decisions. Awareness of this pitfall is essential to prevent unwarranted surgical resections in patients undergoing follow-up for endoscopically resected lesions.
Collapse
Affiliation(s)
- Pooja Dhorajiya
- Department of Pathology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sultan Mahmood
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anne Fabrizio
- Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Vikram Deshpande
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Monika Vyas
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
|
4
|
Gao L, Bai J, Liu K, Wang L, Zhu S, Zhao X, Han Y, Liu Z. Hypertonic solution as an optimal submucosal injection solution for endoscopic resection of gastrointestinal mucosal lesions: Systematic review and network meta-analysis. Dig Endosc 2024; 36:657-669. [PMID: 37767724 DOI: 10.1111/den.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES Based on different physicochemical properties, common submucosal injection solutions could be classified into three categories: normal saline solution (NS), hypertonic solution (HS), and viscous solution (VS). We compared the efficacy and safety of various categories of solutions in this network meta-analysis of randomized controlled trials (RCTs) to identify the optimal submucosal injection fluid. METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for RCTs that compared the efficacy and safety of NS, HS, and VS during endoscopic resection for gastrointestinal (GI) mucosal lesions. Pairwise and network analyses were conducted to determine the ranking of different fluids. RESULTS Thirteen RCTs were included in the final analysis with 1637 patients (1639 lesions). HS outperformed NS in rates of en bloc (pooled relative risk [RR] 1.50; 95% confidence interval [CI] 1.10-1.90), overall bleeding (pooled odds ratio [OR] 0.33; 95% CI 0.10-0.88; lesions >10 mm OR 4.65 × 10-2; 95% CI 1.10 × 10-3-0.46), and intraoperative bleeding (lesions >10 mm OR 7.10 × 10-6; 95% CI 4.30 × 10-18-0.26). HS showed the highest probability of ranking first in each outcome except for the volume of injection. Although VS was superior to NS in rates of en bloc, overall, and intraoperative bleeding in the lesions >10 mm subgroup, and required less fluid in pooled analysis, it ranked last in cost of submucosal injection solution. CONCLUSIONS Both HS and VS were superior to NS in comparisons of efficacy and safety. Considering the better performance and potentially low cost, HS might be an optimal choice during gastrointestinal endoscopic resection, especially for colorectal endoscopic mucosal resection.
Collapse
Affiliation(s)
- Li Gao
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Jiawei Bai
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
- School of Medicine, Yan'an University, Yan'an, China
| | - Kai Liu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Lulu Wang
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Shaohua Zhu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Xin Zhao
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Ying Han
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| |
Collapse
|
|
5
|
Cronin O, Bourke MJ. Endoscopic Management of Large Non-Pedunculated Colorectal Polyps. Cancers (Basel) 2023; 15:3805. [PMID: 37568621 PMCID: PMC10417738 DOI: 10.3390/cancers15153805] [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: 06/13/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Large non-pedunculated colorectal polyps ≥20 mm (LNPCPs) comprise approximately 1% of all colorectal polyps. LNPCPs more commonly contain high-grade dysplasia, covert and overt cancer. These lesions can be resected using several means, including conventional endoscopic mucosal resection (EMR), cold-snare EMR (C-EMR) and endoscopic submucosal dissection (ESD). This review aimed to provide a comprehensive, critical and objective analysis of ER techniques. Evidence-based, selective resection algorithms should be used when choosing the most appropriate technique to ensure the safe and effective removal of LNPCPs. Due to its enhanced safety and comparable efficacy, there has been a paradigm shift towards cold-snare polypectomy (CSP) for the removal of small polyps (<10 mm). This technique is now being applied to the management of LNPCPs; however, further research is required to define the optimal LNPCP subtypes to target and the viable upper size limit. Adjuvant techniques, such as thermal ablation of the resection margin, significantly reduce recurrence risk. Bleeding risk can be mitigated using through-the-scope clips to close defects in the right colon. Endoscopic surveillance is important to detect recurrence and synchronous lesions. Recurrence can be readily managed using an endoscopic approach.
Collapse
Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
| |
Collapse
|
|
6
|
Tate DJ, Argenziano ME, Anderson J, Bhandari P, Boškoski I, Bugajski M, Desomer L, Heitman SJ, Kashida H, Kriazhov V, Lee RRT, Lyutakov I, Pimentel-Nunes P, Rivero-Sánchez L, Thomas-Gibson S, Thorlacius H, Bourke MJ, Tham TC, Bisschops R. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023. [PMID: 37285908 DOI: 10.1055/a-2077-0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.
Collapse
Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
- Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
| | - John Anderson
- Cheltenham General Hospital, Gloucestershire Hospitals Foundation Trust, Cheltenham, UK
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marek Bugajski
- Department of Gastroenterology, Luxmed Oncology, Warsaw, Poland
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Vladimir Kriazhov
- Endoscopy Department, Nizhny Novgorod Regional Clinical Oncology Center, Nizhny Novgorod, Russia Federation
| | - Ralph R T Lee
- The Ottawa Hospital - Civic Campus, University of Ottawa, Ottawa, Canada
| | - Ivan Lyutakov
- University Hospital Tsaritsa Yoanna-ISUL, Medical University Sofia, Sofia, Bulgaria
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| |
Collapse
|
|
7
|
Motchum L, Djinbachian R, Rahme E, Taghiakbari M, Bouchard S, Bouin M, Sidani S, Deslandres É, Takla M, Frija-Gruman NM, Barkun A, von Renteln D. Incomplete resection rates of 4- to 20-mm non-pedunculated colorectal polyps when using wide-field cold snare resection with routine submucosal injection. Endosc Int Open 2023; 11:E480-E489. [PMID: 37206693 PMCID: PMC10191736 DOI: 10.1055/a-2029-2392] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/31/2023] [Indexed: 05/21/2023] Open
Abstract
Background and study aims Incomplete resection of 4- to 20-mm colorectal polyps occur frequently (> 10 %), putting patients at risk for post-colonoscopy colorectal cancer. We hypothesized that routine use of wide-field cold snare resection with submucosal injection (CSP-SI) might reduce incomplete resection rates (IRRs). Patients and methods Patients aged 45 to 80 years undergoing elective colonoscopies were enrolled in a prospective clinical study. All 4- to 20-mm non-pedunculated polyps were resected using CSP-SI. Post-polypectomy margin biopsies were obtained to determine IRRs through histopathology assessment. The primary outcome was IRR, defined as remnant polyp tissue found on margin biopsies. Secondary outcomes included technical success and complication rates. Results A total of 429 patients (median age 65 years, 47.1 % female, adenoma detection rate 40 %) with 204 non-pedunculated colorectal polyps 4 to 20 mm removed using CSP-SI were included in the final analysis. CSP-SI was technical successful in 97.5 % (199/204) of cases (5 conversion to hot snare polypectomy). IRR for CSP-SI was 3.8 % (7/183) (95 % confidence interval [CI] 2.7 %-5.5 %). IRR was 1.6 % (2/129), 16 % (4/25), and 3.4 % (1/29) for adenomas, serrated lesions, and hyperplastic polyps respectively. IRR was 2.3 % (2/87), 6.3 % (4/64), 4.0 % (6/151), and 3.1 % (1/32) for polyps 4 to 5 mm, 6 to 9 mm, < 10 mm, and 10 to 20 mm, respectively. There were no CSP-SI-related serious adverse events. Conclusions Use of CSP-SI results in lower IRRs compared to what has previously been reported in the literature for hot or cold snare polypectomy when not using wide-field cold snare resection with submucosal injection. CSP-SI showed an excellent safety and efficacy profile, however comparative studies to CSP without SI are required to confirm these results.
Collapse
Affiliation(s)
- Leslie Motchum
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Faculty of Medicine of Montreal University, Montreal, Canada
| | - Roupen Djinbachian
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Elham Rahme
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Mahsa Taghiakbari
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Faculty of Medicine of Montreal University, Montreal, Canada
| | - Simon Bouchard
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Mickaël Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sacha Sidani
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Érik Deslandres
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Mark Takla
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Faculty of Medicine of Montreal University, Montreal, Canada
| | | | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
- Division of Clinical Epidemiology, McGill University Health Center, McGill University, Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| |
Collapse
|
|
8
|
Abu Arisha M, Scapa E, Wishahi E, Korytny A, Gorelik Y, Mazzawi F, Khader M, Muaalem R, Bana S, Awadie H, Bourke MJ, Klein A. Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice. Gastrointest Endosc 2023; 97:559-567. [PMID: 36328207 DOI: 10.1016/j.gie.2022.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/14/2022] [Accepted: 10/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice. METHODS We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy. RESULTS Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P < .001; RR = .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups. CONCLUSION TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.
