Forceps Polypectomy Research Articles

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%).

Cold snare versus cold forceps polypectomy for endoscopic resection of diminutive polyps: meta-analysis of randomized controlled trials.

The practices for resection of diminutive colon polyps vary among endoscopists and US Multi-Society Task force (USMSTF) guidelines recommend use of cold snare polypectomy (CSP) for this purpose. In this meta-analysis, we have compared CSP and cold forceps polypectomy (CFP) for resection of diminutive polyps. We reviewed several databases to identify randomized controlled trials (RCTs) that compared CSP and CFP for resection of diminutive polyps. Our outcomes of interest were complete resection of all diminutive polyps, complete resection of polyps ≤ 3mm in size, failure of tissue retrieval and polypectomy time. For categorical variables, we calculated pooled odds ratios (OR) with 95% confidence intervals (CI); for continuous variables, we calculated mean difference (MD) with 95% CI. Data were analyzed using random effects model and heterogeneity was assessed using the I2 statistic RESULTS: We included 9 studies with 1037 patients. Rate of complete resection of all diminutive polyps was significantly higher in the CSP group, OR (95% CI) 1.68 (1.09, 2.58). Subgroup analysis including jumbo or large capacity forceps, found no significant difference in complete resection between groups, OR (95% CI) 1.43 (0.80, 2.56). We found no significant difference in the rates of complete resection of ≤ 3mm polyps between groups, OR (95% CI) 0.83 (0.30, 2.31). Rate of failure of tissue retrieval was significantly higher in CSP group, OR (95% CI): 10.13 (2.29, 44.74). We found no significant difference in polypectomy time between groups. CFP using large capacity or jumbo biopsy forceps is non-inferior to CSP for complete resection of diminutive polyps.

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.

Polyp detection rate and cumulative incidence of post-colonoscopy colorectal cancer in Germany.

Studies have shown that the quality of colonoscopy influences the incidence of post-colonoscopy colorectal cancer (PCCRC). However, data from Germany on this association are lacking. We aimed to assess cumulative incidence of PCCRC in persons undergoing colonoscopy in Germany according to the physician's polyp detection rate (PDR). Using the German Pharmacoepidemiological Research Database (GePaRD) with claims data of ~20% of the German population, we included persons with a baseline colonoscopy between 2008 and 2017 and categorized them according to the procedure at baseline (snare polypectomy, forceps polypectomy, no polypectomy). In each subgroup, we distinguished between persons examined by physicians with a PDR in the lowest quartile vs higher quartiles and described cumulative CRC incidence during follow-up. Overall, 822 715 persons examined by 1752 physicians were included. One quarter of the physicians had a PDR ≤21.8% (lowest quartile). In all subgroups, the 5-year cumulative CRC incidence was statistically significantly higher in persons examined by physicians with a PDR ≤21.8% vs >21.8%: It was 69% higher in persons with snare polypectomy (0.88% vs 0.52%), 87% higher in persons with forceps polypectomy (0.58% vs 0.31%), and 48% higher in persons without polypectomy at baseline (0.31% vs 0.21%). In conclusion, we found a substantially increased PCCRC risk in persons examined by physicians with a low PDR in Germany, irrespective of the baseline findings. Our study highlights the importance of a high-quality colonoscopy to maximize the preventive effect of colonoscopy on CRC incidence.

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.

