Polypectomy Site Research Articles

Endoscopic Ultrasound Findings of Colitis Cystica Profunda With Literature Review

Introduction: Colitis Cystica Profunda (CCP) is a rare benign disease of the colon and rectum of uncertain etiology. Its recognition is important since it often mimics malignant processes. We review a case of CCP in a 50-year-old patient, with emphasis on endoscopic ultrasound findings and present review of the current literature. Case description: 50-year-old male with no past medical history was referred to our institution for further evaluation of a large multilobulated mass in the left proximal colon found on screening colonoscopy. We performed colonoscopy with endoscopic ultrasound and fine needle aspiration and snare polypectomy. Colonoscopy up to the transverse colon revealed a large multilobulated submucosal mass with normal overlying mucosa that extends from 50 cm to 70 cm from the anal verge (fig.1). The endosonographic examination revealed anechoic, round, well demarcated lesions with a hyperechoic rim and hypoechoic foci within (fig.2). They were located within the deep mucosa and submucosal layer. The muscularis propria was intact. The largest submucosal lesion measured 18.6 mm x11.4 mm. Small amount of fluid was aspirated by FNA from two lesions. Snare polypectomy of one of the lesions was then performed. The polypectomy site was closed with two endoclips. Histological examination showed multinucleate giant cells in a background of benign colonic elements and mucin consistent with a diagnosis of CCP. Discussion: CCP is an uncommon benign entity that mimics malignancy on endoscopic views but histologically characterized by mucin-filled cysts beneath the muscularis mucosa. It can present in a localized form with a polypoid lesion or more diffusely along the gastrointestinal tract. Endoscopically, CCP are polypoid lesions covered by normal, edematous or ulcerated mucosa. There are few case reports of the endosonographic features of CCP. They were described as hypoechoic or anechoic lesions involving the mucosa or submucosa, with areas of echorefringent fibrosis between lesions by Hulsmans, F.J., et al. In another case report by Sultan et al. the EUS findings of CCP were described as hypoechoic lesion with cystic/spongy features involving the mucosa and submucosa. Our case depicted similar features of well demarcated mucosal and submucosal anechoic lesions with hypoechoic foci surrounded by hyperechoic rim. Colonic EUS can be a useful tool to assist in establishing the diagnosis of CCP.Figure: Colonoscopy showing large multilobulated submucosal mass with overlying normal looking mucosa.Figure: Endosonographic imaging showing anechoic, round, well demarcated lesions.

Polypectomy for complete endoscopic resection of small colorectal polyps

Small colorectal polyps are encountered frequently and may be incompletely removed during colonoscopy. The optimal technique for removal of small colorectal polyps is uncertain. The aim of this study was to compare the incomplete resection rate (IRR) by using EMR or cold snare polypectomy (CSP) for the removal of small adenomatous polyps. This was a prospective randomized controlled study from a tertiary-care referral center. A total of 358 patients who satisfied the inclusion criteria (polyp sized 6-9mm) were randomized to the EMR (n=179) and CSP (n=179) groups, and their polyps were treated with conventional EMR or CSP, respectively. After polypectomy, an additional 5 forceps biopsies were performed at the base and margins of polypectomy sites to assess the presence of residual polyp tissue. The EMR and CSP samples were compared to assess the IRR. Among a total of 525 polyps, 415 (79.0%) were adenomatous polyps, and 41 (16.4%) were advanced adenomas. The overall IRR for adenomatous polyps was significantly higher in the CSP group compared with the EMR group (18/212, 8.5% vs 3/203, 1.5%; P= .001). Logistic regression analysis revealed that the CSP procedure was a stronger risk factor for the IRR (odds ratio [OR] 6.924; 95% confidence interval [CI], 2.098-24.393; P= .003). In addition, piecemeal resection was the most important risk factor for the IRR (OR 28.696; 95% CI, 3.620-227.497; P= .001). The mean procedure time for polypectomy was not significantly different between the EMR and CSP groups (5.5 ± 2.7 vs 4.7 ± 3.4 minutes; P= .410). None of these patients presented with delayed bleeding. There were no severe adverse events related to the biopsies. EMR was significantly superior to CSP for achieving complete endoscopic resection of small colorectal polyps. Patients with piecemeal resection of polyps had a higher risk for incomplete resection. (Clinical trial registration number: Hongwei-1102-12.).

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Pathology Standards and Datasets.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Pathology Standards and Datasets.