Collapse
Affiliation(s)
- Muhammad Abu Arisha
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Erez Scapa
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Efad Wishahi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Alexander Korytny
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yuri Gorelik
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Fares Mazzawi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Majd Khader
- Department of Gastroenterology, Barzilai Medical Center, Ashkelon, Israel
| | - Rawia Muaalem
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Suzan Bana
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Halim Awadie
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia, and Westmead Clinical School, University of Sydney, New South Wales, Australia
| | - Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.
| |
Collapse
|
|
9
|
Ma MX, Tate DJ, Sidhu M, Zahid S, Bourke MJ. Effect of pre-resection biopsy on detection of advanced dysplasia in large nonpedunculated colorectal polyps undergoing endoscopic mucosal resection. Endoscopy 2023; 55:267-273. [PMID: 35817086 DOI: 10.1055/a-1896-9798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND : Pre-resection biopsy (PRB) of large nonpedunculated colorectal polyps (LNPCPs, ≥ 20 mm) is often performed before referral for endoscopic mucosal resection (EMR). How this affects the EMR procedure is unknown. METHODS : This was a retrospective analysis of a prospectively collected cohort of patients with LNPCPs referred for EMR between 2013 to 2016 at an Australian tertiary center. Outcomes were differences between PRB and EMR histology, and effects of PRB on the EMR procedure. RESULTS: Among 586 LNPCPs, lesions that underwent PRB were larger (median 35 vs. 30 mm; P < 0.007), and more commonly morphologically flat or slightly elevated (P = 0.01) compared with lesions without PRB. PRB histology was upstaged in 26.1 %, downstaged in 13.8 %, and unchanged in 60.1 % after EMR. Sensitivity of PRB was 77.2 % (95 %CI 71.1-82.4) for low grade dysplasia (LGD) and 21.2 % (95 %CI 11.5-35.1) for high grade dysplasia (HGD). Where EMR specimen showed HGD, PRB had detected LGD in 76.9 %. Where EMR specimen showed cancer, PRB had detected dysplasia only. PRB was associated with more submucosal fibrosis (P = 0.001) and intraprocedural bleeding (P = 0.03). EMR success or recurrence was not affected. CONCLUSIONS: Routine PRB of LNPCP did not reliably detect advanced histology and may have affected EMR complexity. PRB should be utilized with caution in guiding endoscopic management of LNPCPs.
Collapse
Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Australia
- Department of Medicine, Midland St. John of God Hospital, Perth, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| |
Collapse
|
|
10
|
Assessment of submucosal distortion and mass effect seen at follow-up after colorectal EMR with ORISE (with video). Gastrointest Endosc 2022; 96:679-682. [PMID: 35550794 DOI: 10.1016/j.gie.2022.04.1344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/30/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ORISE (Boston Scientific, Marlborough, Mass, USA) is a viscous gel used for submucosal injection. We noted anecdotally that ORISE is associated with submucosal distortion of EMR scars at follow-up. METHODS We blindly reviewed photographs of 30 consecutive EMR scars at follow-up after resections using ORISE and 30 resections using other agents. Distortion was scored on a scale of 0 (no submucosal distortion) to 5 (overt submucosal distortion). RESULTS The median submucosal distortion score at follow-up in ORISE cases was 3 (range, 0-5) versus 0 (range, 0-2) with other fluids (P < .001, Mann-Whitney U test) by 1 reviewer and 3 (range, 0-5) versus 2 (range, 0-5), respectively, by a second reviewer (P = .018). The kappa value for agreement in the submucosal distortion scores between the 2 experts was .148 for all photographs and .214 for the ORISE cases (overall minimal agreement). CONCLUSIONS ORISE can cause submucosal distortion in the region of EMR scars when they are viewed at follow-up. Such distortions must not be mistaken for submucosal tumor growth.
Collapse
|
|
11
|
Castillo-Regalado E, Uchima H. Endoscopic management of difficult laterally spreading tumors in colorectum. World J Gastrointest Endosc 2022; 14:113-128. [PMID: 35432746 PMCID: PMC8984535 DOI: 10.4253/wjge.v14.i3.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/01/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Due to the advent of the screening programs for colorectal cancer and the era of quality assurance colonoscopy the number the polyps that can be considered difficult, including large (> 20 mm) laterally spreading tumors (LSTs), has increased in the last decade. All LSTs should be assessed carefully, looking for suspicious areas of submucosal invasion (SMI), such as nodules or depressed areas, describing the morphology according to the Paris classification, the pit pattern, and vascular pattern. The simplest, most appropriate and safest endoscopic treatment with curative intent should be selected. For LST-granular homogeneous type, piecemeal endoscopic mucosal resection should be the first option due to its biological low risk of SMI. LST-nongranular pseudodepressed type has an increased risk of SMI, and en bloc resection should be mandatory. Underwater endoscopic mucosal resection is useful in situations where submucosal injection alters the operative field, e.g., for the resection of scar lesions, with no lifting, adjacent tattoo, incomplete resection attempts, lesions into a colonic diverticulum, in ileocecal valve and lesions with intra-appendicular involvement. Endoscopic full thickness resection is very useful for the treatment of difficult to resect lesions of less than 20 up to 25 mm. Among the indications, we highlight the treatment of polyps with suspected malignancy because the acquired tissue allows an exact histologic risk stratification to assign patients individually to the best treatment and avoid surgery for low-risk lesions. Endoscopic submucosal dissection is the only endoscopic procedure that allows completes en bloc resection regardless of the size of the lesion. It should therefore be indicated in the treatment of lesions with risk of SMI.
Collapse
Affiliation(s)
- Edgar Castillo-Regalado
- Endoscopy Unit, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Barcelona 08916, Spain
- Endoscopic Unit, Creu Groga Medical Center, Calella 08370, Spain
| | - Hugo Uchima
- Endoscopy Unit, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Barcelona 08916, Spain
- Endoscopic Unit, Teknon Medical Center, Barcelona 08022, Spain
| |
Collapse
|
|
12
|
Rex DK, Lahr RE, Peterson MM, Vemulapalli KC. Impact of including epinephrine in the submucosal injectate for colorectal EMR on postprocedural pain: a randomized controlled trial. Gastrointest Endosc 2022; 95:535-539.e1. [PMID: 34896443 DOI: 10.1016/j.gie.2021.11.043] [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: 09/21/2021] [Accepted: 11/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EMR is first-line therapy for colorectal laterally spreading lesions. Some colonoscopists include epinephrine in the submucosal injectate, which we observed increased postprocedure discomfort. Our aim was to determine whether inclusion of epinephrine in the submucosal injectate increases postprocedure pain after EMR. METHODS We performed a randomized, controlled, double-blind trial comparing epinephrine in submucosal injectate versus injectate alone for abdominal pain at 30 and 60 minutes after EMR. RESULTS Mean polyp diameter in both arms was >40 mm. There were no differences in procedure times or amounts of fluid injected. Mean pain was higher on a visual analog scale in the epinephrine group at 30 minutes (47 vs 14, P = .022) and at 60 minutes (44 vs 13, P = .035). Recovery room stay was longer in the epinephrine group (68 vs 53 minutes, P = .034). CONCLUSIONS Epinephrine in the submucosal injectate for EMR increases postprocedural pain, which could cause diagnostic confusion and prolong observation time in the recovery area. (Clinical trial registration number: NCT04065451.).
Collapse
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Merritt M Peterson
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
|
13
|
Vosko S, Gupta S, Shahidi N, van Hattem WA, Zahid S, McKay O, Whitfield A, Sidhu M, Tate DJ, Lee EYT, Byth K, Williams SJ, Burgess N, Bourke MJ. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 94:959-968.e2. [PMID: 33989645 DOI: 10.1016/j.gie.2021.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The endoscopic management of large nonpedunculated colorectal polyps involving the ileocecal valve (ICV-LNPCPs) remains challenging because of its unique anatomic features, with long-term outcomes inferior to LNPCPs not involving the ICV. We sought to evaluate the impact of technical innovations and advances in the EMR of ICV-LNPCPs. METHODS The performance of EMR for ICV-LNPCPs was retrospectively evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by clinical success (removal of all polypoid tissue during index EMR and avoidance of surgery) and recurrence at first surveillance colonoscopy. Accounting for the adoption of technical innovations, comparisons were made between an historical cohort (September 2008 to April 2016) and contemporary cohort (May 2016 to October 2020). Safety was evaluated by documenting the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury, and delayed perforation. RESULTS Between September 2008 to October 2020, 142 ICV-LNPCPs were referred for EMR. Median ICV-LNPCP size was 35 mm (interquartile range, 25-50 mm). When comparing the contemporary (n = 66) and historical cohorts (n = 76) of ICV-LNPCPs, there were significant differences in clinical success (93.9% vs 77.6%, P = .006) and recurrence (4.6% vs 21.0%, P = .019). CONCLUSIONS With technical advances, ICV-LNPCPs can be effectively and safely managed by EMR, independent of lesion complexity. Most patients experience excellent outcomes and avoid surgery.
Collapse
Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
|
14
|
van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, Bar-Yishay I, Schoeman S, Tate DJ, Byth K, Hewett DG, Pellisé M, Hourigan LF, Moss A, Tutticci N, Bourke MJ. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70:1691-1697. [PMID: 33172927 DOI: 10.1136/gutjnl-2020-321753] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known. DESIGN Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods. RESULTS A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively. CONCLUSIONS In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.