S2143 The Gang's All Here: A Rare Case of Polypoid Ganglioneuroma of the Colon

Introduction: Ganglioneuromas are rare benign growths characterized by proliferation of nerve ganglion cells, nerve fibers & supporting cells of the nervous system. These growths have mostly been described in children but occur in adults as well. They are usually found in the mediastinum, retroperitoneum and adrenal glands but rarely, they occur in the gastrointestinal tract. Clinical manifestations depend on the location and size but can include abdominal pain, constipation, bleeding or obstruction. There are no known modifiable risk factors, but in some cases, they are associated with rare genetic syndromes like Cowden, Juvenile Polyposis and Peutz-Jeghers. Herein, we report a rare case of an isolated cecal ganglioneuroma. Case Description/Methods: Our patient was a 63-year-old female with no pertinent past medical history who presented for a routine screening colonoscopy. She had normal vital signs and no abnormal laboratory findings. During the colonoscopy, cold forceps polypectomy was performed to retrieve 2 3-mm polyps in the ascending colon and one 2 mm polyp from the cecum. Hematoxylin and eosin staining of the cecal polyp revealed evidence of spindle cell proliferation accompanied by large cells with prominent nucleoli, consistent with ganglion cells. The immunostaining of the cecal polyp was reactive for the S100 protein but was negative for markers of stromal tissue (CD34, CD117, smooth muscle actin, desmin, epithelial membrane antigen). The concurrence of these findings was consistent with a diagnosis of polypoid ganglioneuroma (Table). Discussion: Colonic ganglioneuromas are divided into 3 major groups: polypoid ganglioneuromas, ganglioneuromatous polyposis & diffuse ganglioneuromatosis. Most of these tumors are found incidentally on screening colonoscopy. Though most of these tumors are benign, few reports have noted an associated incidence of colorectal cancer. Genetic testing is advised if there is existence of a genetic syndrome. There is a lack of guidelines regarding best practice management of these tumors as well as lack of consensus regarding screening measures & follow up surveillance colonoscopy for recurrence. However, similar to other cases reported in the literature that have been successfully treated with polypectomy, the tumor in our case was excised safely endoscopically. Thus endoscopic resection can be a curative method for solitary ganglioneuromas. We believe that awareness & proper counseling will translate into better care of patients with such tumors. Table 1. - Classification of colonic ganglioneuromas with identifying features 1. Polypoid ganglioneuroma - small (< 2cm) & solitary- sessile or pedunculated 2. Ganglioneuromatous polyposis - numerous (often 20-40)- sessile or pedunculated 3. Diffuse ganglioneuromatosis - can range from 1-17 cm in size- present as disseminated, nodular, intramural or transmural lesions

Continuing Medical Education Questions: August 2022.

Article Title: Randomized Controlled-Trial Investigating Cold Snare and Forceps Polypectomy Among Small Polyps in Rates Of Complete Resection: The "TINYPOLYP" Trial.

Prospective multicenter study of the efficacy and safety of cold forceps polypectomy for ≤ 6-mm non-ampullary duodenal low-grade adenomas.

Background and study aims Because the endoscopic treatment for non-ampullary duodenal adenoma (NADA) has a non-negligible risk of adverse events (AEs), a safe and easy treatment for NADA is desirable. This was a multicenter prospective trial evaluating the efficacy and safety of cold forceps polypectomy (CFP) for diminutive NADAs. Patients and methods This study was prospectively conducted at six general hospitals and one university hospital. The inclusion criteria were histologic and endoscopic diagnosis of low-grade NADA measuring ≤ 6 mm. A second endoscopy was scheduled for 1 month after CFP. After confirmation of the success of CFP, 6-month and 12-month surveillance endoscopies were scheduled. The primary endpoint was the endoscopic and histologic disease disappearance rates at the 12-month endoscopy. Results Thirty-nine lesions from 38 patients were prospectively included. Median tumor size at enrollment was 5 mm (range 3–6 mm). There were four cases of remnant lesions at the second endoscopy, and the lesion disappearance rate of single CFP was 89.7 % (35 /39; 95 % confidence interval (CI), 76.9 %–97.9 %). In three cases, complete removal of the lesion was achieved with a single re-CFP, but one case required four repeat CFPs. The lesion disappearance rate at 12-month endoscopy was 97.4 % (38 /39; 95 %CI, 86.8 %–99.5 %). During the follow-up period, no AEs related to CFP were observed. Conclusions CFP for NADA ≤ 6 mm was safe and effective in this study. This common endoscopic method to remove lesions may be an option for treatment of diminutive NADAs.

