post-EMR Bleeding Research Articles

Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial

Background and aimsConventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With...

A119 ACUTE COLONOC PSEUDO-OBSTRUCTION AFTER ENDOSCOPIC RESECTION OF A FULLY CIRCUMFERENTIAL LARGE NON-PEDUNCULATED COLORECTAL POLYP

Abstract Background Complex large non-pedunculated colorectal polyps (LNPCPs), including those involving the full circumference of the bowel, are now readily managed by minimally invasive endoscopic resection techniques. Established procedure-related adverse events include sedation related adverse events, deep mural injury, clinically significant post-resection bleeding, delayed perforation and serositis. An appreciation for potential procedure-related adverse events is critical to the effective implementation of these techniques. Aims To describe a case of acute colonic pseudo-obstruction after endoscopic resection of a fully circumferential LNPCP. Methods Case report and review of the literature Results A 91-year-old male with a history of atrial fibrillation, chronic kidney disease and suspected McKittrick-Wheelock syndrome underwent successful endoscopic mucosal resection (EMR) of a 100mm fully circumferential LNPCP in the sigmoid colon. Histopathology diagnosed a tubulovillous adenoma with high-grade dysplasia. After elective admission, he suffered from clinically significant post-EMR bleeding requiring 2 units of packed red blood cells. On post-operative day 1 he began to suffer from nausea, abdominal pain and obstipation. On examination, he was visibly distended. Abdominal X-ray revealed extensive gas-filled loops of small and large bowel with the absence of gas in the rectum. He was managed conservatively with nasogastric tube decompression. Total duration of hospital stay was 9 days. Conclusions Critical to the continued expansion of minimally invasive endoscopic resection techniques is an awareness for potential procedure-related adverse events. To our knowledge this is the first description of acute colonic pseudo-obstruction after endoscopic resection Funding Agencies None

Can we stop routine biopsy of post-endoscopic mucosal resection scars?

Endoscopic mucosal resection (EMR) is internationally accepted as the gold standard, first-line intervention for large nonpedunculated colorectal polyps. The technique has been incrementally refined over the past decade to allow safe and effective removal of large nonpedunculated colorectal polyps in all areas of the colon, including challenging locations such as the anorectal junction or ileocecal valve. Safety issues have been addressed with techniques to reduce the risks of clinically significant post-EMR bleeding and deep mural injury. Outcomes have also been improved with strategies to detect and predict submucosal invasion so that the optimum resection approach can be chosen [1].

Post-EMR for colorectal polyps, thermal ablation of defects reduces adenoma recurrence: A meta-analysis.

Background and study aims Adenoma recurrence is one of the key limitations of endoscopic mucosal resection (EMR), which occurs in 15 % to 30 % of cases during first surveillance colonoscopy. The main hypothesis behind adenoma recurrence is leftover micro-adenomas at the margins of post-EMR defects. In this systematic review and meta-analysis, we evaluated the efficacy of snare tip soft coagulation (STSC) at the margins of mucosal defects to reduce adenoma recurrence and bleeding complications. Methods Electronic databases such as PubMed and the Cochrane library were used for systematic literature search. Studies with polyps only resected by piecemeal EMR and active treatment: with STSC, comparator: non-STSC were included. A random effects model was used to calculate the summary of risk ratio and 95 % confidence intervals. The main outcome of the study was to compare the effect of STSC versus non-STSC with respect to adenoma recurrence at first surveillance colonoscopy after thermal ablation of post-EMR defects. Results Five studies were included in the systematic review and meta-analysis. The total number patients who completed first surveillance colonoscopy (SC1) in the STSC group was 534 and in the non-STSC group was 514. The pooled adenoma recurrence rate was 6 % (37 of 534 cases) in the STSC arm and 22 % (115 of 514 cases) in the non-STSC arm, (odds ratio [OR] 0.26, 95 % confidence interval [CI], 0.16–0.41, P = 0.001). The pooled delayed post-EMR bleeding rate 19 % (67 of 343) in the STSC arm and 22 % (78 of 341) in the non-STSC arm (OR 0.82, 95 %CI, 0.57–1.18). Conclusions Thermal ablation of post-EMR defects significantly reduces adenoma recurrence at first surveillance colonoscopy.

