Cold Polypectomy Research Articles

Endoscopic resection for colorectal tumors.

Endoscopic resection techniques for colorectal tumors are constantly evolving with improvements. Over the past decade, there has been a paradigm shift towards cold polypectomy for the removal of small lesions (<10 mm), known as the «Cold Revolution». In recent years, underwater endoscopic mucosal resection (EMR) has emerged as an alternative to conventional EMR and has been gaining popularity for resection of intermediate and large-sized lesions (≥10 mm). Although colorectal endoscopic submucosal dissection (ESD) requires a high level of advanced skills, improvements in dissection techniques and devices have facilitated the procedure. In Japan, the safety and efficacy of ESD for resecting large lesions (≥20 mm) has been demonstrated in a large-scale, multicenter, prospective cohort study (CREATE-J). ESD is being increasingly adopted in Western countries. As endoscopic resection continues to advance and include large and more complex defects, a variety of closure techniques and new devices are also being developed. Meanwhile, the number of endoscopic resections for T1-colorectal cancer (T1-CRC), including those intended for total excisional biopsy, has been increasing owing to the aging population and improvements in endoscopic technique. This review provides a broad summary of endoscopic resection for colorectal tumors including advancements in closure techniques and devices for mucosal defects, as well as the potential role of endoscopic resection for patients with T1-CRC.

Endoscopic approaches to the management of dysplasia in inflammatory bowel disease: A state-of-the-art narrative review.

Patients with inflammatory bowel disease (IBD) are at an increased risk of developing colitis-associated neoplasia (CAN), including colorectal cancer (CRC), through the inflammation-dysplasia-neoplasia pathway. Dysplasia is the most reliable, early and actionable marker for CAN in these patients. While such lesions are frequently encountered, adequate management depends on an accurate assessment, complete resection and close surveillance. With recent advances in endoscopic technologies and research in the field of CAN, the management of dysplastic lesions has significantly improved. The American Gastroenterology Association and Surveillance for Colorectal Endoscopic Neoplasia Detection (SCENIC) provide a guideline framework for approaching dysplastic lesions in patients with IBD. However, there are significant gaps in these recommendations and real-world clinical practice. Accurate lesion assessment remains pivotal for adequate management of CAN. Artificial intelligence-guided modalities are now increasingly being used to aid the detection of these lesions further. As the lesion detection technologies are improving, our armamentarium of resection techniques is also expanding and includes hot or cold polypectomy, endoscopic mucosal resection, endoscopic sub-mucosal dissection and full-thickness resection. With the broadened scope of endoscopic resection, the recommendations regarding surveillance after resection has also changed. Certain patient populations such as those with invisible dysplasia or with prior colectomy and ileal pouch anal anastomosis need special consideration. In the present review, we aim to provide a state-of-the-art summary of the current practice of endoscopic detection, resection and surveillance of dysplasia in patients with IBD and provide some perspective on the future directions based on the latest research.

Outcome of Endoscopic Resection of Rectal Neuroendocrine Tumors ≤ 10 mm.

Guidelines suggest endoscopic resection for rectal neuroendocrine tumors (rNETs) < 10 mm, but the most appropriate resection technique is unclear. In real-life clinical practice, the endoscopic removal of unrecognized rNETs can take place with "simple" techniques and without preliminary staging. The aim of the current study is to report our own experience at a referral center for both neuroendocrine neoplasms and endoscopy. Retrospective analyses of polypectomies were performed at the Humanitas Research Hospital for rNETs (already diagnosed or previously unrecognized). A total of 19 patients were included, with a median lesion size of 5 mm (range 3-10 mm). Only five lesions were suspected as NETs before removal and underwent endoscopic ultrasound (EUS) before resection, being removed with advanced endoscopic techniques. Unsuspected rNETs were removed by cold polypectomy in eleven cases, EMR in two, and biopsy forceps in one. When described, the margins were negative in four cases, positive in four (R1), and indeterminate in one. The median follow-up was 40 months. A 10 mm polypoid lesion removed with cold snare polypectomy (G2 R1) needed subsequent surgery. Eighteen patients underwent EUS after a median time of 6.5 months from resection. The EUS identified local recurrence after 14 months in a 7 mm polypoid lesion removed with cold snare polypectomy (G1 R1); the lesion was treated with cap-assisted EMR. For all the other lesions, the follow-up was negative. When rNETs are improperly removed without prior staging, caution must be exercised. The data from our cohort suggest that even if inappropriate resection had happened, patients may be safely managed with early EUS evaluation.