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.

Effects of Jianpi Lishi Jiedu granules on colorectal adenoma patients after endoscopic treatment: study protocol for a randomized, double-blinded, placebo-controlled clinical trial

BackgroundColorectal adenomas (CRAs) are precancerous lesions of the large intestine presenting as colorectal polyps. At present, the conventional treatment methods for CRA mainly include high-frequency electrocoagulation and electroexcision, biopsy forceps polypectomy, cauterization by laser and microwave, and other endoscopic interventions. The principal advantages conferred by these treatment strategies include less trauma, quick postoperative recovery, and simplicity to perform. However, the higher recurrence rates and insignificant improvement of postoperative symptoms after endoscopic surgery are considerable drawbacks to this approach. Besides, there is currently no effective pharmacotherapy to prevent the recurrence of CRA. Jianpi Lishi Jiedu (JLJ) granules are a form of traditional Chinese medicine (TCM) used to manage postoperative patients with CRA, which has shown a certain degree of efficacy in clinical practice. However, its effectiveness and safety profile have not been convincingly evaluated. The purpose of this study is to evaluate the clinical efficacy and safety profile of JLJ granules in the management of postoperative patients with CRA and to observe the recurrence rate of adenoma in these patients.MethodsA randomized, double-blind, and placebo-controlled clinical trial is performed in this study. A total of 80 postoperative patients with CRA will be randomly classified into the Jianpi Lishi Jiedu granules group or the placebo control group. Patients in both groups shall receive 3 months of intervention, after which medical follow-up and safety evaluation will be performed for all of the patients. The primary outcome is the recurrence rate of adenomas within 12 months. The secondary outcomes are the cardinal TCM symptom scores, minor TCM symptom scores, Bristol Stool Scale, efficacy of TCM symptoms, safety indicators, and blinding assessment.DiscussionIn this study, the impact on the recurrence of adenomas and the efficacy and safety of JLJ granules in terms of improving the clinical symptoms of postoperative patients with CRA will be evaluated.Trial registrationTrial registration Chinese Clinical Trial Registry ChiCTR 2100044297. Registered on March 16, 2021

Prevalence of Forceps Polypectomy of Nondiminutive Polyps Is Substantial But Modifiable

The use of forceps for removal of nondiminutive polyps is associated with incomplete resection compared with snare polypectomy. However, few studies have characterized the frequency of forceps polypectomy for nondiminutive polyps or identified strategies to improve this practice. To address this gap, we estimated the prevalence and predictors of forceps polypectomy in clinical practice and examined the effectiveness of a multicomponent intervention to reduce inappropriate forceps polypectomy. We retrospectively reviewed all colonoscopies with polypectomies performed at 2 U.S. health systems between October 1, 2017, and September 30, 2019. We used a mixed-effects logistic regression model to examine the effect of a multicomponent intervention, including provider education and a financial incentive, to reduce inappropriate forceps polypectomy, defined as use of forceps polypectomy for polyps ≥5 mm. A total of 9968 colonoscopies with 25,534 polypectomies were performed by 42 gastroenterologists during the study period. Overall, 8.5% (n= 2176) of polyps were removed with inappropriate forceps polypectomy. Inappropriate forceps polypectomy significantly decreased after the intervention (odds ratio [OR], 0.34, 95% confidence interval [CI], 0.30-0.39), from 11.4% (n= 1539) to 5.3% (n= 637). Predictors of inappropriate forceps polypectomy included inadequate bowel prep (OR, 1.25; 95% CI, 1.06-1.47), polyps in the right colon (vs left: OR, 1.29; 95% CI, 1.09-1.51), and number of polyps removed (OR, 0.96; 95% CI, 0.94-0.97). Inappropriate forceps polypectomy also varied by gastroenterologist (median OR, 3.43). In a post hoc analysis, the proportion of polyps >2 mm removed with forceps decreased from 50.0% before the intervention to 43.0% after it (OR, 0.62; 95% CI, 0.58-0.68). Inappropriate forceps polypectomy is common but modifiable. The proportion of nondiminutive polyps removed with forceps polypectomy should be considered as a quality measure.