Collapse
Affiliation(s)
- W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kaushali Britto
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David James Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
| | - Karen Byth
- Biostatistics, Sydney University, Sydney, New South Wales, Australia
| | - David G Hewett
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - María Pellisé
- Gastroenterology, Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Luke F Hourigan
- Department of gastroenterology and hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,Department of gastroenterology and hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Tutticci
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
|
15
|
Previously Attempted Large Nonpedunculated Colorectal Polyps Are Effectively Managed by Endoscopic Mucosal Resection. Am J Gastroenterol 2021; 116:958-966. [PMID: 33625125 DOI: 10.14309/ajg.0000000000001096] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Endoscopic mucosal resection (EMR) is an effective therapy for naive large nonpedunculated colorectal polyps (N-LNPCPs). The best approach for the treatment of previously attempted LNPCPs (PA-LNPCPs) is undetermined. METHODS EMR performance for PA-LNPCPs was evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by technical success (removal of all visible polypoid tissue during index EMR) and recurrence at first surveillance colonoscopy (SC1). Safety was assessed by clinically significant intraprocedural bleeding, deep mural injury types III-V, clinically significant post-EMR bleeding, and delayed perforation. RESULTS From January 2012 to October 2019, 158 PA-LNPCPs and 1,134 N-LNPCPs underwent EMR. Median PA-LNPCP size was 30 mm (interquartile range 25-46 mm). Technical success was 93.0% and increased to 95.6% after adjusting for 2-stage EMR. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) was required for nonlifting polypoid tissue in 73 (46.2%). Median time to SC1 was 6 months (interquartile range 5-7 months). Recurrence occurred in 9 (7.8%). No recurrence was identified among 65 PA-LNPCPs which underwent margin thermal ablation at SC1 vs 9 (18.0%; P < 0.001) which did not. There were significant differences in resection duration (35 vs 25 minutes; P < 0.001), technical success (93.0% vs 96.6%; P = 0.026), and use of CAST (46.2% vs 7.6%; P < 0.001), between PA-LNPCPs and N-LNPCPs. When adjusting for 2-stage EMR, no difference in technical success was identified (95.6% vs 97.8%; P = 0.100). No differences in adverse events or recurrence were identified. DISCUSSION EMR, using auxillary techniques where necessary, can achieve high technical success and low recurrence frequencies for PA-LNPCPs.
Collapse
|
|
16
|
Chen C, Liu XY, Cheng CE, Xiong YJ, Sun YB, Tan CH, Liu YT, Feng J, Ma YF, Shi DT, Li R. Efficacy and safety of a novel submucosal injection solution for endoscopic resection in porcine models. J Dig Dis 2021; 22:49-56. [PMID: 33236832 DOI: 10.1111/1751-2980.12963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE A submucosal injection is usually required to improve the efficacy and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR). This study aimed to evaluate the performance of 3.3% sodium carboxymethyl starch (Na-CMS) solution, a novel submucosal injection solution, for ESD and EMR. METHODS Na-CMS, normal saline (NS) and two commercially available agents (sigMAVisc and Eleview) were injected into the esophageal submucosa of randomly grouped pigs. The level of submucosal elevation was examined. Subsequently, ESD or EMR procedures using 3.3% Na-CMS or NS as submucosal injections were performed in the gastrointestinal tract of the pigs. RESULTS Submucosal elevation was significantly higher and more sustained in the 3.3% Na-CMS group than in the controls (P < 0.05). The volume required for ESD or EMR was significantly lower in the 3.3% Na-CMS group than in the NS group (ESD: 12.21 ± 4.09 mL vs 28.25 ± 8.02 mL, P < 0.001; EMR: 3.99 ± 1.98 mL vs 7.15 ± 3.67 mL, P = 0.001). The ESD resection time was significantly shorter in the 3.3% Na-CMS group than in the NS group (16.58 ± 7.30 min vs 25.29 ± 11.89 min, P = 0.004). Hemorrhage after ESD in the 3.3% Na-CMS group was less severe than that in the NS group (P = 0.006). CONCLUSION 3.3% Na-CMS is an effective, safe and low-cost submucosal injection solution and holds promise as preferable agent for submucosal injection in ESD and EMR procedures.
Collapse
Affiliation(s)
- Chen Chen
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiao Yu Liu
- Department of Gastroenterology, Yulin No. 2 Hospital, Yulin, Shaanxi Province, China
| | - Cui E Cheng
- Department of Gastroenterology, Changshu No. 2 People's Hospital, Changshu, Jiangsu Province, China
| | - Yu Jia Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yi Bin Sun
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Chen Huan Tan
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yi Ting Liu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Ji Feng
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yi Fan Ma
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Dong Tao Shi
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Rui Li
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| |
Collapse
|
|
17
|
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).
Collapse
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.
| |
Collapse
|
|
18
|
Viscosity and degradation controlled injectable hydrogel for esophageal endoscopic submucosal dissection. Bioact Mater 2020; 6:1150-1162. [PMID: 33134608 PMCID: PMC7588753 DOI: 10.1016/j.bioactmat.2020.09.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 09/27/2020] [Indexed: 12/16/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a common procedure to treat early and precancerous gastrointestinal lesions. Via submucosal injection, a liquid cushion is created to lift and separate the lesion and malignant part from the muscular layer where the formed indispensable space is convenient for endoscopic incision. Saline is a most common submucosal injection liquid, but the formed liquid pad lasts only a short time, and thus repeated injections increase the potential risk of adverse events. Hydrogels with high osmotic pressure and high viscosity are used as an alternate; however, with some drawbacks such as tissue damage, excessive injection resistance, and high cost. Here, we reported a nature derived hydrogel of gelatin-oxidized alginate (G-OALG). Based on the rheological analysis and compare to commercial endoscopic mucosal resection (EMR) solution (0.25% hyaluronic acid, HA), a designed G-OALG hydrogel of desired concentration and composition showed higher performances in controllable gelation and injectability, higher viscosity and more stable structures. The G-OALG gel also showed lower propulsion resistance than 0.25% HA in the injection force assessment under standard endoscopic instruments, which eased the surgical operation. In addition, the G-OALG hydrogel showed good in vivo degradability biocompatibility. By comparing the results acquired via ESD to normal saline, the G-OALG shows great histocompatibility and excellent endoscopic injectability, and enables create a longer-lasting submucosal cushion. All the features have been confirmed in the living both pig and rat models. The G-OALG could be a promising submucosal injection agent for esophageal ESD.
Injectable gel with controlled viscosity. Injectable gel with controlled degradation. Making esophageal submucosal liquid cushion. Potential treatment for early esophageal cancer. Big animal in-situ imaging.
Collapse
|
|
19
|
Chen X, Nishiguchi A, Taguchi T. Adhesive Submucosal Injection Material Based on the Nonanal Group-Modified Poly(vinyl alcohol)/α-Cyclodextrin Inclusion Complex for Endoscopic Submucosal Dissection. ACS APPLIED BIO MATERIALS 2020; 3:4370-4379. [DOI: 10.1021/acsabm.0c00384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Xi Chen
- Polymer-Bio Field, Research Center for Functional Materials, National Institute for Materials Science, 1-1 Namiki, Tsukuba, Ibaraki 305-0044, Japan
| | - Akihiro Nishiguchi
- Polymer-Bio Field, Research Center for Functional Materials, National Institute for Materials Science, 1-1 Namiki, Tsukuba, Ibaraki 305-0044, Japan
| | - Tetsushi Taguchi
- Polymer-Bio Field, Research Center for Functional Materials, National Institute for Materials Science, 1-1 Namiki, Tsukuba, Ibaraki 305-0044, Japan
| |
Collapse
|
|
20
|
Impact of en bloc resection on long-term outcomes after endoscopic mucosal resection: a matched cohort study. Gastrointest Endosc 2020; 91:1155-1163.e1. [PMID: 31887274 DOI: 10.1016/j.gie.2019.12.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Residual or recurrent adenoma (RRA) is the major limitation of piecemeal EMR (p-EMR) for large colonic laterally spreading lesions (LSLs) ≥20 mm. En bloc EMR (e-EMR) has been shown to achieve low rates of RRA but specific procedural and long-term outcomes are unknown. Our aim was to compare long-term outcomes of size-matched LSLs stratified by whether they were resected e-EMR or p-EMR. METHODS Data from a prospective tertiary referral multicenter cohort of large LSLs referred for EMR over a 10-year period were analyzed. Outcomes were compared between sized-matched LSLs (20-25 mm) resected by p-EMR or e-EMR. RESULTS Five hundred seventy LSLs met the inclusion criteria of which 259 (45.4%) were resected by e-EMR. The risk of major deep mural injury (DMI) was significantly higher in the e-EMR group (3.5% vs 1.0%, P = .05), whereas rates of other intraprocedural adverse events did not differ significantly. Five of 9 (56%) LSLs, with endoscopic features of submucosal invasion (SMI), resected by e-EMR were saved from surgery. RRA at first surveillance was lower in the e-EMR group (2.0% vs 5.7%, P = .04), but this difference was negated at subsequent surveillance. Rates of surgical referral were not significantly different between the groups at either surveillance interval. CONCLUSION When comparing e-EMR against p-EMR for lesions ≤25 mm in size of similar morphology in a large prospective multicenter cohort, e-EMR offered no additional advantage for predicted-benign LSLs. However, it was associated with an increased risk of major DMI. Thus, en bloc resection techniques should be reserved for lesions suspicious for invasive disease. (Clinical trial registration number: NCT01368289.).
Collapse
|
|
21
|
Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
Collapse
|
|
22
|
Shahidi N, Sidhu M, Vosko S, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Holt B, Hourigan LF, Lee EY, Burgess NG, Bourke MJ. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69:673-680. [PMID: 31719129 DOI: 10.1136/gutjnl-2019-319785] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/17/2019] [Accepted: 10/26/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs. DESIGN EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC). RESULTS Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027). CONCLUSION EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.
Collapse
Affiliation(s)
- Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,University Hospital of Gent, Gent, Belgium
| | - Bronte Holt
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Luke F Hourigan
- Department of Gastrenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Eric Yt Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
|
23
|
Poley JW, Campos S. Methods and outcome of the endoscopic treatment of ampullary tumors. Ther Adv Gastrointest Endosc 2020; 13:2631774519899786. [PMID: 32030370 PMCID: PMC6977234 DOI: 10.1177/2631774519899786] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022] Open
Abstract
Ampullary tumors are rare neoplasms but increasingly encountered due to an increase in diagnostic procedures, mainly upper gastrointestinal endoscopy. Diagnosis, staging, and treatment of these tumors are described and recommendations given based on the most recent literature.