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions.

The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.

Long-term outcomes of endoscopic mucosal resection for early-stage esophageal adenocarcinoma.

With growing application of endoscopic therapy for early-stage esophageal cancer, we sought to review our experience of endoscopic mucosal resections (EMRs). The aim of our study was to understand the natural course of these patients, especially with positive margins. A prospectively maintained database of all patients undergoing endoscopic therapies at Georgetown University Hospital for esophageal cancer was used for the analysis between 2010 and 2020. Of 80 patients in the EMR database, 35 were performed as index cases for esophageal adenocarcinoma. Majority (74.3%) had a pre-treatment ultrasound confirming absence of regional adenopathy. There were no post-EMR bleeding or perforation events requiring re-intervention. Complete R0 resection was achieved in 22/35 (62.9%) after initial EMR. Thirteen patients had positive margins. Of these 13 patients, only 7 patients underwent repeat endoscopic resection, 2 underwent subsequent esophagectomy, 2 received definitive radiation given poor surgical candidacy, and 2 were lost to follow-up. Overall and 5-year survival of all patients undergoing EMR was 67.9months and 85%, respectively. Subset analysis of the 13 patients with R1 resection demonstrated an overall survival of 49.2months and 60% 5-year survival vs overall survival of 78.9months and 93% 5-year survival for R0 resection. At a median follow-up of 60.5months, cancer recurrence occurred in 3 patients. All of them were successfully managed with repeat EMR. Endoscopic resections represent a safe and effective treatment for early-stage esophageal cancer. Patients with high-risk features should be counseled to undergo an esophagectomy if they are operable candidates.

Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial

Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. None.

ID: 3526518 PROPHYLACTIC ENDOSCOPIC CLIP PLACEMENT PREVENTS CLINICALLY SIGNIFICANT POST ENDOSCOPIC MUCOSAL RESECTION BLEEDING IN THE RIGHT COLON - A RANDOMIZED CONTROLLED TRIAL

Endoscopic mucosal resection (EMR) is a cornerstone in the management of large non-pedunculated colorectal polyps (LNPCPs) ≥ 20mm. Clinically-significant post-EMR bleeding (CSPEB) is commonly encountered after the resection of large lesions. The utility of prophylactic clip closure of the EMR defect in preventing CSPEB in the right colon has not been independently assessed.

Endoscopic Suturing for the Prevention and Treatment of Complications Associated with Endoscopic Mucosal Resection of Large Duodenal Adenomas.

Background/AimsEndoscopic mucosal resection (EMR) is the primary treatment for duodenal adenomas; however, it is associated with a high risk of perforation and bleeding, especially with larger lesions. The goal of this study was to demonstrate the feasibility and safety of endoscopic suturing (ES) for the closure of mucosal defects after duodenal EMR. MethodsConsecutive adult patients who underwent ES of large mucosal defects after EMR of large (>2 cm) duodenal adenomas were retrospectively enrolled. The OverStitch ES system was employed for closing mucosal defects after EMR. Clinical outcomes and complications, including delayed bleeding and perforation, were documented. ResultsDuring the study period, ES of mucosal defects was performed in seven patients in eight sessions (six for prophylaxis and two for the treatment of perforation). All ES sessions were technically successful. No early or delayed post-EMR bleeding was recorded. In addition, no clinically obvious duodenal stricture or recurrence was encountered on endoscopic follow-up evaluation, and no patients required subsequent surgical intervention. ConclusionsES for the prevention and treatment of duodenal perforation after EMR is technically feasible, safe, and effective. ES should be considered an option for preventing or treating perforations associated with EMR of large duodenal adenomas.

Previously Attempted Large Nonpedunculated Colorectal Polyps Are Effectively Managed by Endoscopic Mucosal Resection.