Long-term outcomes of cold snare polypectomy for superficial non-ampullary duodenal epithelial tumors.

The effectiveness of cold snare polypectomy (CSP) for superficial non-ampullary duodenal epithelial tumors (SNADETs) regarding long-term outcomes is not fully clarified. This study aimed to investigate long-term outcomes of CSP for SNADETs. Patients diagnosed with sporadic SNADETs and treated with CSP at Chiba University Hospital between March 2015 and May 2018 were retrospectively analyzed. Long-term outcomes, short-term outcomes, and adverse events were investigated. In total, 35 patients with 46 lesions were included. The en-bloc resection rate was 97.8%. Thirty-seven lesions (80.4%) were diagnosed as adenomatous. The R0 resection rate for adenomatous lesions was 70.3%. Follow-up investigations more than 12months after CSP were completed for 35 adenomatous lesions (94.6%). The median observation period after CSP was 48months. One patient whose observation period was only 3months died from chronic heart failure with cardiac sarcoidosis 6months after CSP. No patient died from SNADETs. The relapse-free survival rate at 12months after CSP was 97.1%. One recurrence (2.7%) was observed 12months after CSP. We removed the recurrence lesion with CSP and cold forceps polypectomy. No new recurrence occurred within the observation period. No perforation or post-operative bleeding occurred for CSP. Cold snare polypectomy for diminutive and small SNADETs is a safe and useful procedure with a high en-bloc resection rate and long-term local control capability.

Current status of diagnostic and therapeutic colonoscopy in Japan: The Japan Endoscopic Database Project.

The Japan Endoscopy Database Project was initiated to develop the world's largest endoscopy data repository. This study describes the first phase of the colonoscopy project in Japan. Data were aggregated offline by integrating information from the endoscopy database software from January 2015 through March 2017. The study population included all patients who underwent colonoscopy at eight centers. A total of 31,395 patients who underwent 38,497 colonoscopy procedures were registered. The majority of procedures were performed for screening (n = 14,156), followed by fecal immunochemical test positivity (n = 3960), abdominal symptoms (n = 3864), post-colorectal surgery surveillance (n = 3431), post-endoscopic treatment surveillance (n = 3757), thorough pre-treatment examination (n = 2822), and therapeutic purposes (n = 6507). In the screening group, advanced cancers, early cancers, and adenomas were diagnosed endoscopically in 2.1%, 1.3%, and 28.7% of cases, respectively, while in the fecal immunochemical test-positive group, they were diagnosed in 2.5%, 1.9%, and 41.6% of cases, respectively. The incidence of complications was 0.177% and 0.152% in the screening and fecal immunochemical test-positive groups, respectively. The therapeutic procedures included 1446 cold forceps polypectomy procedures, 4770 cold snare polypectomy procedures, 368 hot biopsies, 2998 hot snare polypectomy procedures, 9775 endoscopic or piecemeal endoscopic mucosal resections, and 1660 endoscopic submucosal dissections. A total of 173 procedure-related complications (0.82%) occurred in 21,017 therapeutic procedures performed in 15,744 patients. The first phase of the Japan Endoscopy Database Project established the proportions of the diagnostic and therapeutic colonoscopy procedures, and complication rates in real-world settings.