Su1615 Endoscopic Characteristics That Influence Postpolypectomy Bleeding in Consecutive 407 Pedunculated Colonic Polyps, a Retrospective Study

Polypectomy is a standard method for removal of colonic pedunculated polyp. Postpolypectomy bleeding is the most common complication in this polyp and bleeding rate is much higher than other morphological polyp. However, only limited data is available regarding endoscopic and patient’s characteristics related with postpolypectomy bleeding in this polyp. Furthermore, although prophylactic closure of polypectomy sites with clips or endoloop has rarely been studied to reduce postpolypectomy bleeding, effectiveness and safety for postpolypectomy syndrome are still not well known.

Risk for Incomplete Resection after Macroscopic Radical Endoscopic Resection of T1 Colorectal Cancer: A Multicenter Cohort Study.

The decision to perform secondary surgery after endoscopic resection of T1 colorectal cancer (CRC) depends on the risk of lymph node metastasis and the risk of incomplete resection. We aimed to examine the incidence and risk factors for incomplete endoscopic resection of T1 CRC after a macroscopic radical endoscopic resection. Data from patients treated between 2000 and 2014 with macroscopic complete endoscopic resection of T1 CRC were collected from 13 hospitals. Incomplete resection was defined as local recurrence at the polypectomy site during follow-up or malignant tissue in the surgically resected specimen in case secondary surgery was performed. Multivariate regression analysis was performed to analyze factors associated with incomplete resection. In total, 877 patients with a median follow-up time of 36.5 months (interquartile range 16.0-68.3) were included, in whom secondary surgery was performed in 358 patients (40.8%). Incomplete resection was observed in 30 patients (3.4%; 95% confidence interval (CI) 2.3-4.6%). Incomplete resection rate was 0.7% (95% CI 0-2.1%) in low-risk T1 CRC vs. 4.4% (95% CI 2.7-6.5%) in high-risk T1 CRC (P=0.04). Overall adverse outcome rate (incomplete resection or metastasis) was 2.1% (95% CI 0-5.0%) in low-risk T1 CRC vs. 11.7% (95% CI 8.8-14.6%) in high-risk T1 CRC (P=0.001). Piecemeal resection (adjusted odds ratio 2.60; 95% CI 1.20-5.61, P=0.02) and non-pedunculated morphology (adjusted odds ratio 2.18; 95% CI 1.01-4.70, P=0.05) were independent risk factors for incomplete resection. Among patients in whom no additional surgery was performed, who developed recurrent cancer, 41.7% (95% CI 20.8-62.5%) died as a result of recurrent cancer. In the absence of histological high-risk factors, a 'wait-and-see' policy with limited follow-up is justified. Piecemeal resection and non-pedunculated morphology are independent risk factors for incomplete endoscopic resection of T1 CRC.

Pateʼ or Perforation: A Transcolonic Liver Biopsy?

A 68 year old woman underwent screening colonoscopy. The cecum was reached, but residual stool was present throughout the colon. A total of 7 sessile polyps ranging from 5-8 mm were removed successfully using hot snare polypectomy between the ascending colon and splenic flexure. One additional multilobulated polyp 2 cm in diameter was removed from the proximal transverse colon with a hot snare. Post-procedure recovery was routine, and the patient was asymptomatic at discharge. Three days later, the attending pathologist called after initial specimen review. She announced hepatic tissue was present on the third specimen, a proximal ascending colon polyp, and suggested the patient had transcolonic sampling of her hepatic parenchyma. The patient was called and reported mild upper abdominal discomfort. She denied any fever, chills or abdominal distention, and was tolerating a normal diet while passing flatus and stool. On further questioning, she noted her pre-procedure diet included liver ingested a few days before the colonoscopy. Given concern for an unrecognized perforation, she was advised to go to the emergency department, where a CT scan showed no evidence of perforation or bleeding and she was discharged home. Complete review of all pathology specimens demonstrated no evidence of hepatic parenchyma on any other slides. A literature search revealed no cases where hepatic injury occurred during colonoscopy as a result of transmural passage of polypectomy tools. Images from the colonoscopy report were reviewed and demonstrated no evidence of a tissue defect at any polypectomy site. This information, combined with the lack of thermal injury seen on the liver specimen, led to decreased concern for transcolonic hepatic biopsy. Another possibility, contamination with a liver biopsy prepared in the same laboratory, was deemed less likely given review of records showing no liver biopsies on the processing date. To assess the final possibility, ingested animal liver retained in the colon due to incomplete preparation, the attending pathologist obtained the patient's recipe and prepared the same dish. Raw and cooked samples of this liver were sectioned for review. Neither sample had an appearance similar to the findings on the colonic specimen. While the true origin of the colonic liver specimen is unknown, this case highlights the importance of a thorough investigation when unexpected pathology findings occur during routine endoscopy.Figure 1Figure 2

