Endoscopic Resection Of Large Polyps Research Articles

Multicenter evaluation of recurrence in endoscopic submucosal dissection and endoscopic mucosal resection in the colon: A Western perspective.

While colon endoscopic mucosal resection (EMR) is an effective technique, removal of larger polyps often requires piecemeal resection, which can increase recurrence rates. Endoscopic submucosal dissection (ESD) in the colon offers the ability for en bloc resection and is well-described in Asia, but there are limited studies comparing ESD vs EMR in the West. To evaluate different techniques in endoscopic resection of large polyps in the colon and to identify factors for recurrence. The study is a retrospective comparison of ESD, EMR and knife-assisted endoscopic resection performed at Stanford University Medical Center and Veterans Affairs Palo Alto Health Care System between 2016 and 2020. Knife-assisted endoscopic resection was defined as use of electrosurgical knife to facilitate snare resection, such as for circumferential incision. Patients ≥ 18 years of age undergoing colonoscopy with removal of polyp(s) ≥ 20 mm were included. The primary outcome was recurrence on follow-up. A total of 376 patients and 428 polyps were included. Mean polyp size was greatest in the ESD group (35.8 mm), followed by knife-assisted endoscopic resection (33.3 mm) and EMR (30.5 mm) (P < 0.001). ESD achieved highest en bloc resection (90.4%) followed by knife-assisted endoscopic resection (31.1%) and EMR (20.2%) (P < 0.001). A total of 287 polyps had follow-up (67.1%). On follow-up analysis, recurrence rate was lowest in knife-assisted endoscopic resection (0.0%) and ESD (1.3%) and highest in EMR (12.9%) (P = 0.0017). En bloc polyp resection had significantly lower rate of recurrence (1.9%) compared to non-en bloc (12.0%, P = 0.003). On multivariate analysis, ESD (in comparison to EMR) adjusted for polyp size was found to significantly reduce risk of recurrence [adjusted hazard ratio 0.06 (95%CI: 0.01-0.57, P = 0.014)]. In our study, EMR had significantly higher recurrence compared to ESD and knife-assisted endoscopic resection. We found factors including resection by ESD, en bloc removal, and use of circumferential incision were associated with significantly decreased recurrence. While further studies are needed, we have demonstrated the efficacy of ESD in a Western population.

Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort

With the introduction of the national bowel cancer screening program, the detection of sessile and flat colonic lesions≥20mm in size, defined as large nonpedunculated colorectal polyps (LNPCPs), has increased. The aim of this study was to examine the quality of endoscopic treatment of LNPCPs in the Dutch screening program. This investigation comprised 2 related, but separate, substudies (1 with a cross-sectional design and 1 with a longitudinal design). The first examined prevalence and characteristics of LNPCPs in data from the national Dutch screening cohort from February 2014 until January 2017. The second, with screening data from 5 endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015, examined performance on important quality indicators (technical and clinical successes, recurrence rate, adverse event rate, and surgery referral rate). All patients were part of the national Dutch screening cohort. In the national cohort, an LNPCP was detected in 8% of participants. Technical and clinical success decreased with increasing LNPCP size, from 93% and 96% in 20- to 29-mm lesions to 85% and 86% in 30- to 39-mm lesions and to 74% and 81% in≥40-mm lesions (P< .001; P= .034). The cumulative recurrence rate at 12 months increased with LNPCP size, from 9% to 22% and 26% in the respective size groups (P= .095). The adverse event rate was 5%. The overall surgical referral rate for noninvasive LNPCPs was 7%. In this performance of 2 substudies, it was shown that quality parameters for endoscopic resection of large polyps in the Dutch screening cohort are not reached, especially in≥30-mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization either within or between centers.