Endoscopic treatment of colorectal polyps and early colorectal cancer

Background: Colonoscopy offers higher diagnostic sensitivity than other colorectal cancer screening methods and provides the advantage of both diagnostic tissue sampling and polyp removal. Since the majority of colorectal cancers evolve from adenomatous polyps, polyp resection through colonoscopy is widely considered an effective method of preventing colorectal cancer and reducing mortality rates.Current Concepts: Determining colorectal polyp size and shape requires comprehensive endoscopy with enhanced imaging techniques to choose treatment directions and the appropriate colorectal polypectomy method. The selection of the polypectomy method is contingent upon the polyp’s attributes and possible malignancy according to US Multi-Society Task Force on Colorectal Cancer and European gastrointestinal endoscopy guidelines. This article examines eight polypectomy procedures: cold forceps polypectomy, hot biopsy polypectomy, cold snare polypectomy, hot snare polypectomy, endoscopic mucosal resection (EMR), and modified EMR techniques. Each method has unique benefits and is suitable for particular polyp types and sizes. Piecemeal EMR and endoscopic submucosal dissection offer alternatives for larger or challenging lesions that require careful planning and follow-up. After endoscopic resection of early colorectal cancer, further surgery may be necessary depending on the risk of lymph node metastasis as determined by specific histologic findings following Korean and Japanese guidelines.Discussion and Conclusion: The choice of endoscopic resection technique, which depends on factors such as polyp shape, size, and location as well as endoscopist skill, is crucial for ensuring complete polyp removal.

Cold snare polypectomy compared to cold forceps polypectomy for endoscopic resection of guideline defined diminutive polyps: A systematic review and meta-analysis of randomized trials.

International guidelines recommend cold snare polypectomy (CSP) for polyps < 10mm in size. However, recent randomized clinical trials (RCTs) showed conflicting results for the use of cold forceps polypectomy (CFP) vs. CSP for the resection of diminutive colorectal polyps (DCPs) (≤ 5mm), especially for polyps ≤ 3mm. Herein we compared CFP with CSP for patients with DCPs in this meta-analysis of RCTs. We systematically searched the Cochrane Library, PubMed and EMBASE databases from inception to November 24, 2022, (Registration number INPLASY2022110135). The primary endpoint was DCP complete resection rate. The secondary endpoints were mean polypectomy time, polyp retrieval rate and complications. Seven RCTs involving 1023 DCPs were included. The complete resection rate (91.6% vs. 94.7%) for CFP was not significantly lower for polyps ≤ 5mm (relative risk [RR] = 1.03; 95% confidence interval [CI]: 0.98-1.07). Sub-group analysis showed that the complete resection rate (88.7% vs. 92.4%) for CFP was not significantly lower for DCPs > 3mm (RR = 1.04; 95%CI: 0.97-1.12). Another sub-group analysis showed that the complete resection rate (97.0% vs. 96.3%) was similar for polyps ≤ 3mm for CFP vs. CSP (RR = 1.00; 95%CI: 0.98-1.03). The mean polypectomy time was not different between CFP and CSP (95%CI: -11.86-10.18). The polyp retrieval rate (100% vs. 96.9%) was not significantly higher for CFP (RR = 1.02; 95%CI: 0.98-1.07). There were no reported complications in the included studies. The overall study quality was moderate except for the removal of polyps ≤ 5mm (low-quality evidence). CFP was comparable to CSP for theresection of polyps ≤ 3mm; however, caution should be taken for DCPs > 3mm because of the low complete resection rate (< 90%).