Colon in and Polyp Out

Introduction: Tagged red blood cell (RBC) scan has a limited but unique role in the evaluation of overt gastrointestinal bleeding. We present a case where a patient was offered total colectomy at an outside hospital solely based on a tagged RBC scan that suggested a major colonic bleed, when in fact the bleeding was from a duodenal polyp on enteroscopic evaluation. Case Report: 87 year old man with a history of Billroth II surgery for a bleeding peptic ulcer in the 1980s was transferred for further evaluation of gastrointestinal bleeding. He had history of dark stools for 3 weeks. At outside facility, a tagged RBC scan was performed that identified the bleed was localized to his left upper quadrant. An endoscopy was not performed, instead a colectomy was offered. Upon his refusal to surgery, he was transferred to our facility. On our examination, the patient had melena. An esophagogastroduodenoscopy was performed that revealed Billroth II anatomy and a 2cm bleeding polyp with a thick stalk in the afferent limb. A snare-cautery polypectomy was performed. The pathology revealed that the polyp was a benign polypoid duodenal vascular malformation. The tagged RBC scan was later reviewed with radiology, which showed two areas of tracer activity. One was near the mid-abdomen, which corresponded to the polypectomy site, and the other was in the left upper quadrant, which was suspicious of a simultaneous colonic bleed. The next day a colonoscopy was performed which showed only melenic stool in the splenic flexure without evidence of an active bleed. Discussion: Tagged RBC scan has many merits but it does have significant drawbacks as well. Chief among them are non-localization and erroneous localization of bleeding. In a retrospective studyinvolving80 patients, tagged RBC scans were positive in 36% of overt GI bleed cases and negative in 64% cases. Among the positive cases, 10% were determined to be “incorrect positive” and led to incorrect surgeries in 5 out of 8 cases, 15% cases were “truly positive”, and 11% were “unconfirmed positive”. This led to a positive predictive value of 41%. Among the negative cases (64%), 21% were “false negatives” and 34% were “unconfirmed negative”. Its accuracy diminished proximally, with more false negatives reported, when bleeding was in the gastroduodenal region. Conclusion: Results of RBC scan should be interpreted with caution with endoscopic correlation.Figure 1Figure 2Figure 3

Reporting the Rarest of Rare! Duodenal Adenocarcinoma in a Patient with Prior Rectal Adenocarcinoma

Multiple GI malignancies in the same patient have been reported in literature. However, metachronous duodenal adenocarcinoma in a patient with prior rectal adenocarcinoma has been very rarely described. 50 year old black male with PMH of SCC head and neck status post radiation therapy underwent a colonoscopy for positive FOBT. Findings included an ascending colon polyp (tubular adenoma with focal surface high grade dysplasia - unclear margins), a splenic flexure polyp (tubular adenoma with focal surface high grade dysplasia, extending within 1 mm of the cauterized margin) and a rectal polyp (consistent with invasive, moderately differentiated adenocarcinoma extending into the submucosa). PET scan was negative for nodal or distant metastasis. EUS revealed stageT2 N0 disease. Patient was referred for surgery to a different hospital. Repeat colonoscopy showed residual ascending colon polyp (benign pathology). Biopsies from prior rectal polypectomy site were benign. EUS did not reveal any rectal lesion or lymphadenopathy. In light of discordant EUS findings, the patient and surgeon opted for transanal minimally invasive laparoscopic resection of rectal lesion for diagnostic and therapeutic purposes. Pathology revealed focal adenomatous change with negative margins. A month later the patient was re-admitted with nausea, vomiting, abdominal pain and poor oral intake. CT abdomen was normal. EGD was unremarkable till the second portion of duodenum. A small bowel follow through showed markedly dilated stomach and duodenum with a transition point at the ligament of Treitz. Push enteroscopy revealed an obstructing polypoid mass in third portion of duodenum. Biopsies were consistent with invasive adenocarcinoma. Whipple's procedure was performed. Two months later, he returned with similar symptoms. CT abdomen revealed innumerable metastases to liver, lymphadenopathy, and phlegmonous inflammatory changes within abdomen. Patient elected home hospice. Because of their rarity, indifferent symptomatology, and diagnostic elusiveness, small bowel tumors are often missed or diagnosed and treated late in their course with correspondingly poor results. The diagnostic difficulty is compounded when these tumors arise metachronously in patients with treated colorectal cancers. High index of suspicion coupled with effective communication between gastroenterologists, radiologists, surgeons and pathologists is essential in appropriate management of these patients.