Impact of margin status on outcomes after endoscopic resection of well-differentiated duodenal neuroendocrine tumors

Duodenal neuroendocrine tumors (DNETs) are known to have low metastatic potential and follow an indolent course. Although DNETs<1 cm in size are amenable to endoscopic resection, little is known about the long-term outcomes and recurrence rates of this approach. Sixty-three patients with DNETs from 3 centers were retrospectively studied from 2003 to 2018. We analyzed their resection modality (EMR, snare polypectomy, or forceps polypectomy), margin status, risk factors for recurrence, recurrence rate, and endoscopic surveillance patterns. Of the 63 patients who underwent endoscopic resection, 13 (20.6%) had recurrence. The presence of R1 margins was found to be a statistically significant risk factor for recurrence (P= .048). Mean surveillance time for all DNETs was 2.8 ± 2.6 years. Ninety-two percent of recurrences were detected within 3 years of resection. Our data suggest that the main predictor of recurrence in low-grade DNETs<1.0 cm is the presence of positive tumor margins at the initial endoscopic resection. More frequent, earlier surveillance after resection than that currently recommended by European Neuroendocrine Tumor Society guidelines may be warranted to promptly capture DNET recurrences. Additionally, no recurrences occurred in our cohort after 4 years of surveillance.

Endoscopic resection of local recurrences of diminutive polyps by cold forceps polypectomy

Objectives Cold forceps polypectomy (CFP) is an effective treatment for diminutive colorectal polyps. However, polyps occasionally recur, and there is no consensus on their long-term clinical management. Therefore, we investigated the short- and long-term clinical outcomes of re-CFP for recurrent diminutive colorectal polyps. Materials and methods This was a follow-up of a multicenter, prospective study investigating the clinical outcomes of diminutive colorectal polyps excised by CFP with narrowband imaging-enhanced endoscopy and jumbo forceps. We evaluated short-term outcomes of re-CFP and patients at 1-year follow-up post re-CFP for recurrent colorectal polyps to determine long-term recurrence rates. Additionally, complete resection rates, clinicopathological features, number of forceps bites, and rate of short-term adverse events managed by re-CFP were evaluated. Results At 1-year follow-up, local recurrence was identified in 18 patients from the original study. The mean size of local recurrent polyps was 1.5 ± 0.6 mm, and all recurrent lesions were < 3 mm. Re-CFP could successfully excise locally recurrent polyps in all cases. All recurrent lesions were low-grade adenomas; no adverse events were reported. Additionally, 16 of 18 patients were evaluated endoscopically at 2-year follow-up; no recurrence was observed. Conclusions Recurrent lesions following initial CFP were small and pathologically benign, and re-CFP was an effective treatment.

Follow-up of 3 Million Persons Undergoing Colonoscopy in Germany: Utilization of Repeat Colonoscopies and Polypectomies Within 10 Years.

INTRODUCTION:Given the sparsity of longitudinal studies on colonoscopy use, we quantified utilization of repeat colonoscopy within 10 years and the proportion of persons with polypectomies at first repeat colonoscopy using a large German claims database.METHODS:Based on the German Pharmacoepidemiological Research Database, we identified persons who underwent colonoscopy between 2006 and 2015 (index colonoscopy) and assessed colonoscopies and polypectomies during follow-up. We defined 3 subcohorts based on available procedure/diagnosis codes at index colonoscopy: persons with snare polypectomy, which is reimbursable for lesions ≥5 mm in size (cohort 1), with a forceps polypectomy (cohort 2), and without such procedures/diagnoses (cohort 3). We stratified all analyses by diagnostic vs screening index colonoscopy.RESULTS:Overall, we included 3,076,657 persons (cohort 1–3: 15%, 13%, 72%). Among persons with screening index colonoscopy (30%), the proportions with a repeat colonoscopy within 10 years in cohorts 1, 2, and 3 were 78%, 66%, and 43%, respectively, and a snare polypectomy at first repeat colonoscopy was performed in 27%, 17%, and 12%, respectively. In cohort 1, 32% of persons with a (first) repeat colonoscopy after 9 years had a snare polypectomy (after 3 years: 25%). Among persons with diagnostic index colonoscopies, 80%, 78%, and 65% had a repeat colonoscopy, and 27%, 17%, and 10% had a snare polypectomy at first repeat colonoscopy, respectively.DISCUSSION:Our study suggests substantial underuse of repeat colonoscopy among persons with previous snare polypectomy and overuse among lower risk groups. One-quarter of persons with a snare polypectomy at baseline had another snare polypectomy at first repeat colonoscopy.