Collapse
Affiliation(s)
- Jan-Werner Poley
- Gastroenterology & Hepatology, Erasmus MC, Dr Molewaterplein 40, 3000 CA Rotterdam, The Netherlands
| | - Sara Campos
- Gastroenterology & Hepatology, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
|
24
|
Sriram N, Bar-Yishay I, Kumarasinghe P, Yusoff I, Segarajasingam D, Bourke MJ, Raftopoulos S. Definitive therapy of colonic angioectasia by submucosal coagulation. Endosc Int Open 2019; 7:E1773-E1777. [PMID: 31828216 PMCID: PMC6904233 DOI: 10.1055/a-0965-6688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Colonic angioectasia are the most common vascular lesions in the gastrointestinal tract and are among the most common causes for chronic or recurrent lower gastrointestinal bleeding. Endoscopic treatment involves a variety of techniques, all of which focus on destruction of the mucosal abnormality. However, recurrent bleeding after endoscopic treatment is common, with more than one treatment frequently necessary. We report a technique for definitive treatment of colonic angioectasia by targeting the feeding submucosal vessel. Patients and methods Analogous to endoscopic mucosal resection, a submucosal injection is made beneath the target lesion which is then removed by electrocautery snare resection of the mucosal lesion. The exposed feeding vessel is then destroyed by application of coagulation current. The resection defect is closed by clips. Results Six patients with a total of 14 colonic angioectasia were treated over the study period. All lesions were destroyed without adverse events. Conclusion Elevation, hot snare resection and coagulation (ESC) of the visible vessel for treating colonic angioectasia appears safe and effective. Larger prospective comparative studies are required to assess its specific role.
Collapse
Affiliation(s)
- Nagaraj Sriram
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology, Westmead Public Hospital, Sydney, NSW, Australia
| | | | - Ian Yusoff
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia,Department of Gastroenterology, Hollywood Private Hospital, Perth, Western Australia, Australia
| | - Dev Segarajasingam
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia,Department of Gastroenterology, Hollywood Private Hospital, Perth, Western Australia, Australia
| | - Michael J. Bourke
- Department of Gastroenterology, Westmead Public Hospital, Sydney, NSW, Australia,University of Sydney, Sydney, NSW, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia,Department of Gastroenterology, Hollywood Private Hospital, Perth, Western Australia, Australia,Department of Gastroenterology, Peel Health Campus, Perth, Western Australia, Australia,Corresponding author Spiro Raftopoulos Department of GastroenterologySir Charles Gairdner HospitalPerth, Western AustraliaAustralia+61288905637
| |
Collapse
|
|
25
|
Rex DK, Broadley HM, Garcia JR, Lahr RE, MacPhail ME, McWhinney CD, Searight MP, Sullivan AW, Mahajan N, Eckert GJ, Vemulapalli KC. SIC-8000 versus hetastarch as a submucosal injection fluid for EMR: a randomized controlled trial. Gastrointest Endosc 2019; 90:807-812. [PMID: 31288028 DOI: 10.1016/j.gie.2019.06.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Viscous solutions provide a superior submucosal cushion for EMR. SIC-8000 (Eleview; Aries Pharmaceuticals, La Jolla, Calif) is a commercially available U.S. Food and Drug Administration-approved solution, but hetastarch is also advocated. We performed a randomized trial comparing SIC-8000 with hetastarch as submucosal injection agents for colorectal EMR. METHODS This was a single-center, double-blinded, randomized controlled trial performed at a tertiary referral center. Patients were referred to our center with flat or sessile lesions measuring ≥15 mm in size. The primary outcome measures were the Sydney resection quotient (SRQ) and the rate of en bloc resections. Secondary outcomes were total volume needed for a sufficient lift, number of resected pieces, and adverse events. RESULTS There were 158 patients with 159 adenomas (SIC-8000, 84; hetastarch, 75) and 57 serrated lesions (SIC-8000, 30; hetastarch, 27). SRQ was significantly better in the SIC-8000 group compared with hetastarch group (9.3 vs 8.1, P = .001). There was no difference in the proportion of lesions with en bloc resections. The total volume of injectate was significantly lower with SIC-8000 (14.8 mL vs 20.6 mL, P = .038). CONCLUSIONS SIC-8000 is superior to hetastarch for use during EMR in terms of SRQ and total volume needed, although the absolute differences were small. (Clinical trial registration number: NCT03350217.).
Collapse
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heather M Broadley
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan R Garcia
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Margaret E MacPhail
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Connor D McWhinney
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Meghan P Searight
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew W Sullivan
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neal Mahajan
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - George J Eckert
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
|
26
|
Pang Y, Liu J, Moussa ZL, Collins JE, McDonnell S, Hayward AM, Jajoo K, Langer R, Traverso G. Endoscopically Injectable Shear-Thinning Hydrogels Facilitating Polyp Removal. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2019; 6:1901041. [PMID: 31592420 PMCID: PMC6774062 DOI: 10.1002/advs.201901041] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/13/2019] [Indexed: 05/17/2023]
Abstract
Submucosal elevation, the process of instilling material in the submucosal space for separation of the surface mucosa and deeper muscularis layer, is a significant aspect of the endoscopic mucosal resection of large lesions performed to facilitate lesion removal and maximize safety. Submucosal injection, when applied, has historically been performed with normal saline, though this is limited by its rapid dissipation; solutions ideally need to be easily injectable, biocompatible, and provide a long-lasting submucosal cushion with a desirable height. Here, reported is a new set of materials, endoscopically injectable shear-thinning hydrogels, meeting these requirements because of their biocompatible components and ability to form a solid hydrogel upon injection. These findings are supported by evaluation in a large animal model and ultimately demonstrate the potential of these shear-thinning hydrogels to serve as efficient submucosal injection fluids for cushion development. Given these unique characteristics, their broad application in mucosal resection techniques is anticipated.
Collapse
Affiliation(s)
- Yan Pang
- Department of OphthalmologyNinth People's HospitalShanghai Key Laboratory of Orbital Diseases and Ocular OncologyShanghai Jiao Tong University School of MedicineShanghai200011China
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Jinyao Liu
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
- Institute of Molecular MedicineState Key Laboratory of Oncogenes and Related GenesShanghai Institute of CancerRenji HospitalShanghai Jiao Tong University School of MedicineShanghai200127China
| | - Zaina L. Moussa
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Joy E. Collins
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Shane McDonnell
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Alison M. Hayward
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchDivision of Comparative MedicineMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Kunal Jajoo
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical SchoolBostonMA02115USA
| | - Robert Langer
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchHarvard‐MIT Division of Health Sciences and TechnologyMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Giovanni Traverso
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical SchoolBostonMA02115USA
- Department of Mechanical EngineeringMassachusetts Institute of TechnologyCambridgeMA02139USA
| |
Collapse
|
|
27
|
Abstract
Cold resection for small colonic polyps, and larger lesions, is being rapidly and widely adopted. Driven by an impressive safety and cost profile compared with conventional polypectomy, these advantages are offset by the limitations of smaller and shallower resection, and absent thermal effects that may permit persistence of residual neoplasia. To overcome this, optimal cold snare technique requires inclusion of a margin of normal mucosa and a piecemeal resection technique for larger polyps. This article examines the fundamentals of cold snare resection and evidence for its application, theorizes on limits to its application, and identifies areas for further research.
Collapse
Affiliation(s)
- Nicholas J Tutticci
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Cnr Kessels and Troughton Roads, Coopers Plains, Brisbane, Queensland 4108, Australia; Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Ammar O Kheir
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Cnr Kessels and Troughton Roads, Coopers Plains, Brisbane, Queensland 4108, Australia; Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE. https://twitter.com/ammarkheir
| | - David G Hewett
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Cnr Kessels and Troughton Roads, Coopers Plains, Brisbane, Queensland 4108, Australia; Brisbane Colonoscopy, Brisbane, Queensland, Australia.
| |
Collapse
|
|
28
|
Jideh B, Bourke MJ. How to Perform Wide-Field Endoscopic Mucosal Resection and Follow-up Examinations. Gastrointest Endosc Clin N Am 2019; 29:629-646. [PMID: 31445687 DOI: 10.1016/j.giec.2019.05.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Wide-field endoscopic mucosal resection (EMR) is the primary management option for noninvasive laterally spreading colorectal lesions. It has been proved to be safe, highly effective, efficient, and cost-effective. Careful lesion interrogation before resection is essential because it provides essential information, including the risk of submucosal invasive disease. Adjuvant thermal ablation to the post-EMR defect margin has recently been shown to substantially reduce adenoma recurrence. Adenoma recurrence is predictable using the Sydney EMR Recurrence Tool. Adenoma recurrence can be accurately detected using standardized imaging of the post-EMR scar, and can be effectively treated.
Collapse
Affiliation(s)
- Bilel Jideh
- Department of Gastroenterology and Hepatology, Endoscopy Unit, Westmead Hospital, Cnr Hawkesbury & Darcy Roads, Westmead, Sydney, New South Wales 2145, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Endoscopy Unit, Westmead Hospital, Cnr Hawkesbury & Darcy Roads, Westmead, Sydney, New South Wales 2145, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|
|
29
|
Matsushita M, Takahashi Y, Wakamatsu T, Nishio A, Seki T, Okazaki K. Ideal submucosal injection solution for colorectal endoscopic submucosal dissection. Gastrointest Endosc 2019; 90:533. [PMID: 31439133 DOI: 10.1016/j.gie.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/02/2019] [Indexed: 02/08/2023]
Affiliation(s)
| | - Yu Takahashi
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Takahiro Wakamatsu
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Akiyoshi Nishio
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Toshihito Seki
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| |
Collapse
|
|
30
|
Tate DJ, Klein A, Sidhu M, Desomer L, Awadie H, Lee EYT, Mahajan H, McLeod D, Bourke MJ. Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video). Gastrointest Endosc 2019; 90:467-479.e4. [PMID: 31077699 DOI: 10.1016/j.gie.2019.04.242] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 04/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgery-sparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen-confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort. METHODS Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months. RESULTS Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence. CONCLUSIONS ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only. (Clinical trial registration number: NCT02306707.).