Complication of endoscopic tattooing: a case report of covered perforation

Laparoscopy is considered a good approach in treatment of colorectal neoplastic diseases; the endoscopic tattooing is then recommended (Evidence Level III and grade of recommendation A) to mark a lesion or a polypectomy site for intraoperative identification. We describe the case of perforation after tattoing treated conservatively. 63 years old woman, underwent colonoscopy for lipoma tattooing with India ink SPOT® solution kit and saline test. Immediately after the procedure the patient has been referred the appearance of colic epi-mesogastric pain and fever; Computed Tomography (CT) without MDC identified an irregular thickening of transverse colon with some microbubbles compatible with focal peritonitis. Initial paralytic ileus was present too. The blood count and metabolic panel examinations reveal a neutrophil leucocytosis (WBC: 11.000/mmc, 80% neutrophils). On the base of WSES sepsis severity score and recent literature patient was treated conservatively with total parenteral nutrition, and intravenous antibiotic therapy. After the resolution of fever and reactivation of peristalsis. The discharge occurred after six days with no early complications. India ink tattooing with SPOT® solution kit and saline test represent the first choice. It is a feasible technique although perforation is a possible complication. It may need an immediately surgical operation but in most cases a conservative management is a good and safe tool even if surgery may be attempted too.

Development of a murine colonoscopic polypectomy model (with videos)

Colonoscopy provides a means for screening and removal of colon adenomas, preventing such lesions from progressing to late-stage carcinoma. No preclinical model currently exists that closely parallels the clinical scenario with respect to polyp resection and recovery after endoscopy. When we used the polyposis in rat colon (Pirc) model, a new polypectomy methodology was developed. A novel PLC classification system (polyp number/location/clockwise orientation) also was devised in order to accurately and reproducibly specify the location of each lesion within the colon. One week after surgery, injuries to the polypectomy site were confined to the submucosa, indicating that little or no damage occurred to the inner muscle layer of the colon. Polypectomy sites occasionally continued to show ulcer formation, whereas others exhibited tissue regeneration. A pilot study (n= 6 animals), involving a total of 37 polypectomies, confirmed that the new methodology could be applied by using either air insufflation or water-assisted techniques, with either hot or cold snare. As a general observation, polyps tended to be more fully distended and less flattened against the colon mucosa by using the water-assisted protocol, increasing the technical ease of ensnaring and resecting lesions. The PLC system proved to be straightforward and facilitated longitudinal studies by allowing the investigator to track each polypectomy site on repeated examination. The Pirc model was ideally suited to colonoscopy with polypectomy. Because the main cause of morbidity in the Pirc model is blockage of the colon, polypectomy can be used as a preventive strategy and will likely facilitate long-term investigations of single agent and combination therapies with potential direct clinical relevance.

An Incidental Finding of Rectal Carcinoid Tumor

Adenocarcinoma is the most common malignancy found in the rectum. However, the incidence of rectal carcinoid has been rising after implementation of screening colonoscopy. The rectum is the second most common anatomic site for carcinoid tumor. Embryologically, rectal carcinoids are hindgut tumors which are non secretory. Hence, they rarely present with carcinoid syndrome even in patients with metastatic disease. A recent systematic review of rectal carcinoid by McDermott et.al was unable to perform a metaanalysis on optimal treatment strategies for localized and widespread disease due to the wide variety of data recorded from various sources. Our aim is to make physicians aware that the rectal carcinoid is becoming a common diagnosis thus clinicians should have current knowledge of classification, management and treatment options available. A 62-year-old African American male with a significant past medical history of hypertension and tobacco abuse presented to the gastrointestinal (GI) lab for colorectal cancer screening colonoscopy. Patient had no specific GI complaints and a 10-point review of symptoms was unremarkable except for decreased exercise tolerance. Physical examination was unremarkable including digital rectal exam. During colonoscopy, a 7-10 mm firm polypoid submucosal lesion was noted in distal rectum and was resected using an electrocautery snare and ERBE endocut current. Histologic evaluation of the resected polyp demonstrated a well-differentiated neuroendocrine neoplasm that stained positive for chromogramin, synaptophysin, and Ki-67 proliferation marker. Patient underwent repeat colonoscopy about a month later. Biopsy obtained from previous polypectomy site was negative for carcinoid tumor cells. The rectal carcinoid classification, management and treatment options have been defined based on the size and aggressiveness of the lesion. As there is no defined TNM system classification, there is no homogenous data available yet on how to manage rectal carcinoid. Treatment strategy is based on tumor size, radiologic testing and surveillance examination including use of rectal EUS.Figure 1