1192 The Safety, Efficacy, and Outcomes for the Endoscopic Resection of Large Non-Ampullary Duodenal Polyps in Familial Adenomatous Polyposis (FAP)

INTRODUCTION: Nearly all patients with FAP will develop duodenal adenomas. Duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging (SS) system. Endoscopic resection (ER) of larger duodenal polyps is technically challenging because of the duodenum’s thin wall, narrow lumen, multiple folds, and increased vascularity. However, successful removal of these large duodenal lesions can potentially avoid foregut surgery by downstaging the SS. We evaluated the safety, feasibility, and outcomes, including the effect on SS, for the ER of large duodenal polyps in FAP. METHODS: This is a single-center retrospective cohort study including consecutive FAP patients who underwent ER of large (defined as &gt;1.5 cm) duodenal polyps between 4/2016-2/2019. Resection techniques used included injection-assisted endoscopic mucosal resection (EMR) and hybrid EMR-Endoscopic submucosal dissection (ESD) by an advanced endoscopist specialized in endoscopic resection. Primary aim was to determine safety of the technique, particularly perforation, immediate (&gt;2-gram hemoglobin drop &lt; 48 hrs after procedure) and delayed (active bleeding from a post-resection ulcer diagnosed by emergency or planned follow-up endoscopy) bleeding. SS before and after resection was calculated. RESULTS: 35 unique FAP patients (48.6% male; age 47.7 years) with 55 large duodenal polyps were identified. All 35 underwent endoscopic resection (54 EMR, 1 ESD/EMR hybrid) of at least one large duodenal polyp [Table 1]. 7 polyps were resected from the duodenal bulb, 33 in D2, 10 in D3/D4, and 2 in the neoduodenum. Median lesion size is 2.4 cm [25-75 IQR:1.65-3], median procedure time 49 min[30-60], and median resection speed 0.16 cm2/min [0.073-0.208]. No duodenal perforations or delayed bleeding occurred. 1 case of immediate bleeding was managed endoscopically. 53/55 polyps were completely resected endoscopically. The 2 incomplete resections were poorly-lifting lesions, preventing safe resection. Of the 35 patients included, 25 had adequate endoscopic surveillance over the study period. 11/25 started at SS IV and 8 were downstaged to SS III (73%) with endoscopic resection, avoiding surgery (Figures 1 and 2). CONCLUSION: Endoscopic resection of large duodenal polyps in FAP is safe when performed with adequate expertise. Endoscopic resection of large polyps allows downstaging of advanced SS in many of these patients. Long-term benefit of downstaging needs to be further evaluated.

Outcome of endoscopic resection of colonic polyps larger than 10 mm in patients with inflammatory bowel disease.

Background and study aims There are limited published data on endoscopic removal of colorectal polyps by endoscopic mucosal resection (EMR) and endoscopic mucosal dissection (ESD) in patients with inflammatory bowel disease (IBD). Patients and methods We performed a retrospective review of patients with colonic IBD and colonic polyps >10mm who underwent EMR and/or ESD at our institution between January 1, 2012 and June 31, 2016. Results Ninety-seven patients with pathology-confirmed IBD (median disease duration 16 years) were included. Mild or moderate active colitis (in background biopsies) was seen in 85 %. Of the total 124 polyps, location was ascending colon in 44 %, transverse in 15 % and sigmoid in 18.5 %; of the total, 55 % were < 20 mm and 45 % were ≥20mm in maximal diameter. Using the Paris classification, 56 % of polyps were polypoid sessile (Is) polyps, while 38 % were non-polypoid (IIa, IIb, IIc). EMR was used in 118 polyps, three required ESD, and three by combined EMR-ESD. Seventy-two percent were resected en-bloc; 28 % underwent piecemeal resection. Histology included low-grade dysplasia in 75, serrated adenoma in 31, and tubular adenoma in 14 polyps. Chromoendoscopy was used in 33 (26.6 %). Adverse events occurred in three patients. Colectomy was performed in 11 patients within 12 months. Recurrence was seen in 20 polyps, 11 of which were successfully resected en-bloc using EMR. Polyps ≥ 20 mm and polyps treated with APC were found to have a statistically significantly higher risk of recurrence. Conclusion This study demonstrates the efficacy and safety of endoscopic resection of large polyps in patients with IBD, making them effective alternatives to colectomy.

Endoscopic Resection of Large Polyps Using Detachable Snare: Up to Which Size Can We Remove Safely?