Collapse
Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia; University Hospital Ghent, Ghent, Belgium
| | - Amir Klein
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Hema Mahajan
- University of Western Sydney, Sydney, New South Wales, Australia
| | - Duncan McLeod
- University of Western Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
|
31
|
Meier B, Wannhoff A, Klinger C, Caca K. Novel technique for endoscopic en bloc resection (EMR+) - Evaluation in a porcine model. World J Gastroenterol 2019; 25:3764-3774. [PMID: 31391771 PMCID: PMC6676554 DOI: 10.3748/wjg.v25.i28.3764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic en bloc resection of larger polyps is relevant because risk of advanced neoplasia or malignancy correlates with tumor size. Recurrence rates after piecemeal endoscopic mucosal resection (EMR) are high and endoscopic submucosal dissection (ESD) is associated with higher complication rates in the western world.
AIM To develop a modified endoscopic en bloc resection technique using an external additional working channel and novel agent for submucosal injection.
METHODS EMR+ was considered as modified grasp and snare technique. For simultaneous use of a grasping and cutting device a novel additional working channel was used (AWC®, Ovesco Endoscopy, Tübingen, Germany). AWC® is installed on the outer surface of the endoscope, covered with a plastic sleeve and designed for single use. For submucosal injection a new agent consisting of poloxamers was used (LiftUp®, Ovesco Endoscopy, Tübingen, Germany). The agent is liquid at room temperature and forms a stable and permanent gel cushion after injection. Safety of LiftUp® has been shown in a pre-clinical study in domestic pigs. LiftUp® is commercially not yet available but approval is expected in early 2019. EMR+ was first developed ex vivo (explanted pig stomach) and subsequently evaluated in vivo (stomach, porcine model, 3 domestic pigs). Main outcome measurements were: Procedure time, macroscopic en bloc resection and adverse events.
RESULTS Concept of EMR+ was first developed ex vivo (explanted pig stomach). Ex vivo, 22 resections were performed after technique was established. Median procedure time (measured from begin of injection to extraction of resection specimen) was 7 min (range 5-11, SD 1.68) and median size of resection specimens was 30 mm × 26 mm × 11 mm ex vivo. Subsequently 13 resections were performed in vivo (stomach, porcine model, 3 domestic pigs). In vivo, median procedure time (measured from begin of injection to extraction of resection specimen) was 5 min (range 3-12, SD 2.72) and median size of resection specimens was 35 mm × 35 mm × 11 mm. In vivo, resection was macroscopic complete in 92.3%, major adverse events were not observed. In one case (7.7%) minor periprocedural bleeding was observed and managed by coagulation.
CONCLUSION EMR+ appeared to be effective and safe and was easy and fast to perform in the porcine model. EMR+ needs to be further evaluated clinically in comparative trials.
Collapse
Affiliation(s)
- Benjamin Meier
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg 71640, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg 71640, Germany
| | - Christoph Klinger
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg 71640, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg 71640, Germany
| |
Collapse
|
|
32
|
Khalid S, Abbass A, Khetpal N, Shen B, Navaneethan U. Endoscopic detection and resection of dysplasia in inflammatory bowel disease-techniques with videos. Int J Colorectal Dis 2019; 34:569-580. [PMID: 30854573 DOI: 10.1007/s00384-019-03269-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with ulcerative colitis and Crohn's colitis have an increased risk of developing dysplasia and colorectal cancer as compared to the general population; surveillance colonoscopy is recommended in this patient population. METHODS This review of the published literature aimed to assess the published evidence. RESULTS Detection of dysplasia requires examination of mucosa with targeted biopsies of the visible lesions as well as random biopsies to detect invisible lesions. Newer endoscopic techniques, in particular chromoendoscopy, increase the yield of identifying dysplastic lesions. The surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus (SCENIC) guidelines recommends that colonoscopy using chromoendoscopy is the optimal endoscopic surveillance strategy to detect dysplasia. Once dysplastic lesions are discovered on surveillance endoscopic examination, careful and meticulous descriptions of lesions is mandatory to aid in further decision making. Management of dysplastic lesions in inflammatory bowel disease patients depends on endoscopic (morphological) and histologic findings and patient characteristics such as age, general condition of the patient, and patient preferences. Endoscopic mucosal resection, endoscopic submucosal dissection, and surgery are different therapeutic options for colonic dysplastic lesions detected in the setting of inflammatory bowel disease. CONCLUSIONS In this review, we discuss the various techniques for endoscopic resection of dysplasia in patients with inflammatory bowel disease. Further research is required to determine the optimal approach to diagnosis and management of dysplasia in patients with inflammatory bowel disease.
Collapse
Affiliation(s)
- Sameen Khalid
- Department of Internal Medicine, Advent Health, Orlando, FL, USA
| | - Aamer Abbass
- Department of Internal Medicine, Advent Health, Orlando, FL, USA
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health, Orlando, FL, USA
| | - Bo Shen
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, Advent Health, University of Central Florida College of Medicine, 601 E Rollins Street, Orlando, FL, 32803, USA.
| |
Collapse
|
|
33
|
Raju G, Lum P, Ross W, Thirumurthi S, Miller E, Lynch P, Lee J, Bhutani MS, Shafi MA, Weston B, Blechacz B, Chang GJ, Hagan K, Rashid A, Davila M, Stroehlein J. Quality of endoscopy reporting at index colonoscopy significantly impacts outcome of subsequent EMR in patients with > 20 mm colon polyps. Endosc Int Open 2019; 7:E361-E366. [PMID: 30834295 PMCID: PMC6395098 DOI: 10.1055/a-0746-3520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/09/2018] [Indexed: 12/26/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is safe and cost-effective in management of patients with colon polyps. However, very little is known about the actions of the referring endoscopist following identification of these lesions at index colonoscopy, and the impact of those actions on the outcome of subsequent referral for EMR. The aim of this study was to identify practices at index colonoscopy that lead to failure of subsequent EMR. Patients and methods Two hundred and eighty-nine consecutive patients with biopsy-proven non-malignant colon polyps (> 20 mm) referred for EMR were analyzed to identify practices that could be improved from the time of identifying the lesion at index colonoscopy until completion of therapy. Results EMR was abandoned at colonoscopy at the EMR center in 71 of 289 patients (24.6 %). Reasons for abandoning EMR included diagnosis of invasive carcinoma (n = 9; 12.7 %), tethered lesions (n = 21; 29.6 %) from prior endoscopic interventions, and overly large (n = 22; 31 %) and inaccessible lesions (n = 17; 24 %) for complete and safe resection whose details were not recorded in the referring endoscopy report, or polyposis syndromes (n = 2; 2.8 %) that were not recognized. Conclusions In our practice, one in four EMR attempts were abandoned as a result of inadequate diagnosis or management by the referring endoscopist, which could be improved by education on optical diagnosis of polyps, comprehensive documentation of the procedure and avoidance of interventions that preclude resection.
Collapse
Affiliation(s)
- Gottumukkala Raju
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States,Corresponding author Gottumukkala Raju The University of Texas MD Anderson Cancer CenterGastroenterology, Hepatology and Nutrition1515 Holcombe BoulevardGI Division – Unit 1466Houston, TX 77030-4009United States+1-713-563-4408
| | - Phillip Lum
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - William Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ethan Miller
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Patrick Lynch
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jeffrey Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Mehnaz A. Shafi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Brian Weston
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Boris Blechacz
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Katherine Hagan
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Asif Rashid
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Marta Davila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - John Stroehlein
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| |
Collapse
|
|
34
|
Castro R, Libânio D, Pita I, Dinis-Ribeiro M. Solutions for submucosal injection: What to choose and how to do it. World J Gastroenterol 2019; 25:777-788. [PMID: 30809079 PMCID: PMC6385015 DOI: 10.3748/wjg.v25.i7.777] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/18/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The use of submucosal injection is essential for the majority of EMR techniques and is an integral part of ESD, whereas during polipectomy it is not crucial in most cases except to prevent bleeding in large polyps and/or those with large stalks as an alternative to mechanical methods. Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them. For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages. We also discuss, based on current recommendations and our own experience, how and when to preform submucosal injection, depending on lesions features and endoscopic resection technique that´s being used, to assure complete resection and to prevent associated adverse events. Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.