A prospective randomized comparative study of cold forceps polypectomy by using narrow-band imaging endoscopy versus cold snare polypectomy in patients with diminutive colorectal polyps

A previous study reported that cold snare polypectomy (CSP) was superior to cold forceps polypectomy (CFP) for the removal of diminutive colorectal polyps (DCPs) (≤5 mm) when the techniques were assessed for completeness of resection. However, completeness is expected to be greater with CFP when strict investigation of the remnant polyp is performed. The aim of this study was to assess the efficacy of CFP with narrow-band imaging (NBI) evaluation of polypectomy sites for removal of DCPs, compared with CSP. This was a randomized, controlled, noninferiority trial at a tertiary-care referral hospital. Of the 380 patients screened, 146 patients with 231 DCPs were enrolled. CFP was used to resect DCPs until no remnant polyp was visible by NBI endoscopy. The primary noninferiority endpoint was histologic eradication of polyps, with a noninferiority margin of -10%. A size of >3 mm was seen in 129 polyps (55.8%). The overall rates of histologic eradication were 90.5% in the CFP group and 93.0% in the CSP group (difference, 2.5%; 95% confidence interval [CI], -9.67 to 4.62). However, when confined to the polyps >3 mm, the histologic eradication rate was 86.8% and 93.4% (95% CI, -17.2 to 3.6), respectively. Polyp size, histology, location, and time taken for polypectomy did not differ between the groups. The failure rate of tissue retrieval was higher in the CSP than in the CFP group (7.8% vs 0.0%, respectively; P =.001). In this study, >90% of all DCPs were completely resected by using CFP with NBI evaluation of polypectomy sites, showing noninferiority compared with CSP. However, in polyps measuring >3 mm, CFP failed to show noninferiority versus CSP. CFP appears to be the proper method for resection of DCPs 1 to 3 mm in size if no remnant polyp is visible by NBI endoscopy, but CFP is likely to be insufficient for larger polyps. ( NCT02201147.).

PTH-316 Management of colorectal polyp cancers: Abstract PTH-316 Table 1

Introduction Management of colorectal polyp cancers is variable, with no clear consensus on whether endoscopic mucosal resection (EMR) or local resection is optimal. We studied the outcome of 42 patients with colorectal polyp cancers in our hospital over a 3year period. Method 42 cases of malignant colorectal polyps between May 2012 and May2014 were identified retrospectively from the histology database. Data was collected on polyp morphology and histology including resection margin, tumour grade, lymphovascular invasion and Haggitt/Kikuchi level of invasion. All specimens were examined by a single histopathologist. Adverse oncological outcome was defined as residual tumour at the polypectomy site and/or lymph node metastases in the surgical group and local/distant recurrence in the surveillance group. Post operative morbidity and method and timing of surveillance were documented. Results 42 polyps (22 male and 20 female patients, mean age: 68 years, range: 33 to 90 years) were included. 59% of polyps appeared pedunculated at endoscopy with 27% sessile and 14% described as a “lesion.” 5 patients had radiological evidence of metastases. 43% of tumours were visible on imaging with 19% having mesorectal/presacral nodes. 13 patients underwent colonic resection. 8 of those had pedunculated polyps, 5 had sessile polyps. In 7 patients who underwent colectomy, polypectomy or EMR had been performed. Morbidity included 3 stomas (all reversed), 2 anastomotic leaks, 1 wound infection and 1 high output stoma. There were no deaths. Endoscopic resection was the sole treatment in 29 patients; 7 patients with sessile polyps, 17 patients with pedunculated polyps and 5 with “lesions.” Follow up was by imaging only in 15 patients, endoscopy only in 9 patients and a combination of imaging and endoscopy in 11 patients. 6 patients had no follow up. Conclusion This study illustrates the varied management of malignant colorectal polyps. It is clear that resection margins adversely affect outcome. A strategy is needed for managing patients with clear resection margins, including nature and timing of follow up. Disclosure of interest None Declared. References Williams J. G, et al . Managament of the Malignant colorectal polyp: ACPGBI position statement. Colorectal Dis. 2013;15:1–38 Naqvi S, et al . Management of colorectal polyp cancers. Ann R Coll Surg Engl. 2012;94:574–578