Endoscopic mucosal resection (EMR) is an effective therapy for naive large nonpedunculated colorectal polyps (N-LNPCPs). The best approach for the treatment of previously attempted LNPCPs (PA-LNPCPs) is undetermined. EMR performance for PA-LNPCPs was evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by technical success (removal of all visible polypoid tissue during index EMR) and recurrence at first surveillance colonoscopy (SC1). Safety was assessed by clinically significant intraprocedural bleeding, deep mural injury types III-V, clinically significant post-EMR bleeding, and delayed perforation. From January 2012 to October 2019, 158 PA-LNPCPs and 1,134 N-LNPCPs underwent EMR. Median PA-LNPCP size was 30 mm (interquartile range 25-46 mm). Technical success was 93.0% and increased to 95.6% after adjusting for 2-stage EMR. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) was required for nonlifting polypoid tissue in 73 (46.2%). Median time to SC1 was 6 months (interquartile range 5-7 months). Recurrence occurred in 9 (7.8%). No recurrence was identified among 65 PA-LNPCPs which underwent margin thermal ablation at SC1 vs 9 (18.0%; P < 0.001) which did not. There were significant differences in resection duration (35 vs 25 minutes; P < 0.001), technical success (93.0% vs 96.6%; P = 0.026), and use of CAST (46.2% vs 7.6%; P < 0.001), between PA-LNPCPs and N-LNPCPs. When adjusting for 2-stage EMR, no difference in technical success was identified (95.6% vs 97.8%; P = 0.100). No differences in adverse events or recurrence were identified. EMR, using auxillary techniques where necessary, can achieve high technical success and low recurrence frequencies for PA-LNPCPs.

Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods

ObjectiveLarge (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse...

Risk Factors Associated With Postendoscopic Mucosal Resection Bleeding in Patients With Cirrhosis: A Retrospective Multicenter Cohort Study.

There is limited data regarding the safety of endoscopic mucosal resection (EMR) in the cirrhotic population. Our study aimed to evaluate the safety of colonoscopic EMR in cirrhosis. This was a retrospective review of cirrhotics who underwent colonic EMR at 8 Cleveland Clinic Centers between January 1, 2006, and December 31, 2018. Patient data including polyp details and complications occurring within 30 days of the procedure were noted. Univariable and multivariable logistic regression analyses were conducted to find risk factors for post-EMR bleeding. A total of 238 patients who underwent EMR were included. There were 145 males (60.9%) and the mean age was 61.9±8.6 years. Immediate and delayed bleeding, and postpolypectomy syndrome rates were 9.2%, 5.8%, and 1.3%, respectively. Significant risk factors for postpolypectomy bleeding were: increased age (P=0.001), procedure duration >37 minutes (P=0.001), antiplatelet use within 5 days (P=0.023), and lesion diameter >15 mm (P=0.004). Multivariable analysis revealed independent predictors of procedure-related bleeding: age above 65 years [odds ratio (OR) 2.14, P=0.044], antiplatelet use within 5 days (OR 2.42, P=0.047), right colon polyp (OR 3.51, P=0.001), and lesion diameter >15 mm (OR 3.22, P=0.003). EMR in cirrhotics has an acceptable bleeding risk. Age above 65 years, right colon polyp, polyp size >15 mm, and use of antiplatelets within 5 days are independent risk factors for bleeding.

Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video)

Conventional EMR using a hot snare is the standard of care for resection of large (≥20mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly because of electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). This study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized≥20mm. All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps≥20mm over a 2-year period, from January 2016 to December 2017, were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records. CSP-EMR was performed on 204 polyps sized≥20mm in 186 patients (men, 33.8%; median age, 68 years). SC1 for 164 polyps (80.4%) at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% confidence interval, 3%-11%). SC2 for 113 polyps (72.9%) at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% confidence interval, .9%-8.5%) after a normal SC1. Intraprocedural bleeding was successfully treated in 4 patients (2.2%), whereas 7 patients (3.8%) experienced self-limited clinically significant post-EMR bleeding and 1 patient (.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events. CSP-EMR of sessile colonic polyps≥20mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR and to further determine the polyp morphologies that are best suited for CSP-EMR.