Editorial: Optimizing the success of cold snare polypectomy in colonoscopy practice

Editorial: Optimizing the success of cold snare polypectomy in colonoscopy practice

Impact of cold snare versus cold forceps resection of diminutive adenomas on segmental incomplete resection rate.

Polypectomy technique, for diminutive lesion resection, is variable amongst colonoscopists using either cold snare (CSP) or cold forceps (CFP) polypectomy. While it is well described that CSP is a preferred technique to resect small lesions, there is little data evaluating the impact resection techniques have on metachronous adenoma burden. The study aim was to evaluate the rate of incomplete resection attributable to CSP and CFP of diminutive adenomas. This is a two-center retrospective cohort study evaluating the segmental incomplete resection rate (S-IRR) of diminutive tubular adenomas (TA). S-IRR was calculated by subtracting the segmental metachronous adenoma rate in a specific colonic segment without adenoma from segments with adenoma on index colonoscopy. The primary outcome was the S-IRR of diminutive TA resected by CSP or CFP on index colonoscopy. 1504 patients were included in the analysis: 1235 with TA <6 mm and 269 with TA 6-9 mm as the most advanced lesion. The S-IRR in a segment that had a <6 mm TA incompletely resected by CFP on index colonoscopy was 13%. The S-IRR in a segment which had a <6 mm TA incompletely resected by CSP was 0%. Among 12 included colonoscopists, the range of overall S-IRR was 1.1% - 24.4% with an average S-IRR of 10.3%. S-IRR was 13% higher with CFP resection of diminutive TA than with CSP. A proposed S-IRR metric of <5% is a target goal for all diminutive polyp resection, as 3/12 colonoscopists achieved this low rate. S-IRR can be utilized as a methodology to compare and quantify the difference in segmental metachronous adenoma burden across various polypectomy removal methods.

Complete endoscopic removal rate of detected colorectal polyps in a real world out-patient practical setting

Objectives Colonoscopy with adenomatous polypectomy reduces the incidence and mortality of colorectal cancer. We introduced a strategy of removing all neoplastic polyps in single-session out-patient colonoscopy using cold polypectomy. We aimed to investigate the achievement of single-session complete removal rate of detected colorectal polyps in clinical practice. Materials and methods This retrospective study included colonoscopy-scheduled 40–79-year-old outpatients, with at least one colorectal neoplasm, between January 2015 and December 2016. Exclusion criteria were: colorectal neoplasms 21 mm or larger in size; pre-examination for colorectal surgery or endoscopic submucosal dissection; colonoscopy performed by health check program; ongoing antithrombotic treatment; inflammatory bowel disease; familial adenomatous polyposis. We defined ‘clean colon’ as the removal of all detected neoplastic polyps in a single-session colonoscopy. We evaluated clean colon rate, factors relating to clean colon failure and complications. Results We evaluated 2527 patients (mean age 68 years; 799 women) with 8203 colorectal polyps (7675 adenomas, 423 serrated lesions, 105 Tis and T1 cancers). In 1–4 mm polyps, cold snare polypectomy (CSP; 51.8%) and cold forceps polypectomy (CFP; 45.8%) were applied. Clean colon rates were 95.1% per patient and 97.1% per lesion. The significant factors denoting clean colon failure were inadequate bowel preparation, ≥5 lesions, and the most advanced estimated histology of adenocarcinoma, on multivariate analyses. Post-polypectomy bleeding requiring endoscopic hemostasis occurred in five patients (0.2%) who had undergone endoscopic mucosal resection (EMR) or hot snare polypectomy (HSP). Perforation occurred in one patient (0.04%) with EMR. Conclusions The clean colon rates were satisfactory in single-session out-patient colonoscopy using cold polypectomy.

Adoption of Optimal Small (6-9mm) Colorectal Polyp Resection Technique Over Time.