PWE-276 High-frequency mini-probe ultrasound as a useful adjunct in surveillance of patients after excision of malignant colorectal polyps

Introduction Colorectal polyps with a focus of malignancy, identified postpolypectomy, pose a management challenge of whether endoscopic treatment is adequate or whether further surgical resection is required. This study assessed 12- and 20-MHz colonoscopic ultrasound to evaluate the presence of residual disease and local lymph nodes. Method Consecutive cases of all colorectal polyps with a focus of malignancy were included. Colonoscopic high-frequency ultrasound was performed (20-MHz mini-probes for residual polyps and 12-MHz ultrasound for local lymph nodes) in the region of previous polypectomy. Biopsies were taken of the polypectomy site if any abnormalities were seen. Results Fifty malignant polyps (sigmoid, n = 19; rectum, n = 25; descending colon, n = 1; transverse colon, n = 1; hepatic flexure, n = 2; ascending colon, n = 1; and caecum, n = 1) were identified. 3 were neuroendocrine tumours and 47 were invasive adenocarcinomas; 9 were intramucosal and 38 were submucosal (seven sm1 lesions in the upper third of the submucosa; 11 sm2 lesions in the middle third of the submucosa, seven sm3 lesions in the lower third of the submucosa, one Haggitt level 1, one Haggitt level 2, two Haggitt level 3 and 9 with an unspecified submucosa level). Two patients had T2 tumours extending into the muscularis propria. Excision was histologically complete in 31 patients, five had involved margins and histology was uncertain in fourteen owing to diathermy artefacts or piecemeal resections. High-frequency 12- and 20-MHz ultrasound imaging was normal in 40 patients and four had changes either subsequently proved to be scar related or due to minor benign polyp recurrence. At the time of writing, 39 (89%) of the 44 patients were disease free without further surgery. Five of the 21 patients underwent surgery, despite normal high-frequency ultrasound findings, because of submucosal invasion (sm1 or sm2) and uncertain completeness of resection. The specimens were free of cancer in all five patients. Conclusion High frequency mini probe ultrasound is feasible in the colon and rectum for the assessment of the polypectomy site post endoscopic resection of malignant polyps. Definitive management cannot be exclusively based on the ultrasound findings but this may act as a useful adjunct to histology in providing a more complete prediction of poorer prognosis. Disclosure of interest None Declared.

Portal Hypertensive Polyposis: A Consequence of Esophageal Variceal Ligation?

A 59-year-old man with history of nonalcoholic steatohepatitis (NASH) cirrhosis and portal hypertension with previous esophageal variceal ligation presented with 2 days of melena and fatigue. He was taking 20 mg of propranolol 3 times per day. Hemoglobin was 7 g/dL and platelets were 59,000/L. Esophagogogastroduodenostomy (EGD) performed 1 year earlier revealed large distal esophageal varices requiring ligation with 5 bands and gastritis located in the antrum. EGD during this admission revealed small distal esophageal varices, as well as 3 large polyps and many small polyps in the distal body and antrum (Figures 1 and 2). The large polyps were resected via hot snare polypectomy (Figure 3). Two hemoclips were applied to 1 polypectomy site and argon plasma coagulation ablation was performed for the base of the largest polyp. Histopathologic examination of the polyps revealed hyperplastic-like gastric polyps with marked foveolar hyperplasia with cystic dilations, edematous and fibrotic stroma, a prominent capillary proliferation in the lamina propria, and scattered telangiectactic vessels, consistent with portal hypertensive polyposis (PHP).