Colorectal endoscopic mucosal resection with submucosal injection of epinephrine versus hypertonic saline in patients taking antithrombotic agents: propensity-score-matching analysis

BackgroundEndoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents. The safety of EMR with submucosal saline injection has not been clearly demonstrated in this population.AimsThe present study aimed to evaluate the efficacy and safety of submucosal injection of saline–epinephrine versus hypertonic saline in colorectal EMR of patients taking antithrombotic agents.MethodsThis study enrolled 204 patients taking antithrombotic agents among 995 consecutive patients who underwent colonic EMR from April 2012 to March 2018 at Ureshino Medical Center. Patients were divided into two groups according to the injected solution: saline–epinephrine or hypertonic (10%) saline (n = 102 in each group). Treatment outcomes and adverse events were evaluated in each group and risk factors for immediate and post-EMR bleeding were investigated.ResultsThere were no differences between groups in patient or polyp characteristics. The main antithrombotic agents were low-dose aspirin, warfarin, and clopidogrel. Propensity-score matching created 80 matched pairs. Adjusted comparisons between groups showed similar en bloc resection rates (95.1% with saline–epinephrine vs. 98.0% with hypertonic saline). There were no significant differences in adverse events (immediate EMR bleeding, post-EMR bleeding, perforation, or mortality) between groups. Multivariate analyses revealed that polyp size over 10 mm was associated with an increased risk of immediate EMR bleeding (odds ratio 12.1, 95% confidence interval 2.0–74.0; P = 0.001).ConclusionsTwo tested solutions in colorectal EMR were considered to be both safe and effective in patients taking antithrombotic agents.

Prophylactic endoscopic coagulation to prevent delayed post-EMR bleeding in the colorectum: a prospective randomized controlled trial (with videos)

Post-EMR bleeding (PEB) is the most common adverse event after EMR. However, there are no established endoscopic methods for the prevention of PEB. This study aimed to investigate whether prophylactic endoscopic coagulation (PEC) using coagulation probes reduces the incidence of overall delayed PEB. We performed a randomized controlled study of patients undergoing EMR for large (≥10mm) sessile lesions and laterally spreading tumors. Patients were randomized 1:1 to the EMR with coagulation group (n=285) or EMR (control) group (n= 285). Immediate bleeding during colon EMR or clean-based ulcer afterEMR was excluded. Clinically significant PEB was defined as bleeding requiring endoscopic hemostasis, hospitalization, or a decrease in the hemoglobin level >2 g/dL. A total of 569 patients were analyzed. The incidence of overall PEB was significantly lower in the EMR with coagulation group than in the control group (12.6% [36/285] vs 18.7% [53/284], P= .048). However, this waslargely because of a reduction in minor bleeding. There was no difference in clinically significant PEB (1.8% [5/285] vs 3.2% [9/284], P= .276). Rectal location was a risk factor associated with overall PEB (odds ratio, 1.256; 95% confidence interval, 1.12-1.41; P< .001). Although this study found reduced PEB with prophylactic cautery of visible vessels, this was largely because of a reduction in minor bleeding with no benefit observed for clinically significant bleeding. Overall, PEB was more frequent with rectal lesions. (Clinical trial registration number: KCT0000779.).

A systematic description of the post-EMR defect to identify risk factors for clinically significant post-EMR bleeding in the colon

Clinically significant post-EMR bleeding (CSPEB) is the most-frequent serious adverse event after EMR of large laterally spreading colonic lesions (LSLs). There is no proven prophylactic therapy, and it remains a significant drawback of EMR. We aimed to systematically describe and evaluate the features of the post-EMR mucosal defect (PED) and their relationship to CSPEB. A prospective study of LSLs referred for EMR at a tertiary center was performed. PEDs without visible features were recorded as bland blue. Nonbland blue (NBB) PED features included size, number, and herniation of submucosal vessels and presence of submucosal hemorrhage, fibrosis, fat, and exposed muscle. NBB PEDs were analyzed for association with CSPEB, defined as bleeding occurring after completion of the procedure necessitating readmission or reintervention. From April 2012 to May 2017, 501 lesions in 501 patients were eligible for analysis. The frequency of CSPEB was 30 of 501 (6.0%). More than or equal to 3 visible vessels was a significant predictor of CSPEB (P= .016). None of the following showed a significant correlation with CSPEB: presence of visible vessels, their diameter, herniation, or other nonvascular PED features. Submucosal vessels were more common in the left-sided colon segment (88.6% vs 78.3%, P= .004) and were significantly larger (20.8% vs 12.1%≥1mm, P= .037), more numerous (median 4 vessels [interquartile range, 2-7] vs 2 vessels [interquartile range, 1-4], P< .001), and more often herniated (32% vs 22.2%, P= .022). More than or equal to 3 visible vessels within the PED may be predictive for CSPEB and may define a target group for real-time prophylactic intervention. No other endoscopically visible features of the PEDs were predictive of CSPEB. (Clinical trial registration number: NCT03117400.).

