Colonic Endoscopic Resection Research Articles

Prevalence of Endoscopically Curable Low-Risk Cancer Among Large (≥20 mm) Nonpedunculated Polyps in the Right Colon

Background and aimsEndoscopic submucosal dissection (ESD) is increasingly promoted for the treatment of all large non-pedunculated colorectal polyps (LNPCP), to cure potential low-risk cancers (superficial submucosal invasion without additional high-risk histopathological features). The effect of a universal en bloc strategy on oncological outcomes for the treatment of LNPCP in the right colon is unknown. We evaluated this in a large Western population. MethodsA prospective cohort of patients referred for endoscopic resection (ER) of LNPCP was analysed. Patients found to have cancer after ER and those referred directly to surgery were included. The primary outcome was to determine the proportion of right colon LNPCP with low-risk cancer. ResultsOver 180 months until June 2023, 3294 sporadic right colon LNPCP in 2956 patients were referred for ER at 7 sites (median size 30mm [IQR 15]). 63 (2.1%) patients were referred directly to surgery and cancer was proven in 56 (88.9%). 2851/2956 (96.4%) LNPCP underwent ER (median size 35mm [IQR 20]) of which 75 (2.6%) were cancers. The overall prevalence of cancer in the right colon was 4.4% (131/2956). Detailed histopathological analysis was possible in 115/131 (88%) cancers (71 after ER, 44 direct to surgery). After excluding missing histopathological data, 23/2940 (0.78%) sporadic right colon LNPCP were low-risk cancers. ConclusionsThe proportion of right colon LNPCP referred for ER containing low-risk cancer amenable to endoscopic cure was <1%, in a large, multicentre Western cohort. A universal ESD strategy for the management of right colon LNPCP is unlikely to yield improved patient outcomes given the minimal impact on oncological outcomes. Clinical TrialAustralian Colonic Endoscopic Resection (ACE) cohort: NCT01368289 (https://classic.clinicaltrials.gov/ct2/show/NCT01368289); NCT02000141 (https://classic.clinicaltrials.gov/ct2/show/NCT02000141)

Image-enhanced endoscopy and endoscopic resection practices in the colon among endoscopists in India.

Background and study aims Clinical practice patterns for image-enhanced endoscopy (IEE) and colonic endoscopic resection practices vary among endoscopists. We conducted a survey to understand the differences in IEE and colonoscopic resection practices among endoscopists from India. Methods An online cross-sectional survey comprising 40 questions regarding quality control of colonoscopy, IEE, and colonic endoscopic resection practices was circulated through the registry of the Indian Society of Gastroenterology and Association of Colon and Rectal Surgeons of India. Participation was voluntary and response to all questions was compulsory. Results There were 205 respondents to the survey (93.2 % gastroenterologists, 90.2 % male, 54.6 % aged 30 to 40 years, 36.1 % working in academic institution, 36.1 % working in corporate hospitals). Of the endoscopists, 50.7 % had no training in IEE and 10.7 % performed endoscopy on systems without any IEE modalities. Endoscopists with more experience were more likely to use IEE modalities in practice routinely ( P = 0.007). Twenty percent never used IEE to classify polyps. Sixty percent of respondents did not use dye-chromoendoscopy. Less experienced endoscopists used viscous solutions as submucosal injectate ( P = 0.036) more often. Of the respondents, 44 % never tattooed the site of endoscopic resection. Ablation of edges post-endoscopic mucosal resection was not done by 25.5 % respondents. Most respondents used electronic chromoendoscopy (36.1 %) or random four-quadrant sampling (35.6 %) for surveillance in inflammatory bowel disease. Surveillance post-endoscopic resection was done arbitrarily by 24 % respondents at 6 months to 1 year. Conclusions There are several lacunae in the practice of IEE and colonic endoscopic resection among endoscopists, with need for programs for privileging, credentialing and proctoring these endoscopic skills.

Ability of prophylactic clipping to reduce the incidence of delayed bleeding in patients undergoing endoscopic resection of colonic polyps: a rapid evidence assessment review

Background: Delayed bleeding is a recognised complicationf ollowing colonic endoscopic resection. Prophylactic clip application is often used to reduce this. However, there is a lack of guidelines to support this. Aims: This article aims to review the most recent evidence on the question: 'In patients undergoing endoscopic resection of colonic polyps, does prophylactic clipping of the resection, compared with not clipping, reduce the incidence of delayed bleeding?'. Methods: A rapid assessment was undertaken regarding prophylactic clipping efficacy to reduce delayed bleeding. A search of three databases (Medline, the University of Derby Library Plus and the Cochrane Library) was undertaken to identify articles from the past 4 years. Findings: Eight publications were reviewed: three meta-analyses and five randomised control trials. Five publications recommended against prophylactic clipping following colonic endoscopic resection and three, the most recent publications, strongly recommended it, specifically for those at high risk of delayed bleeding. Conclusion: Prophylactic clip application to reduce delayed bleeding is not effective across all colonic resections. However, there is evidence in favour of clipping for patients with high risk of delayed bleeding.

Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer.

Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer.

Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions

The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models. A multicenter cohort study was performed in patients with nonpedunculated lesions≥20mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies. DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets. The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT03050333.).

The relationship between local recurrence and positive lateral margin after en bloc resection of colorectal neoplasm

Background: The factors associated with recurrence of colonic neoplasm after endoscopic resection with a positive lateral margin are not well known. Thus, we evaluate the relationship between recurrence and positive lateral margin after endoscopic en bloc resection of colorectal neoplasm.Methods: A retrospective review of 9302 patients who underwent colonic endoscopic resection from January 2008 to January 2015. Of these, a total of 76 patients with positive lateral margins with clear evidence of the its location on endoscopic picture after endoscopic en bloc resection of colorectal neoplasm (>10 mm) were included.Results: Ten of 76 (13.2%) patients experienced recurrence during the follow-up period (mean f/u month, 21.7 ± 15.6). In cases with positive lateral margins, the 3- and 5-year local recurrence rate of colorectal neoplasm was 28.1% and 40.1%, respectively. The histological features of the recurrence group were as follows: one case of adenocarcinoma [from low-grade adenoma (LGA)]; two cases of high-grade adenoma (HGA) (one from HGA and one from LGA); and seven cases of LGA (four from adenocarcinoma, two from LGA, and one from HGA). The mean age of patients, locations of the lesions, and histologic type were not significantly associated with local recurrence. In multivariate Poisson regression analyses, total length of lateral margin involvement ≥8 mm (relative risk 12.51; 95% CI 1.11–140.34, p = .040) was a significant predictor of local recurrence.Conclusions: Positive lateral margins ≥8 mm may be a reliable predictor of local recurrence after endoscopic en bloc resection of colorectal neoplasm.

The influence of clips on scars after EMR: clip artifact

Laterally spreading lesions ≥20 mm are conventionally removed by EMR. Endoscopic clips are increasingly used to mitigate the risk of delayed bleeding. Clips may alter the endoscopic appearance of the scar after EMR, interfering with the assessment of adenoma recurrence. We aimed to evaluate this. Prospective, single-center data from the Australian Colonic Endoscopic resection study (January 2011-May 2015) were analyzed. Patients undergoing EMR of laterally spreading lesions with endoscopic clips used at the EMR defect were eligible. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Clips were used in 111 of 885 lesions (12.5%). A total of 62 of 111 clipped lesions had standardized, high-definition, white light, and narrow-band images of the scars after EMR at first surveillance colonoscopy, and the patients were enrolled. Analysis of the images showed 4 situations: a bland scar (N = 27), residual adenoma (N = 6), mucosal elevation with normal pit pattern (N = 14), or granulation tissue related to the presence of residual clips (N = 15). The latter 2 entities were termed post-EMR scar clip artifact (ESCA). Overall, 29 of 62 previously clipped EMR sites (46.8%) had ESCA at a median follow-up of 5.2 months. Twenty scars had residual clips, and 15 of 20 (75.0%) showed ESCA (P = .002). Lesions clipped for prophylaxis of bleeding were more likely to show ESCA than those clipped for deep mural injury or intraprocedural bleeding (65.5% vs 41.7%; P = .006). ESCA was associated with female sex (P = .010) and greater age (P = .011). ESCA is characterized by a nodular elevation of the mucosa with a normal pit pattern and can occur with or without residual clips. Prophylactic clip closure and the presence of residual clips are associated with ESCA. ( NCT01368289.).

A Management Algorithm Based on Delayed Bleeding After Wide-Field Endoscopic Mucosal Resection of Large Colonic Lesions

Bleeding is the main complication of wide-field endoscopic mucosal resection (WF-EMR) for large colonic lesions. Few studies have examined bleeding outcomes after WF-EMR, and thereare no evidence-based guidelines for management of bleeding in this group. We analyzed outcomes of patients with clinically significant post-EMR bleeding (CSPEB) and present a management algorithm based on our findings. In a prospective study, we collected data from WF-EMR of sessile colorectal polyps 20 mm or larger from 1039 patients who participated in the Australian Colonic Endoscopic resection multicenter study from July 2008 through May 2012. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Patients participated in a structured telephone interview 14 days after the procedure; independent predictors of a moderate or severe outcome by American Society of Gastrointestinal Endoscopists criteria, or any intervention for hemostasis, were identified. Sixty-two patients had CSPEB (6.0%); 34 were managed conservatively (55%) and 27 underwent colonoscopy (44%). One patient had primary embolization. Endoscopic therapy was applied in 21 cases; 14 had active bleeding. Two of the conservatively managed cases underwent colonoscopy for rebleeding after discharge. On multivariable analysis, moderate or severe bleeding events were associated with hemodynamic instability (odds ratio, 12.3; P= .046) and low level of hemoglobin at presentation (odds ratio, 0.50 per 1.0 g/dL; P= .005). Intervention for hemostasis was associated with hourly or more frequent hematochezia (odds ratio, 36.7; P= .001), American Society of Anesthesiologists grade 2 or higher (odds ratio, 20.1; P < .001), and transfusion (odds ratio, 18.7; P= .003). Based on a multicenter prospective study, CSPEB resolves spontaneously in 55% of patients. We developed a risk factor-based algorithm that might assist physicians in the management of bleeding. Patients responding to initial resuscitation can be observed, with a lower threshold forintervention in those with the identified risk factors.

Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide-field Endoscopic Mucosal Resection of Large Colonic Lesions

Wide-field endoscopic mucosal resection (WF-EMR) of large sessile colonic polyps is a safe and cost-effective outpatient treatment. Bleeding is the main complication. Few studies have examined risk factors for bleeding during the procedure (intraprocedural bleeding [IPB]) or after it (clinically significant post-endoscopic bleeding [CSPEB]). We investigated factors associated with IPB and CSPEB in a large prospective study. We analyzed data from WF-EMRs of sessile colorectal polyps ≥ 20 mm in size (mean size, 35.5 mm), which were performed on 1172 patients (mean age, 67.8 years) from June 2008-March 2013 at 7 tertiary hospitals as part of the Australian Colonic Endoscopic Resection Study. Data were collected on characteristics of patients and lesions, along with outcomes of procedures and clinical and histologic analyses. Independent predictors of IPB and CSPEB were identified by multiple logistic regression analysis. Of the patients studied, 133 (11.3%) had IPB. Independent predictors included increasing lesion size (odds ratio, 1.24/10 mm; P < .001), Paris endoscopic classification of 0-IIa + Is (odds ratio, 2.12; P = .004), tubulovillous or villous histology (odds ratio, 1.84; P = .007), and study institutions that performed the procedure on fewer than 75 patients (odds ratio, 3.78; P < .001). All IPB was successfully controlled endoscopically. IPB prolonged procedures and was associated with early recurrence (relative risk, 1.68; P = .011). Seventy-three patients (6.2%) had CSPEB. On multivariable analysis, CSPEB was associated with proximal colon location (odds ratio, 3.72; P < .001), use of an electrosurgical current not controlled by a microprocessor (odds ratio, 2.03; P = .038), and IPB (odds ratio, 2.16; P = .016). Lesion size and comorbidities did not predict CSPEB. In a prospective study of patients undergoing WF-EMR of large sessile colonic polyps, IPB is associated with larger lesions, lesion histology, and Paris endoscopic classification of type 0-IIa + Is. IPB prolongs the duration of the procedure, is a marker for recurrence, and is associated with CSPEB. CSPEB occurs most frequently in the proximal colon and less when current is controlled by a microprocessor.

A Randomized, Double-Blind Trial of Succinylated Gelatin Submucosal Injection for Endoscopic Resection of Large Sessile Polyps of the Colon

Succinylated gelatin (SG) is an inexpensive, safe, colloidal solution. It was superior to normal saline (NS) in a porcine colon endoscopic resection (ER) model. Our aim was to compare the efficacy, efficiency, and safety of ER with SG vs. NS. A randomized double-blind trial of submucosal injection with SG vs. NS was conducted for patients undergoing colonoscopy and ER for sessile lesions ≥20 mm in size at an Australian academic hospital endoscopy unit. The primary end point was the "Sydney Resection Quotient" (SRQ), defined as "lesion size in mm divided by the number of pieces to resect." This allows a comparison of technical outcomes for lesions of various sizes. A large lesion removed in fewer pieces gives a greater value. Eighty patients (45 men, mean age 69) with lesions sized 20-100 mm were randomized. A total of 41 SG subjects were well matched to 39 NS subjects, with median (interquartile range) lesion size 40 mm (25-45) vs. 35 mm (30-50), respectively (P=0.382). Complete single-session lesion excision was 90% in both groups. There were no adverse events attributable to SG. The SRQ (median (interquartile range)) was SG 10.0 (7.5-20.0) vs. NS 5.9 (4.4-11.7), P=0.004. Other end points (median (interquartile range)) included fewer resections per lesion in the SG group: 3.0 (1.0-6.0) vs. NS 5.5 (3.0-10.0), P=0.028; fewer injections per lesion with SG: 2.0 (1.0-3.0) vs. NS 3.0 (2.0-11.0), P=0.002; lower injection volume: 14.5 ml (8.5-23.0) vs. NS 20.0 ml (16.0-46.0), P=0.009; and shorter procedure duration with SG: 12.0 min (8.0-28.0) vs. NS 24.5 min (15.0-36.0), P=0.006. SG significantly improves SRQ by almost halving the number of resections for piecemeal ER. SG also safely halves procedure duration.