Cold snare polypectomy versus cold forceps polypectomy for diminutive and small colorectal polyps: a randomized controlled trial

The optimal technique for removal of diminutive or small colorectal polyps is debatable. To compare the complete resection rates of cold snare polypectomy (CSP) and cold forceps polypectomy (CFP) for the removal of adenomatous polyps≤7mm. Prospective randomized controlled study. A university hospital. A total of 139 patients who were found to have≥1 colorectal adenomatous polyps≤7mm. Polyps were randomized to be treated with either CSP or CFP. After the initial polypectomy, additional EMR was performed at the polypectomy site to assess the presence of residual polyp tissue. Absence of residual polyp tissue in the EMR specimen of the polypectomy site was defined as complete resection. Among a total of 145 polyps, 128 (88.3%) were adenomatous polyps. The overall complete resection ratefor adenomatous polyps was significantly higher in the CSP group compared with the CFP group (57/59, 96.6% vs 57/69, 82.6%; P= .011). Although the complete resection rates for adenomatous polyps≤4mm were not different (27/27, 100% vs 31/32, 96.9%; P= 1.000), the complete resection rates for adenomatous polyps sized 5 to 7mm was significantly higher in the CSP group compared with the CFP group (30/32, 93.8% vs 26/37, 70.3%; P= .013). Single-center study. CSP is recommended for the complete resection of colorectal adenomatous polyps≤7mm. ( NCT01665898.).

The Use of Hemospray® in Refractory Post-Polypectomy Bleeding From a Large Antral Polyp

SymbolIntroduction: The management of refractory upper gastrointestinal bleeding (UGIB) despite exhaustive use of conventional techniques is a challenge. A novel technology that has recently emerged is Hemospray® (Cook Medical), which is licensed in Canada and Europe for the management of non-variceal upper gastrointestinal bleeding. We present a case of Hemospray® in the treatment of refractory UGIB after removal of a large antral polyp.SymbolCase Report: A 77-year-old man with a past medical history of systolic heart failure requiring a HeartMate II left ventricular assist device presented to our emergency room with one week of melena. Esophagogastroduodenoscopy (EGD) showed an actively oozing 2 cm sessile polyp in the antrum. Initial hemostasis was attempted using 7 mL of epinephrine (1:10,000) and the polyp was removed with hot snare polypectomy. The post-polypectomy site was treated with argon plasma coagulation (APC) and three hemostatic clips. At discharge, he had no further episodes of bleeding and both his aspirin and warfarin were held. After 35 days post-discharge, his warfarin was restarted. However, 10 days later he had two episodes of melena. His EGD showed the post-polypectomy site with active oozing and no visible vessel. This site was injected with 3ml of epinephrine (1:10,000) and a hemostatic clip was applied. Four days later, he developed an acute episode of melena. Repeat EGD demonstrated blood in the gastric antrum with previous clip still in place and a fresh clot with active oozing at the polypectomy site. Cauterization was performed and five hemostatic clips were placed to achieve hemostasis. He was eventually discharged after his hemoglobin stabilized and no further evidence of active bleeding. Fourteen days after discharge, he returned with weakness, hemoglobin drop and melena. Again, his EGD showed an adherent clot and active oozing at the polypectomy site. One Ovesco® “bear trap” clip was placed at the polypectomy site but there was continual oozing. He received numerous rounds of APC but the bleeding persisted. Given that he failed conventional endoscopic therapies and was not a candidate for interventional radiology treatment, Hemospray was attempted. After Hemospray® was applied to the polypectomy site, there was no further evidence of active bleeding or oozing. He was monitored for several days and eventually discharged with stable hemoglobin and no additional episodes of bleeding. Conclusion: This case highlights the novel application of Hemospray® and its effectiveness in achieving acute hemostasis in a patient with refractory post-polypectomy bleeding from a large antral polyp. To date, there have only been 15 cases of its use in the United States.

Early Detection and Non-surgical Treatment of Squamous Cell Carcinoma of the Esophagus