Diagnostic Accuracy of Optical Detection of Residual Colorectal Neoplasia After Endoscopic Mucosal Resection: Impact of Endoclip Closure at EMR Site

Introduction: Application of clips after EMR may reduce post EMR bleeding but also interfere with the recurrent adenoma detection at follow up due to nodular distortions of scar tissue. This could lead to an overtreatment of benign lesions. In a prospective trial, we aimed to evaluate the diagnostic accuracy of white light and narrow band imaging (NBI) with near-focus capability in recurrent adenoma detection with or without clip artifact. Methods: This prospective trial was started in January 2016 and is ongoing. Consecutive patients undergoing follow-up colonoscopy after a previous EMR of ≥20mm colorectal polyps were included. Endoscopists predicted the presence of neoplasia recurrence of EMR scars with or without clip artifact and their level of confidence (high or low) based on visual assessment of the previous EMR site subsequently with the four modalities 1) white light without and 2) with near-focus, and 3) NBI without and 4) with near-focus. Each EMR site was biopsied as a reference standard and histology assessed by a pathologist blinded to the endoscopist's visual assessment. Diagnostic accuracy was calculated for all diagnostic modalities for the real-time endoscopic assessment of the EMR scar tissue with or without clip artifacts. Results: A total of 172 patients (54% male, mean age: 65 years with 180 scar sites were included perprotocol, with a median follow up of 8 months (range: 3-71 months). At the original EMR, clips were used in 82/180 (45%) lesions. The rate of post-EMR scar clip artifact was 61% (50 of 82). Diagnostic accuracy for all EMR-scar sites with or without clip- artifact and confidence level in real time are shown at Table 1 and 2. The prevalence of residual neoplasia was 25% for all EMR scars. 27% of cases were over treated for benign disease when clips were used versus 8% of cases when clips were not used. Overall, clips reduced the proportion of high confidence diagnoses and appeared to lower the accuracy of EMR scar assessment in low confidence diagnoses but not for high confidence diagnoses.Table: Table. Diagnostic value of optical detection of residual neoplasia with or without clip artifactConclusion: These results suggest that clips used to close colonic EMR defects may impair the ability to accurately assess the EMR scar at follow up. Clips reduced the proportion of high confidence diagnoses as well as the accuracy of scar assessment in low confidence diagnoses, and furthermore, increased the proportion of over treated benign clip artifact. Alternative methods to potentially reduce post-EMR bleeding are needed.

Expanding the field of cold snare polypectomy.

Expanding the field of cold snare polypectomy.

Is the Double Channel Gastroscope Useful in Endoscopic Mucosal Resection for Large Sessile Colon Polyps?