Cold snare polypectomy (CSP) is the preferred resection technique for small (6-9mm) polyps due to lower rate of incomplete resection compared to cold forceps polypectomy (CFP) and improved safety profile over hot snare polypectomy (HSP). To describe resection techniques for small (6-9mm) polyps and determine factors associated with sub-optimal technique. This was retrospective cohort study of colonoscopies performed by gastroenterological and surgical endoscopists from 2012 to 2019 where at least one 6-9mm polyp was removed. Patient, provider, and procedure characteristics were collected. Univariate and multivariate regression analyses were performed to determine factors associated with sub-optimal technique. In total, 773 colonoscopies where 1,360 6-9mm polyps removed by 21 endoscopists were included. CSP was used for 1,122 (82.5%), CFP for 61 (4.5%), and HSP for 177 (13.0%). Surgeon specialty was associated with CFP use (aOR 7.81; 95% CI 3.02-20.16). Polyp location in left colon (aOR 1.65; 95% CI 1.17-2.33) and pedunculated morphology (aOR 12.76; 95% CI 7.24-22.50) were associated with HSP. There was a significant increase in overall CSP use from 30.4% in 2012 to 96.8% in 2019. 82.5% of all 6-9mm polyps removed from 2012 to 2019 were removed using a cold snare with significant increase in CSP from 2012 to 2019. Differences in how optimal technique was adopted over time based on specialty highlight the need for standardized practice guidelines and quality monitoring.

Randomized Controlled Trial Investigating Cold Snare and Forceps Polypectomy Among Small POLYPs in Rates of Complete Resection: The TINYPOLYP Trial.

Optimizing complete resection during colonoscopy is important because residual neoplastic tissue may play a role in interval cancers. The US Multi-Society Task Force recommends diminutive (≤5 mm) and small (6-9 mm) polyps be removed by cold snare polypectomy (CSP). However, evidence is less clear whether CSP retains significant advantage over cold forceps polypectomy (CFP) for polyps ≤3 mm. This study is a single-center prospective noninferiority randomized clinical trial evaluating CFP and CSP for nonpedunculated polyps ≤3 mm. Patients 18 years and older undergoing colonoscopy for any indication were recruited. During each colonoscopy, polyps underwent block randomization to removal with CFP or CSP. After polypectomy, 2 biopsies were taken from the polypectomy margin. The primary noninferiority outcome was the complete resection rate, defined by absence of residual polyp in the margin biopsies. A total of 179 patients were included. Patients had similar distribution in age, sex, race/ethnicity, as well as indication of procedure. A total of 279 polyps ≤3 mm were identified, with 138 in the CSP group and 141 in the CFP group. Mean polypectomy time was longer for CSP compared with CFP (42.3 vs 23.2 seconds, P &lt; 0.001), although a higher proportion of polyps removed by CFP were removed in more than 1 piece compared with CSP (15.6 vs 3.6%, P &lt; 0.001). There were positive margin biopsies in 2 cases per cohort, with a complete resection rate of 98.3% in both groups. There was no significant difference in cohorts in complete resection rates (difference in complete resection rates was 0.057%, 95% confidence interval: -4.30% to 4.53%), demonstrating noninferiority of CFP compared with CSP. Use of CFP was noninferior to CSP in the complete resection of nonpedunculated polyps ≤3 mm. CSP required significantly more time to perform compared with CFP. CFP should be considered an acceptable alternative to CSP for removal of polyps ≤3 mm.

Guidelines for Colorectal Cold Polypectomy (supplement to "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection").

The Japan Gastroenterological Endoscopy Society published the second edition of the "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection" in 2019 to clarify the indications for colorectal endoscopic mucosal resection (EMR) and endoscopic submucosal dissection and to ensure appropriate preoperative diagnoses as well as effective and safe endoscopic treatment in front-line clinical settings. Endoscopic resection with electrocautery, including polypectomy and EMR, is indicated for colorectal polyps. Recently, the number of facilities introducing and implementing cold polypectomy without electrocautery has increased. Herein, we establish supplementary guidelines for cold polypectomy. Considering that the level of evidence for each statement is limited, these supplementary guidelines must be verified in clinical practice.