Collapse
Affiliation(s)
- Rui Castro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Inês Pita
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
- CIDES/CINTESIS, Faculty of Medicine, University of Porto, Porto 4200-319, Portugal
| |
Collapse
|
|
35
|
Klein A, Tate DJ, Jayasekeran V, Hourigan L, Singh R, Brown G, Bahin FF, Burgess N, Williams SJ, Lee E, Sidhu M, Byth K, Bourke MJ. Thermal Ablation of Mucosal Defect Margins Reduces Adenoma Recurrence After Colonic Endoscopic Mucosal Resection. Gastroenterology 2019; 156:604-613.e3. [PMID: 30296436 DOI: 10.1053/j.gastro.2018.10.003] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/24/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) can be prevented by colonoscopy and polypectomy. Endoscopic mucosal resection (EMR) is performed to remove large laterally spreading colonic lesions that have a high risk of progression to CRC. Endoscopically invisible micro-adenomas at the margins of the EMR site might contribute to adenoma recurrence, which occurs in 15% to 30% of patients who undergo surveillance. We aimed to determine the efficacy of adjuvant thermal ablation of the EMR mucosal defect margin in reducing polyp recurrence. METHODS We performed a prospective study of 390 patients with large laterally spreading colonic lesions (≥ 20 mm, n = 416) referred for EMR at 4 tertiary centers in Australia. After complete lesion excision by EMR, lesions were randomly assigned to thermal ablation of the post-EMR mucosal defect margin (n = 210) or no additional treatment (controls, n = 206). We performed surveillance colonoscopies with standardized photo documentation and biopsies of the scar after 5 to 6 months. Patient, procedure, and lesion characteristics were similar between the groups. The primary endpoint was detection of lesion recurrence at first surveillance colonoscopy. RESULTS A significantly lower proportion of patients who received thermal ablation of the post-EMR mucosal defect margin had evidence of recurrence at first surveillance colonoscopy (10/192, 5.2%) than controls (37/176, 21.0%) (P < .001). The relative risk of recurrence in the thermal ablation group was 0.25 compared with the control group (95% confidence interval 0.13-0.48). Rates of adverse events were similar between the groups. CONCLUSIONS In a multicenter randomized trial, thermal ablation of the post-EMR mucosal defect margin significantly reduced polyp recurrence at first surveillance colonoscopy, compared with no additional treatment. Routine implementation of this simple and safe technique could increase the utility of EMR, decrease surveillance burdens, and reduce morbidity and mortality from CRC. ClinicalTrials.gov no: NCT01789749.
Collapse
Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia
| | - Vanoo Jayasekeran
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Luke Hourigan
- Department of Gastroenterology and Hepatology Princess Alexsandra Hospital, Brisbane, QLD, Australia; Gallipoli Medical Research Institute, School of Medicine, The University of Queensland, Greenslopes Private Hospital, Brisbane, QLD, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology Alfred Hospital, Melbourne, VIC, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Westmead Clinical School, University of Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia.
| |
Collapse
|
|
36
|
Hirose R, Daidoji T, Naito Y, Dohi O, Yoshida N, Yasuda H, Konishi H, Nakaya T, Itoh Y. A New Ex Vivo Model for the Evaluation of Endoscopic Submucosal Injection Material Performance. J Vis Exp 2018. [PMID: 30394381 DOI: 10.3791/58029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Increasing the performance of submucosal injection materials (SIMs) is important for endoscopic therapy of early gastrointestinal cancer. It is essential to establish an ex vivo model that can evaluate SIM performance accurately, for developing high-performance SIMs. In our previous study, we developed a new ex vivo model that can be used to evaluate the performance of various SIMs in detail by applying constant tension to the specimen's ends. We also confirmed that the proposed new ex vivo model allows accurate submucosal elevation height (SEH) measurement under uniform conditions and detailed comparisons of the performances of various types of SIMs. Here, we describe the new ex vivo model and explain the detailed setup methodology of this model. Since all parts of the new model were easy to obtain, the setup of the new model could be completed quickly. SEH of various SIMs could be measured more accurately by using the new model. The critical factor that determines SIM performance can be identified using the new model. SIM development speed will drastically increase after the factor has been identified.
Collapse
Affiliation(s)
- Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine;
| | - Tomo Daidoji
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takaaki Nakaya
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| |
Collapse
|
|
37
|
Hirose R, Nakaya T, Naito Y, Daidoji T, Dohi O, Yoshida N, Yasuda H, Konishi H, Itoh Y. Identification of the critical viscoelastic factor in the performance of submucosal injection materials. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2018; 94:909-919. [PMID: 30423779 DOI: 10.1016/j.msec.2018.10.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022]
Abstract
High-performance submucosal injection materials (SIMs) contribute to the success of endoscopic therapy for early-stage gastrointestinal neoplasms. This study aimed to identify the most important factor (viscoelastic parameter) that determines SIM performance and the ease of injection. To determine the ideal viscoelastic parameters of SIMs, submucosal elevation heights (SEHs) and the ease of submucosal injection [characterized by injection pressures (IPs)] were evaluated using a newly developed ex vivo model, in which a constant tension was applied to the studied specimen. The strongest positive correlation was observed between the loss modulus determined at an oscillation frequency of 0.1 rad/s and SEH (correlation coefficient > 0.9) and between the loss modulus at 10 rad/s and IP (correlation coefficient > 0.9). SIMs with high loss moduli (0.1 rad/s) also contributed to maintenance of the submucosal elevation. Moreover, the SEHs of pseudoplastic fluid SIMs (whose loss moduli increased slightly with increasing angular frequency) were greater than those of Newtonian fluid SIMs (whose loss modulus increased drastically with increasing angular frequency). In this study, the ideal viscoelastic SIM parameters were clarified. The loss modulus (0.1 rad/s) was the most important viscoelastic factor affecting SIM performance. Additionally, the development of pseudoplastic fluid SIMs may lead to the creation of next-generation SIMs, with a performance superior to that of sodium hyaluronate, which is currently used widely in endoscopic treatments.
Collapse
Affiliation(s)
- Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Takaaki Nakaya
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomo Daidoji
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
|
38
|
Repici A, Wallace M, Sharma P, Bhandari P, Lollo G, Maselli R, Hassan C, Rex DK. A novel submucosal injection solution for endoscopic resection of large colorectal lesions: a randomized, double-blind trial. Gastrointest Endosc 2018; 88:527-535.e5. [PMID: 29750983 DOI: 10.1016/j.gie.2018.04.2363] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/30/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS SIC-8000 (Eleview) is a new U.S. Food and Drug Administration (FDA)-approved solution for submucosal injection developed to provide a long-lasting cushion to facilitate endoscopic resection maneuvers. Our aim was to compare the efficacy and safety of SIC-8000 with those of saline solution, when performing EMR of large colorectal lesions. METHODS In a randomized double-blind trial, patients undergoing EMR for colorectal non-pedunculated lesions ≥20 mm were randomized in a 1:1 ratio between SIC-8000 and saline solution as control solution in 5 tertiary centers. Endoscopists and patients were blinded to the type of submucosal solution used. Total volume to complete EMR and per lesion size and time of resection were primary endpoints; the Sydney Resection Quotient (SRQ), as well as other EMR outcomes, and the rate of adverse events were secondary endpoints. A 30-day telephone follow-up was performed. An alpha level <0.05 was considered as statistically significant. RESULTS Of the 327 patients screened, 226 (mean age, 66 ± 10 years; males, 56%) were enrolled in the study and randomized between the 2 submucosal agents. Of these, 211 patients (mean size of the lesions 33 ± 13 mm; Paris class Is, 36%; proximal colon, 74%) were entered in the final analysis (SIC-8000, 102; saline solution, 109). EMR was complete in all cases. The total volume needed for EMR was significantly less in the SIC-8000 arm compared with saline group (16.1 ± 9.8 mL vs 31.6 ± 32.0 mL; P < .001). This corresponded to an average volume per lesion size of 0.5 ± 0.3 mL/mm and 0.9 ± 0.6 mL/mm with SIC-8000 and saline solution, respectively (P < .001). The mean time to completely resect the lesion tended to be lower with SIC-8000 than with saline solution (19.1 ± 16.8 minutes vs 29.7 ± 68.9 minutes; P = .1). The SRQ was significantly higher with SIC-8000 compared with saline solution (10.3 ± 8.1 vs 8.0 ± 5.7; P = .04) with a trend for a lower number of resected pieces (5.7 ± 6.0 vs 6.5 ± 5.04; P = .052) and a higher rate of en bloc resections (19/102, 18.6% vs 12/111, 11.0%; P = .1). The rate of adverse events was similar between the 2 arms (SIC-8000, 18.6%; saline solution, 17%), and none of the serious adverse events (SIC-8000, 8.8%; saline solution, 10.7%) were related to the study treatment. CONCLUSIONS In a double-blind, randomized clinical trial, a new FDA-approved agent for sub-mucosal injection appeared to be a more effective and equally safe submucosal agent for EMR injection than saline solution. (Clinical trial registration number: NCT02654418.).
Collapse
Affiliation(s)
| | - Michael Wallace
- Department of Gastroenterology and Hepatology Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Prateek Sharma
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Pradeep Bhandari
- Solent Centre for Digestive Diseases, Portsmouth, United Kingdom
| | - Gianluca Lollo
- Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Roberta Maselli
- Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Douglas K Rex
- Indiana University Medical Center, Indianapolis, Indiana, USA
| |
Collapse
|
|
39
|
Girotra M, Triadafilopoulos G, Friedland S. Utility and performance characteristics of a novel submucosal injection agent (Eleview TM) for endoscopic mucosal resection and endoscopic submucosal dissection. Transl Gastroenterol Hepatol 2018; 3:32. [PMID: 30050992 DOI: 10.21037/tgh.2018.06.01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 05/29/2018] [Indexed: 12/30/2022] Open
Abstract
Background Submucosal injection of a lifting agent is a critical step in endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Literature suggests superiority of other viscous solutions over normal saline (NS), but research to determine the ideal submucosal injection is still ongoing. In this prospective cohort study, we evaluated the utility and performance characteristics of a novel submucosal injection agent (EleviewTM) for EMR and ESD. Methods Twelve consecutive patients referred for EMR/ESD to a tertiary referral center with experienced large polyp expert were prospectively enrolled. Ten patients with large colon polyps (mean age 66.3 years), and one patient each with esophageal and gastric lesions were included. EleviewTM was injected as submucosal lifting agent, and EMR/ESD performed. Main outcome measurements included the duration of submucosal elevation, volume and number of injections required to maintain cushion, and complications. Results Single injection of 3-5 cc of EleviewTM outlasted the duration of EMR. However, mean duration of cushion achieved during longer procedures (ESD) was 12.5 min, requiring several additional injections. R0 resection was achieved in 10/12 patients. One patient had minor bleeding which was managed intra-operatively. Conclusions EleviewTM was successful in achieving long duration of submucosal elevation, allowing safe and efficient performance of EMR as a single injection, but needed repeated injections during longer ESD procedures. Prospective controlled trials are required to compare its performance to other available viscous submucosal solutions.