See Use of a Double-Channel Gastroscope Reduces Procedural Time in Large Left-Sided Colonic Endoscopic Mucosal Resections by Evangelos Voudoukis, Georgios Tribonias, Aikaterini Tavernaraki, et al., on page 136-141 Most colon polyps are less than 1 cm in size. However, endoscopists often encounter large sessile colon polyps greater than 2 cm in practice. Removal of a large sessile colon polyp is difficult due to a high rate of procedure-related complications, such as bleeding and perforation. Therefore, patients with large sessile colon polyps are referred to a tertiary hospital for appropriate treatment. There are two usual endoscopic treatments for large sessile colon polyps: conventional endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). ESD using various knives was initially introduced for the treatment of early gastric cancer, but has recently, been used for large sessile colon polyps. Theoretically, ESD is preferable to en bloc resection for better pathologic evaluation. However, because of high complication rates, ESD is not widely used for the treatment of large sessile colon polyps. Despite the advent of gastric ESD, piecemeal EMR is more widely used than ESD in such polyps. In Western countries, because of the technical difficulty and longer procedure time of ESD, piecemeal EMR is still the gold standard therapy for large sessile colon polyps >20 mm in diameter.1 Although many endoscopists are performing colonic EMR, little attention has been paid to reducing the procedure time, which can be a very important issue in high-volume centers. Longer procedure times may influence the work of physicians and other personnel in the endoscopy room. One study reported that the total procedure time for EMR in patients with large sessile colon polyps (2 cm or larger) averaged 51.4 minutes (standard deviation, 25.6).2 The mean size of the polyps was 34.2 mm, the perforation rate was 1.1%, and the post-EMR bleeding rate was 7.3%. Procedure time was measured from endoscope insertion to examination completion. In another large-scale study on ESD for large colon polyps, the mean procedure time was 116 minutes, with a mean tumor size of 35 mm; perforation occurred in 4.9%, and postoperative bleeding in 1.5%.3 In this issue of Clinical Endoscopy, Voudoukis et al.4 present their experience with large (>2 cm) sessile or flat left-sided colon polyp resection, focusing on the benefits of the double channel (DC) gastroscope for EMR. In their retrospective series, they compared the procedure time using a DC gastroscope to that for a standard colonoscope or gastroscope (OS). They measured the EMR procedure time from first submucosal injection to just following polyp resection. This measurement method was different from that used by other researchers. The mean procedure time differed significantly between the DC group (33±21 minutes) and the OS group (58.7±20.6 minutes, p=0.015); in the subgroup of patients with polyps larger than 40 mm, the statistical difference in the mean procedural time between the two groups was even more pronounced (p=0.004). They suggest that use of a DC gastroscope for large non-pedunculated rectosigmoid lesions significantly reduces the procedure time. A DC scope is sometimes used in a difficult colonic EMR, but is not widely used in a routine procedure. The primary technique using a DC scope is the simultaneous insertion of a forceps, which can grasp polyp tissue and pull it into position for snare polypectomy5 or EMR; endoscopists can use the injection needle and snare at the same time with the DC scope. This might reduce the total operative time, and enable endoscopists to perform procedures without interruption. Nishizawa et al.6 called it the two-sword fencing technique in ESD, which also saves the time of changing endoscopic devices. The two-sword fencing technique allows mucosal resection just after injection, before the collapse of the submucosal cushion. However, endoscopists must be careful when snare EMR using forceps, because the proper muscle is held inside the forceps. It is difficult to keep the dissection plane horizontal to the intestinal wall with ESD using a DC gastroscope. Information on use of a DC gastroscope would be useful in EMR or ESD for large sessile colon polyps. This study has several important features. It is the first study in which the authors have compared the DC scope with single channel scopes in EMR for large sessile colonic polyps. However, as the authors state in their discussion, the number of patients was too small to be able to generalize the results of the study. In addition, the authors compared the DC gastroscope with single channel scopes. Upper endoscopy and colonoscopy were included in the single channel OS scope group, and should have been compared individually with the DC gastroscope. Finally, this retrospective study was conducted by a single experienced endoscopist. The procedure time might be dependent on the features of the endoscopist. A prospective study with multiple endoscopists will be needed.

Control of immediate post-EMR bleeding by using monopolar hemostatic forceps

A 58-year-old patient with hypertension was referred for EMR of a large flat polyp in the ascending colon. Colonoscopy revealed a Paris IIa lesion measuring roughly 3 cm in diameter. The polyp was removed by first injecting diluted indigo carmine to achieve an adequate submucosal lift. A 25-mm snare (Snaremaster Spiral; Olympus America Inc, Center Valley, Pa) was used to capture the lifted polyp. Using a blended cut current (Endocut; ERBE USA, Inc, Marietta, Ga), we removed the polyp en bloc. Immediately an arterial bleed was identified with brisk spurting of blood from the submucosa.