Top tips for cold snare polypectomy (with video)

Cold snare polypectomy has revolutionized our approach to the resection of diminutive and small polyps found during colonoscopy. Recent data show its safety and efficacy even for larger colon polyps specifically for serrated lesions. As the indications for cold polypectomy continue to expand, it is critical that we understand the rationale, tools required, and the technique for performing a high-quality cold snare polypectomy. Several important tips including type of snare required, managing bleeding, how much tissue to resect, and how fast to close the snare are addressed in this state-of-the-art review by Michael Bourke.

Experience with cold polypectomy during screening colonoscopy

Experience with cold polypectomy during screening colonoscopy

Safety of Cold Snare Polypectomy for Small Colorectal Polyps in Patients Receiving Antithrombotic Therapy

Background and AimsRecent guidelines do not specify the bleeding risk of cold polypectomy. We investigated delayed postpolypectomy bleeding (DPPB) after cold snare polypectomy (CSP) for colorectal polyps in patients receiving antithrombotic (AT) therapy. MethodsA total of 4770 patients who underwent endoscopic resection of colorectal polyps between April 2017 and December 2019 were included. Of them, we analyzed 3600 patients and 10,152 polyps with a size of < 10 mm, including 640 patients who took AT drugs. The patients were subdivided into 3 groups according to AT drug use: 1) continued use, 2) withdrawal, and 3) no use. We compared DPPB rates between hot snare polypectomy (HSP) and CSP in each group. ResultsThe DPPB rates in the CSP group were approximately one-tenth lower than those in the HSP group (per-patient analysis: 0 (0/2598) vs 0.9% (9/1002), per-polyp analysis: 0.04 (3/7928) vs 0.58% (13/2224)). The DPPB rates of HSP were significantly different among the continued use, withdrawal, and no use groups (per-polyp analysis: 2.08 (6/289), 0 (0/159), and 0.40% (7/1771), P = 0.0015). However, the DPPB rates of CSP did not differ among groups (per-polyp analysis: 0 (0/983), 0.17 (1/591), and 0.03% (2/6348), P = 0.2087). No DPPB was observed after CSP in patients with continued use of thienopyridine, aspirin, cilostazol, direct oral anticoagulants, or warfarin; except for 1 patient with direct oral anticoagulant withdrawal. ConclusionThe DPPB of CSP in patients taking an AT drug was low and similar to that in patients not taking drugs. CSP could be a safe procedure for colorectal polyps, even with continued use of AT drugs.

Real-world local recurrence rate after cold polypectomy in colorectal polyps less than 10 mm using propensity score matching.

BACKGROUNDCold polypectomy (CP) is a simple and safe procedure for polyps less than 10 mm in size; however, there is concern about local recurrence following CP because of unidentified margins of excised specimens and the lack of tumor suppression effect by coagulation. Some clinical trials have evaluated local persistent recurrence; their results suggest that a higher rate of local recurrence has not been documented so far. There were few reports that observed the course over long periods of time after CP in clinical practice.AIMTo evaluate the presence of local recurrence following CP and hot polypectomy (HP) using propensity score matching.METHODSWe analyzed 275 patients who underwent polypectomy for non-pedunculated colorectal polyps less than 10 mm (959 Lesions) between October 2016 and 2017 and underwent follow-up endoscopy subsequently. We divided them into the CP group (706 Lesions), wherein CP was performed, and the HP group (253 Lesions), wherein HP was performed. Using propensity score matching, we extracted 215 Lesions in each group and evaluated the local recurrence and content of CP in the real clinic and adverse events using medical records.RESULTSAfter propensity score matching, there were no significant differences in the patients’ and their endoscopic background (age, use of antithrombotics, indications, size, morphology, location of polyps, and polypectomy device) between the groups. The mean duration between colorectal polypectomy and the next follow-up colonoscopy was 17.5 ± 7.1 (range, 6-39) mo in the CP group and 15.7 ± 6.0 (range, 6-35) mo in the HP group, which was significantly longer in the CP group (P = 0.005). The local recurrence rate was 0.93% in the CP group and 0.93% in the HP group, without a significant difference (P = 0.688). Additionally, no differences were observed in the macroscopic en bloc resection rate, histopathological complete resection rate, and pathological results between the groups. Adverse events did not occur in either group.CONCLUSIONLocal recurrence after CP was equivalent to that following HP in clinical practice. CP is useful and safe in the treatment of non-pedunculated polyps of less than 10 mm.

Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high volume centers.

Data on endoscopic resection (ER) for superficial duodenal epithelial tumors (SDETs) are insufficient owing to their rarity. There are two main ER techniques for SDETs: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In addition, modified EMR techniques, such as underwater EMR (UEMR) and cold polypectomy, are becoming popular. We conducted a large-scale retrospective multicenter study to clarify the detailed outcomes of duodenal ER. Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs; defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using the Kaplan-Meier method. In total, 3107 patients (including 1017 undergoing ESD) were included. En bloc resection rates were 79.1 %, 78.6 %, 86.8 %, and 94.8 %, and delayed AE rates were 0.5 %, 2.2 %, 2.8 %, and 6.8 % for cold polypectomy, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher in the ESD group than in non-ESD groups for lesions < 19 mm (7.4 % vs. 1.9 %; P < 0.001), but not for lesions > 20 mm (6.1 % vs. 7.1 %; P = 0.64). The local recurrence rate was significantly lower in the ESD group than in the non-ESD groups (P < 0.001). Furthermore, for lesions > 30 mm, the cumulative local recurrence rate at 2 years was 22.6 % in the non-ESD groups compared with only 1.6 % in the ESD group (P < 0.001). ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.

Endoscopic resection of superficial non-ampullary duodenal epithelial tumor.

Although superficial non‐ampullary duodenal epithelial tumor (SNADET) was previously considered a rare disease, in recent years, the opportunities to detect and treat SNADET are increasing. Considering the high morbidity of pancreatoduodenectomy, endoscopic resection can be a treatment option that preserves the organs and contributes maintain patients’ quality of life. Endoscopic mucosal resection (EMR) is a standard treatment for relatively small lesions in gastrointestinal tracts, however, it is difficult because submucosal fibrosis frequently occurs due to the previous biopsy. Recently, some modified EMR techniques including underwater EMR (UEMR) and cold polypectomy (CP) have been proposed. In UEMR, the duodenal lumen is filled with water or saline and resected the targe lesion with a snare without injection into the submucosa. It would be a treatment option that could reduce candidates for ESD especially SNADET less than 20 mm. CP was reported as a safe and convenient means for SNADET. It would also be one of the standard treatments for diminutive lesions, though there remain some concerns on its resectability. ESD for SNADET is technically challenging, especially with an extremely high risk of adverse event (AE) with a reported bleeding rate of more than 20% and perforation rate up to about 40%. However, modified treatment techniques including the water pressure method and pocket creation method have been reported to potentially contribute to improving outcomes of ESD. Moreover, accumulated evidence shows closing the mucosal defect significantly reduces delayed adverse events after duodenal endoscopic treatments. Further studies are warranted to elucidate curative criteria, long‐term outcomes, and appropriate surveillance strategy.

Colonoscopic Polypectomy Preferences of Asian Endoscopists: Results of a Survey-Based Study.

Background/AimsThe clinical practice pattern of polypectomy is not well-investigated in Asian countries. We aimed to survey Asian endoscopists about their preferred polypectomy techniques for given conditions and images of polyps.MethodsA survey was performed using questionnaires composed of two parts a scenario-based questionnaire using scenarios of polyps, which were adopted from the European Society of Gastrointestinal Endoscopy guidelines, and an image-based questionnaire using provided endoscopic images of polyps.ResultsA total of 154 endoscopists participated in this survey. The most preferred resection techniques for diminutive (≤5 mm), small (6–9 mm), and benign-looking intermediate (10–19 mm) nonpedunculated polyps were cold forceps polypectomy, hot snare polypectomy, and endoscopic mucosal resection (EMR), respectively, in both the scenario- and image-based questionnaires. For benign-looking large (≥20 mm) nonpedunculated polyps, EMR and endoscopic submucosal dissection (ESD) were preferred in the scenario- and image-based surveys, respectively. In case of malignant nonpedunculated polyps, EMR and ESD were preferred for intermediate-sized and large lesions, respectively, according to the scenario-based survey. However, ESD was preferred in both intermediate-sized and large malignant nonpedunculated polyps according to the image-based survey. Trainee endoscopists, endoscopists working in referral centers, and endoscopists in the colorectal cancer–prevalent countries were independently associated with preference of cold snare polypectomy for removing small polyps.ConclusionsThe polypectomy practice patterns of Asian endoscopists vary, and cold snare polypectomy was not the most preferred resection method for polyps <10 mm in size, in contrast to recent guidelines. (Gut Liver 2021;15-400)