Collapse
Affiliation(s)
- Mohit Girotra
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
|
40
|
Tate DJ, Desomer L, Awadie H, Goodrick K, Hourigan L, Singh R, Williams SJ, Bourke MJ. EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointest Endosc 2018; 87:1279-1288.e2. [PMID: 29309777 DOI: 10.1016/j.gie.2017.12.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/03/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding because of poor endoscopic access to the appendiceal lumen and the thin colonic wall at the base of the cecum. We aimed to assess the feasibility and safety of EMR for PA-LSLs. METHODS Consecutive LSLs ≥20 mm and PA-LSLs ≥10 mm detected at 3 academic endoscopy centers from September 2008 until January 2017 were eligible. Prospective patient, procedural, and lesion data were collected. PA-LSLs were compared with LSLs in other colonic locations. RESULTS Thirty-eight PA-LSLs were compared with 1721 LSLs. Referral for surgery without an attempt at EMR was more likely with PA-LSLs (28.9% vs 5.1%, P < .001), and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (P = .038). Most PA-LSLs (10/11) were not attempted because of deep extension into the appendiceal lumen; 2 of 11 of these surgical specimens contained invasive cancer. Once attempted, complete clearance of visible adenoma (92.6% PA-LSLs vs 97.6% LSLs, P = .14), adverse events, and rates of adenoma recurrence did not vary significantly between PA-LSLs and LSLs. All 7 patients with prior appendicectomy achieved complete adenoma clearance. There were no cases of post-EMR appendicitis. Twenty of 22 PA-LSLs (91%) eligible for surveillance avoided surgery to longest follow-up. CONCLUSIONS EMR is a safe, effective, and durable treatment for PA-LSLs when specific criteria are fulfilled. If the distal margin of the PA-LSL within the AO cannot be visualized or if more than 50% of the circumference of the orifice is involved, surgery should be considered. (Clinical trial registration number: NTC01368289.).
Collapse
Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Kathleen Goodrick
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Luke Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Gallipoli Medical Research Institute, School of Medicine, The University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell-McEwan Hospital, Adelaide, South Australia, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
|
41
|
Dekker E, Rex DK. Advances in CRC Prevention: Screening and Surveillance. Gastroenterology 2018; 154:1970-1984. [PMID: 29454795 DOI: 10.1053/j.gastro.2018.01.069] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 12/16/2022]
Abstract
Colorectal cancer (CRC) is among the most commonly diagnosed cancers and causes of death from cancer across the world. CRC can, however, be detected in asymptomatic patients at a curable stage, and several studies have shown lower mortality among patients who undergo screening compared with those who do not. Using colonoscopy in CRC screening also results in the detection of precancerous polyps that can be directly removed during the procedure, thereby reducing the incidence of cancer. In the past decade, convincing evidence has appeared that the effectiveness of colonoscopy as CRC prevention tool is associated with the quality of the procedure. This review aims to provide an up-to-date overview of recent efforts to improve colonoscopy effectiveness by enhancing detection and improving the completeness and safety of resection of colorectal lesions.
Collapse
Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| |
Collapse
|
|
42
|
Mehta N, Strong AT, Franco M, Stevens T, Chahal P, Jang S, Lopez R, Patil D, Abe S, Saito Y, Uraoka T, Vargo J, Bhatt A. Optimal injection solution for endoscopic submucosal dissection: A randomized controlled trial of Western solutions in a porcine model. Dig Endosc 2018; 30:347-353. [PMID: 29181852 DOI: 10.1111/den.12993] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/21/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIM When carrying out endoscopic submucosal dissection (ESD), procedural safety increases with greater tissue elevation and efficiency increases with longer-lasting submucosal cushion. Fluids specifically developed for ESD in Asia are not commercially available in the West, leaving endoscopists to use a variety of injectable fluids off-label. To determine the optimal fluid available in the West, we compared commonly used fluids for Western ESD. METHODS All phases were carried out in an ex vivo porcine stomach model. Phase 1 compared tissue elevation and duration of submucosal cushions produced by various standard volumes of various injectable solutions used for ESD. The two best-performing solutions used off-label were tested head-to-head in ESD in Phase 2. Phase 3 compared the best solution from Phase 2 to Eleview® , currently the only submucosal injection fluid approved in the USA. In Phases 2 and 3, five ESD were carried out with each solution. The solutions were randomized and the endoscopist blinded to the solution. RESULTS The best-performing solutions in Phase 1 were 0.4% hyaluronic acid, 6% hydroxyethyl starch (HES), and Eleview® . Phase 2 compared 6% HES and hydroxypropyl methylcellulose (HPMC), showing that ESD with 6% HES was easier (P = 0.007), faster (P = 0.041) and required less injection volume (P = 0.003). In Phase 3, resection speed, ease of ESD and total volume per area resected were comparable between 6% HES and Eleview® . CONCLUSIONS Of the submucosal injection fluids currently available in the West, Eleview® and 6% HES are the best-performing solutions for ESD in a porcine model.
Collapse
Affiliation(s)
- Neal Mehta
- Internal Medicine Institute, Cleveland Clinic, Cleveland, USA
| | - Andrew T Strong
- Section of Surgical Endoscopy, Cleveland Clinic, Cleveland, USA
| | - Matheus Franco
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Rocio Lopez
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA
| | - Deepa Patil
- Department of Pathology, Cleveland Clinic, Cleveland, USA
| | - Seichiiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology, National Hospital Organization, Tokyo Medical Center, Tokyo, Japan
| | - John Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| |
Collapse
|
|
43
|
Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 2018; 87:837-842. [PMID: 29133196 DOI: 10.1016/j.gie.2017.11.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/04/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The optimal technique for the resection of sessile serrated polyps (SSPs) is unknown, with established limitations and risks with conventional polypectomy. Although cold snare polypectomy is safe, the efficacy of piecemeal resection for large lesions is untested. In this study we evaluate the safety and efficacy of cold EMR for large SSPs. METHODS Patients presenting for elective colonoscopy at an academic endoscopy center with 1 or more SSPs ≥10 mm in size were enrolled, excluding those on anticoagulant or antiplatelet therapy other than aspirin. Lesions were resected with a cold EMR technique comprising submucosal injection of succinylated gelatin and dilute methylene blue before piecemeal cold snare resection of all visible polyp with a margin of normal tissue. Outcomes were the presence of residual serrated neoplasia in biopsy specimens from the defect margin and findings on surveillance colonoscopy. RESULTS Cold EMR was performed on 163 SSPs during 105 procedures in 99 patients (97% women; median age, 57 years). The mean size was 17.5 mm: 61 SSPs were ≥20 mm and 13 SSPs ≥30 mm, and 97.5% were in the proximal colon. Cytologic dysplasia was present in 2 (1.2%). Margin biopsy specimens were positive in 2 lesions (1.2%). Surveillance colonoscopy for 82% of lesions (median, 5 months) showed residual serrated tissue in 1, treated with cold snare, but no evidence of recurrence in the remainder. Minor adverse events were seen in 3 patients; no delayed bleeding was observed. CONCLUSIONS Cold EMR is a safe and effective method for the removal of large SSPs.