Introduction: Squamous cell carcinoma of the esophagus, despite decreasing in incidence in the U.S. in relation to adenocarcinoma, is still a very devastating diagnosis. Due to symptoms such as dysphagia and odynophagia not occurring until greater than 60% of the esophageal circumference is infiltrated, these are often diagnosed late in their course. The presentations of the lesions on endoscopy are often very minute, stressing the value of vigilance and a low threshold for biopsy. The patient was a 76-year-old Caucasian male with a history of hypertension, coronary artery disease, COPD, and PUD with anemia and heme-positive brown stool. He also had an extensive history of tobacco and alcohol abuse, as well as a family history of various GI malignancies. On EGD, he was found to have a 2-mm gastric polyp that came back as adenomatous with focal intestinal metaplasia. On repeat EGD 2 years later, the polypectomy site was unremarkable, but there was a small area of erythema in the mid-esophagus that was biopsied. This biopsy showed squamous cell carcinoma. After the initial finding of squamous cell carcinoma was confirmed by 2 pathologists, the patient was sent for CT scan to evaluate for distal metastasis and for EUS to complete staging. The CT was negative for distant metastases. The EUS showed extension into the submucosa, but not the adventitia with no lymphadenopathy. Throughout this work-up, he remained asymptomatic from a GI standpoint. Despite the recommendations of a cardiothoracic surgeon, the patient chose to forgo resection and trial chemotherapy and radiation. He was treated with 5FU, leucovorin, and radiation therapy. The patient had good response to treatment and was cancer-free for 3 years when he was found to have thickening of the esophagus with biopsy showing squamous carcinoma. He was treated with Taxotere and carboplatin, and remained cancer-free until his death of an MI 7 years later. Throughout this patient’s course, he remained free of GI symptomatology.Figure 1: (A) Erythematous esophageal lesion at 30 cm from the incisors (arrow), visualized by EGD on July 12, 1999, with biopsy results of in situ squamous cell carcinoma. (B) Repeat EGD 1year following treatment showing a small non-bleeding possible vascular ectasia (arrow), 30 cm from the incisors.

Hemospray for Refractory Gastrointestinal Bleeding: Initial United States Experience

Introduction: Endoscopic interventions including injection of epinephrine, bipoloar coagulation, clipping and argon plasma coagulation have revolutionized the endoscopic breadths of managing acute gastrointestinal bleeds(GIB). Hemospray, a novel technology used for the management of acute GIB allows for further capabilities in achieving endoscopic hemostasis. The aim of this study is to show the initial United States (U.S.) experience of hemospray for intractable GIB. Methods: Hemospray is a hemostatic spray (Cook Medical) used for the management of upper GIB (non-variceal) in Canada and Europe. Hemospray is not currently approved in the U.S., unless it is being utilized for compassionate use. A powder spray is spread evenly over the bleeding surface via a catheter passed through the endoscope and combines with water, creating a barrier which allows for hemostasis. We performed a 10 center retrospective study evaluating the use of hemospray for control of acute GIB. Results: A total of 10 cases were included, dating from February 2012 to March 2014. The mean age of subjects in our study was 59 (range 13-77). Indications for the use of hemospray included bleeding from peptic ulcer, ulcers at previous polypectomy site, ulcerated kaposi’s sarcoma, herpes virus infection causing mucosal damage, metastatic rhabdomyosarcoma, pancreatic cancer invasion into the stomach, neuroendocrine tumor invading the jejunum, ulcerated gastrointestinal stromal tumor and renal cell carcinoma invasion of the duodenum. Location of bleeding included the esophagus, gastric antrum, gastric cardia, gastric body, duodenum (2nd portion) and jejunum (at the level of previous choledochojejunostomy from previous Roux-en-y whipple resection of pancreas). All cases were evaluated endoscopically after the clinical presentation revealed sequelae of acute blood loss from the gastrointestinal tract. The endoscopic evaluations revealed active oozing in the majority of the cases (80%), presence of fibrin plug (10%) and presence of multiple vessels without active bleeding (10%). All cases had previous attempts with alternative hemostasis techniques which included APC, embolization, clipping, bipolar coagulation and epinephrine without success. Hemospray was used alone in 80% of the cases and used in conjunction with epinephrine injection in one case and an over the scope clip in another. Acute hemostasis was achieved in all cases. Acute rebleed occurred in three of the ten cases within 7 days post-procedure. No adverse events were reported. Conclusion: Hemospray is a safe and effective mechanism used to achieve acute hemostasis for the management of GIB not controlled by traditional methods. This is the largest US study evaluating this novel technology to treat acute, life threatening GIB. Disclosure - Seth A. Gross, MD - Consultant: Cook Medical. *Our study has been reviewed by the Conflict of Interest Committee at NYU in order to obtain IRB approval. We are happy to share the letter written by this committee which was required for IRB approval.

Results of a Standardized Endoscopic Approach to Resection of Polyps >20 mm

Results of a Standardized Endoscopic Approach to Resection of Polyps >20 mm