Double-balloon endoscopy facilitates efficient endoscopic resection of duodenal and jejunal polyps in patients with familial adenomatous polyposis.

BACKGROUND : Many patients with familial adenomatous polyposis (FAP) have adenomatous polyps of the duodenum and the jejunum. We aimed to elucidate the long-term outcomes after double-balloon endoscopy (DBE)-assisted endoscopic resection of duodenal and jejunal polyps in patients with FAP. METHODS : We retrospectively reviewed patients who underwent more than two sessions of endoscopic resection using DBE from August 2004 to July 2018. RESULTS : A total of 72 DBEs were performed in eight patients (median age 30 years, range 12-53; 1.4 DBE procedures/patient-year) during the study period, and 1237 polyps were resected. The median observation period was 77.5 months (range 8-167). There were 11 adverse events, including seven delayed bleeds and four episodes of acute pancreatitis. No delayed bleeding occurred after cold polypectomy. Although, in one patient, one endoscopically resected duodenal polyp was diagnosed as being intramucosal carcinoma, none of the patients developed an advanced duodenal or jejunal cancer during the study period. CONCLUSIONS : Endoscopic resection of duodenal and jejunal polyposis using DBE in patients with FAP can be performed safely, efficiently, and effectively.

Endoscopic Analysis of Microstructures of the Colon Mucosa on the Edge of the Post-Resection Defect as a Measure of Preventing Recurrence of Polyps after a Cold Polypectomy

The aim of this study was to assess the usefulness of endoscopic removal of small (less than 10 mm) colon polyps with a cold snare on the basis of endoscopic microstructural analysis of the edges of the post-resection defect using high-resolution video endoscopic equipment.Methods. In 74 patients (22 men and 52 women) aged 28 to 84 years (average age 59.3 ± 3.6 years), 103 colon polyps of types 0-IIa — 82 (79.7 %) and 0-Is — 21 (20.3 %), without the signs of severe dysplasia and cancer, were removed through the endoscope by the using of a cold snare, followed by mandatory inspection of the edges of the post-resection defect. A complete endoscopic analysis of the microstructures and the capillary vessels of the mucosa was performed on the edge of the post-resection defect, and then was compared to the histological image.Results. The endoscopic criteria for completely performed cold snare resection were identified, they are parallel crypts and the structure of intestinal pits of type I (S. Kudo) in the edge of the post-resection defect, which were observed in 93 (90.3 %) cases. Signs of residual tissue were dilated altered crypts with a violation of the parallelism of their location, which were observed in 10 (9.7 %) cases. The difference between the spatial location of crypts in the rectum (the effect of “falling crypts”) was identified, which complicates the differential diagnosis of normal and residual tumor tissue. In the endoscopic diagnosis of the vascular pattern of the colon mucosa was determined that flat-elevated polyps have a fine capillary network, which reduces the risk of bleeding when use a cold resection method. An observation (diagnostic colonoscopy) was performed in 11 (10.7 %) patients, including a case with the polyp with high grade displasia. No advance adenomas and interval cancers were detected.Conclusion. Тhis research helps to ensure reliable diagnosis of the completeness of performed endoscopic intervention and the possibility of removal of residual tumor tissue (if present) immediately after its completion, it’s allow a reduction in the number of recurrences of tumors.