Collapse
Affiliation(s)
- Nicholas J Tutticci
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - David G Hewett
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Mater Health, Brisbane, Queensland, Australia
| |
Collapse
|
|
44
|
Spadaccini M, Hassan C, Maselli R, D'Amico F, Lamonaca L, Craviotto V, Repici A. Efficacy and safety of SIC-8000 (Eleview®) for submucosal injection for endoscopic mucosal resection and endoscopic submucosal dissection in an in vivo porcine model. Dig Liver Dis 2018; 50:260-266. [PMID: 29396133 DOI: 10.1016/j.dld.2017.11.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/24/2017] [Accepted: 11/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Submucosal injection is generally required for both endoscopic-mucosal resection (EMR) and submucosal dissection (ESD). SIC-8000 (Eleview™) is a new FDA 510(k) cleared and CE marked liquid composition for submucosal injection, containing a biocompatible polymer as a cushioning agent. AIMS The aim of this randomized study was to compare Eleview with saline solution when performing upper- and lower-GI EMR/ESD in a porcine model. METHODS EMR/ESD procedures were performed in a total of 10 white domestic pigs comparing Eleview vs. NaCl 0.9% containing methylene blue at 0.001% (control solution) as submucosal solution to be injected. Animals were randomized between EMR (22 procedures) and ESD (22 procedures) and between upper- (8 animals) and lower-(2 animals) GI procedures. All procedures were performed aiming for a resection size of 1 cm × 1 cm for EMR and 2 cm × 2 cm for ESD. Volume of injected fluid, number of injections, time of resection, technical success, en-bloc resection, and adverse events were collected. Endoscopic surveillance was conducted each week for 4 weeks after the EMR/ESD, including biopsies on the margins of resection sites at week-1 of follow-up. After four weeks, pigs were sacrificed and necropsy performed. RESULTS Overall, 22 EMR and 22 ESD were performed in 10 live pigs. The average total volume needed for EMR and ESD was statistically significantly lower with Eleview as compared with control solution for both of the techniques (EMR: 5.6 ± 3.4 ml vs. 11.5 ± 6.7 ml; p = 0.02; ESD: 19.0 ± 10.0 ml vs. 36.3 ± 16.9 ml; p = 0.02). The rate of adverse events was statistically significantly lower in the Eleview than in the control group (2/26, 7.7% vs. 6/18, 33.3%; p = 0.03), but most of them were minor. No difference between Eleview and control solution was found in the rate of technical success (EMR: 11/13, 84.6% vs. 7/9, 77.8%; p = 0.7; ESD: 13/13, 100% vs. 9/9, 100%; p = 1), en-bloc resection (EMR: 6/13, 46.2% vs. NaCl: 5/9, 55.6%; p = 0.06; ESD: 12/13, 92.3% vs. 8/9, 88.9%; p = 0.8), and time of resection (EMR: 9.1 ± 7.75 min vs. 9.4 ± 9.6 min; p = NS; ESD: 38.4 ± 17.2 min vs. 40.2 ± 19.1 min; p = NS). At endoscopic follow up and necropsy, no difference in the process of healing of post-endoscopic ulcer and in the histological inflammation at the site of resection was shown between the two groups. CONCLUSIONS The new submucosal injection composition Eleview appeared to be an effective alternative to saline solution for submucosal injection for EMR/ESD, resulting in a substantial reduction of the volume administered to achieve an adequate lifting. No signs of adverse local or distant tissue reaction to Eleview were found at long-term follow up.
Collapse
Affiliation(s)
- Marco Spadaccini
- Humanitas University, Department of Biomedical Science, Rozzano, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.
| | - Ferdinando D'Amico
- Humanitas University, Department of Biomedical Science, Rozzano, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.
| | - Laura Lamonaca
- Humanitas University, Department of Biomedical Science, Rozzano, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.
| | - Vincenzo Craviotto
- Humanitas University, Department of Biomedical Science, Rozzano, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.
| | - Alessandro Repici
- Humanitas University, Department of Biomedical Science, Rozzano, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.
| |
Collapse
|
|
45
|
Endoscopic non-ablative fractional laser therapy in an orthotopic colon tumour model. Sci Rep 2018; 8:1673. [PMID: 29374265 PMCID: PMC5785993 DOI: 10.1038/s41598-018-19792-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/02/2018] [Indexed: 12/28/2022] Open
Abstract
Colorectal cancer is one of the leading causes of cancer-related deaths. Although several therapeutic management strategies are available at the early colon cancer stages, such as endoscopic mucosal or submucosal dissection, associated complications often include bleeding or bowel perforations. As an alternative approach, we investigated endoscopic non-ablative fractional laser (eNAFL) irradiation as a minimally invasive therapeutic modality for the treatment of early-stage colorectal cancer. By implanting SL4-DsRed colon cancer cells into the colons of the C57BL/6 mice, we developed an orthotopic colon tumour mouse model and demonstrated the early-stage tumour growth delay following the eNAFL irradiation. Additionally, we evaluated the temperature changes in the eNAFL-irradiated area using numerical simulations, and induced inflammation using histological analysis. Our results indicate a minimal thermal damage confined to the irradiated spot, sparing the adjacent tissue and alteration in the tumour microenvironment. eNAFL irradiation may be clinically useful as a minimally invasive therapeutic intervention at the early stage of tumourigenesis. In future, an optimal eNAFL therapeutic dose should be determined, in order to increase the efficacy of this approach.
Collapse
|
|
46
|
Hirose R, Nakaya T, Naito Y, Daidoji T, Yasuda H, Konishi H, Itoh Y. Development of a new ex vivo model for evaluation of endoscopic submucosal injection materials performance. J Mech Behav Biomed Mater 2018; 79:219-225. [PMID: 29329031 DOI: 10.1016/j.jmbbm.2018.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/28/2017] [Accepted: 01/02/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Development of high-performance submucosal injection materials (SIMs) contribute to the advancement of endoscopic therapy for early-stage gastrointestinal neoplasms. This study aimed to develop a new ex vivo model that mimics the human gastrointestinal tract to evaluate the performance (the height and duration of the submucosal elevation) of various SIMs in detail. METHODS A new ex vivo model that applies a constant tension to the tested specimen (the porcine gastric specimen) was developed. SIMs were injected into the submucosa at the center or edge of the tested specimen, and submucosal elevation heights (SEHs) were measured over time. RESULTS The average value and standard deviation of SEH determined using the conventional model (the tested specimen was fixed with pins) were higher than those obtained using the new model, which showed that the new model could precisely measure the SEH of a given SIM. In addition, the performance (SEH) of SIMs decreased with increasing tension applied to the specimen, suggesting that the performance of SIMs deteriorates with the over-expansion of the gastrointestinal tract. The submucosal elevation formed at the specimen edge disappeared faster than that formed at the specimen's center. CONCLUSIONS The proposed new ex vivo model allows accurate SEH measurement under uniform conditions and detailed comparison of the performances of various types of SIMs and can contribute to the development of high-performance materials.
Collapse
Affiliation(s)
- Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Takaaki Nakaya
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Tomo Daidoji
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| |
Collapse
|
|
47
|
Facciorusso A, Muscatiello N. Submucosal Injection Solutions for Colon Polypectomy. COLON POLYPECTOMY 2018:89-106. [DOI: 10.1007/978-3-319-59457-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
48
|
Repici A, Maselli R, Carrara S, Anderloni A, Enderle M, Hassan C. Standard needle versus needleless injection modality: animal study on different fluids for submucosal elevation. Gastrointest Endosc 2017; 86:553-558. [PMID: 28161450 DOI: 10.1016/j.gie.2017.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Submucosal injection is currently used in GI endoscopy to reduce resection risks and to perform submucosal dissection; it is usually performed via an injection needle or a needleless device. The aim of the study was to compare 2 submucosal injection modalities (needle-assisted vs needleless) by using substances with different viscosities. METHODS Needle and needleless injections were compared by assessing the efficacy of tissue elevation with 5 different substances in an ex vivo porcine model. The height of the submucosal elevation was measured 0(t0), 10(t1), and 30 minutes after injection (t2). Viscosity of the solution was also measured. RESULTS For both stomach and rectum, at t0, t1, and t2 no difference in the height of the elevation was found between the needle and needleless technique, irrespective of the substance. Tissue elevation in the stomach was similar between the 2 techniques at t0 (9.9 ± 1.58 vs 9.4 ± 1.3 mm, P = .3), t1 (7.2 ± 1.56 vs 6.9 ± 1.4 mm, P =. 26), and t2 (6 ± 1.6 vs 5.5 ± 1.3 mm, P = .18). No difference was found in the rectum at t1 and t2, whereas a slightly higher elevation with the needle-assisted technique was observed at t0 (t0: 12.4 ± 1.3 vs 11.2 ± 1.6 mm, P = .003; t1: 8.7 ± 1.3 vs 8.3 ± 1.5 mm; P = .32; t2: 7.0 ± 1.4 vs 7.2 ± .76 mm; P = .75). When comparing the substances with normal saline solution, more viscous solutions showed a significantly higher elevation at t0, t1, and t2 irrespective of the injection modalities and the location. CONCLUSIONS No differences were found in the height of submucosal injection or in the persistence of such elevation when comparing needleless with needle-assisted injection, with the only minor exception of the initial elevation in the rectum, which does not appear to be clinically relevant. Viscous solutions resulted in higher and more persistent elevations as compared with normal saline solution.
Collapse
Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Markus Enderle
- Research Department, Erbe Elektromedizin GmbH, Tubingen, Germany
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| |
Collapse
|
|
49
|
Moss A, Nalankilli K. Standardisation of polypectomy technique. Best Pract Res Clin Gastroenterol 2017; 31:447-453. [PMID: 28842055 DOI: 10.1016/j.bpg.2017.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/28/2017] [Indexed: 02/07/2023]
Abstract
There are several approaches to polypectomy for sessile polyps <20 mm and for pedunculated polyps. Recent evidence is leading towards standardisation of polypectomy technique. Key recent polypectomy developments include: 1. Use of cold snare polypectomy (CSP) for sessile polyps <10 mm; 2. Use of hot snare polypectomy (HSP) following submucosal injection for sessile polyps sized 10-19 mm; 3. Piecemeal cold snare polypectomy (PCSP), with or without prior submucosal injection, for select sessile polyps sized 10-19 mm, where the potential risk for an adverse event is increased (e.g. polyps in the caecum or ascending colon, or patients with increased risk of post-polypectomy bleeding), and where the risk of submucosal invasion is low; 4. Avoidance of hot biopsy forceps (HBF); 5. Limiting the use of cold biopsy forceps (CBF) to the smallest of diminutive polyps, where CSP is not feasible; 6. Mechanical haemostasis prior to polypectomy for large pedunculated polyps with head ≥20 mm or stalk ≥10 mm.
Collapse
Affiliation(s)
- Alan Moss
- Gastroenterology Department, Western Health, Melbourne, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia.
| | - Kumanan Nalankilli
- Gastroenterology Department, Western Health, Melbourne, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia
| |
Collapse
|
|
50
|
Training and competency in endoscopic mucosal resection. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|