Background: Large colonic polyps are a challenge to endoscopists because of the risk of significant hemorrhage, perforation, and inadequate polypectomy. It has been reported that the use of a detachable snare can effectively prevent both immediate and delayed bleeding. This study examined whether endoscopic resection of large polyps using detachable snare is feasible and safe and to determine up to which size of the polyp can be removed. Methods: Endoscopic resection using detachable snare of 78 polyps were reviewed retrospectively from 1999 to 2006.

A Retrospective Analysis of Large Polypectomies Using a Methylene Blue/Epinephrine/Saline Lift Technique

Purpose: To retrospectively evaluate the technical success and complication rates of endoscopic polypectomy of large polyps using a methylene blue/epinephrine/saline lift technique. Background: Large colonic polyps may present a management challenge. A small but significant risk of colonic perforation, hemorrhage or incomplete polypectomy must be weighed against the inherent risks of surgery. Endoscopic snare resection of large polyps using a methylene blue/epinephrine lift technique may present a minimally invasive alternative to surgery. This may improve identification of polyp margins making assessment of complete excision easier. Methods: A retrospective series of 32 patients was analyzed. All patients underwent endoscopic resection of large polyps (>20mm) using the above technique. Polypectomies were performed by two experienced endoscopists (JML, GB and KB) at our institution (2003 to present). Backup by an experienced laparoscopic surgeon (DEML) was available for all cases. Results: Thirty-one large polyps were endoscopically removed from 30 patients. The remaining two patients were sent directly for laparoscopic resection after the polyp failed to lift. The mean age of the patients was 65 years with 47% being male. Nineteen polyps were found on the right side of the colon (7 in the cecum). Thirty-one percent of the polyps revealed either high-grade dysplasia or adenocarcinoma with average size being 33.8mm as deemed endoscopically. Six patients underwent surgery (4 laparoscopically). In 2 patients, whose polyps failed to lift, surgical pathology revealed invasive adenocarcinoma. Of the remaining 4 patients, 3 had no residual adenomatous tissue in the resected specimen. There were 2 complications. One patient had a post-polypectomy bleed which was endoscopically managed, and the other patient presented with abdominal pain with portal-venous air which resolved with conservative management. Conclusions: Large polypectomies were safely performed with a methylene blue/epinephrine/saline lift technique in this retrospective series. This technique allows for improved endoscopic delineation of polyp margins. Methylene Blue/Epinephrine/Saline Lift Technique with laparoscopic surgical back-up may, therefore, present a minimally invasive alternative to surgical resection of large polyps.

Approach to benign duodenal polyps

Approach to benign duodenal polyps

3459 High resolution endoscopic imaging using catheter probe endoscopic ultrasonography: a comparison of 20 mhz and 30 mhz cathter probes.

Introduction: CPEUS has potential application in the endoscopic treatment of early stage cancers where it is important to clearly distinguish the muscularis mucosa from the submucosa. Also, CPEUS can image submucosal vessels which may have implications for guiding therapy for bleeding ulcers and endoscopic resection of large polyps. CPEUS using 20 MHz catheter probes shows the muscularis mucosa indistinctly and resolution is only sufficient to image larger vessels in the submucosa. Aim: To compare performance of the existing 20 MHz catheter probe (UMS 20R, Olympus)with a newly available 30 MHz catheter probe (XUM S30 25R, Olympus) in terms of image resolution and ability to identify muscularis mucosa and submucosal vessels. Methods: CPEUS was used to image normal appearing gastrointestinal wall at different anatomic sites in patients undergoing elective endoscopic procedures. For CPEUS imaging during EGD, a water filled balloon sheath was used. Images were videotaped and objectively rated in terms of image quality, number of layers seen, depth of penetration and identification of microscopic structures. Results: Twentyone histologically normal sites (5 each of esophageal, gastric, duodenal, colonic and 3 rectal sites) in 10 patients were examined with the 30 MHz catheter probe. Another 21 sites (5 esophageal, 4 gastric, 2 duodenal, 6 colonic and 4 rectal sites) in 17 patients were examined with the 20 MHz catheter probe. Average depth of penetration was significantly lower with the 30 MHz catheter probe (11 mm vs. 17 mm, p