Evaluation of complete cold forceps polypectomy resection rate for 3- to 5-mm colorectal polyps.

The propriety of cold forceps polypectomy (CFP) using jumbo biopsy forceps for diminutive polyps remains controversial. We conducted a prospective study to evaluate the complete CFP resection rate of 3-5-mm polyps using additional endoscopic mucosal resection (EMR) specimens following CFP. Patients with 3-5-mm protruded or flat elevated colorectal polyps diagnosed endoscopically as adenomas or serrated lesions were prospectively enrolled. CFP using jumbo biopsy forceps was used to remove the eligible polyps and repeated until the absence of residuals were confirmed via image-enhanced endoscopy or chromoendoscopy. After CFP, saline was injected at the defect, and the marginal specimen of the defect was resected using EMR to histologically evaluate the residue. The primary outcome was the complete CFP resection rate, which was defined as no residue at the EMR site. Other outcomes were the number of CFP bites and the complete resection rate by lesion size. Eighty patients with 120 polyps were enrolled. The mean polyp size was 4.1±0.7mm. The overall complete resection rate was 96.7% (95% confidence interval [CI], 91.7-98.7), and the rates for 3-, 4- and 5-mm polyps were 100% (95% CI, 86.7-100), 96.0% (95% CI, 86.5-98.9) and 95.5% (95% CI, 85.1-98.8), respectively. The one-bite CFP rates were 92%, 60% and 31% for the 3-, 4- and 5-mm polyps, respectively. The complete CFP resection rate for 3-5-mm polyps was acceptable, although the one-bite clearance rate decreased as the polyp size increased (UMIN000028841).

S0297 Impact of GI Fellow Participation on Polyp Resection Technique During Screening Colonoscopy

INTRODUCTION: Polypectomy techniques vary widely in clinical practice and are often driven by physician preference due to the lack of standardized training. Recent evidence showed superiority of certain polypectomy techniques over others in terms of safety and rates of complete and efficient resection. Recent USMSTF guidelines recommend cold snare polypectomy for diminutive and small lesions <1 cm while cold forceps resection should be limited to lesions ≤2 mm. Selection of polypectomy technique is affected by several factors. It remains unclear whether participation of GI fellows affects the polypectomy quality of colorectal lesions. We aim to investigate whether the participation of GI fellows at different stages of training affect the selection of polypectomy technique compared to screening colonoscopies performed by attendings without fellows. METHODS: We performed a retrospective review of all patients who underwent a screening colonoscopy at our institution between January 2018 and June 2019. Descriptive statistics were reported as proportions. Categorical variables were compared using Chi-Square test of association with a 95% confidence interval. RESULTS: A total of 895 colonoscopies were reviewed. From 950 polyps resected during the study period, 43.8% were performed with a GI fellow. 96.3% of diminutive polyps ≤2 mm and 39.7% of polyps 3–5 mm were resected using cold biopsy forceps. In addition, 51.1% of small polyps 6–9 mm were removed using a hot snare. Fellow participation lead to significantly less utilization of hot snare polypectomy for 6–9 mm polyps (55.3% vs 44.7%, P < 0.001) but significantly more use of cold forceps polypectomy for 3–9 mm polyps. Cold snare polypectomy rates were comparable between the 2 groups regardless of polyp size. More senior fellows were significantly more likely to use a cold snare for 3–9 mm polyps (P = 0.004). CONCLUSION: Adherence to recent evidence on appropriate polypectomy techniques remains suboptimal in clinical practice regardless of fellow participation. Selection of polypectomy technique by GI fellows appears to be related to endoscopy skill level given more frequent use of cold forceps polypectomy and less frequent use of hot snare polypectomy compared to GI attendings. Standardized training with adherence to USMSTF recommendations should be emphasized during fellowship training for complete and safe removal of colorectal lesions in order to optimize prevention of colorectal cancer in the future.