Polypectomy Techniques Research Articles

Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting

Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting

Protocol design for randomized clinical trial to compare underwater cold snare polypectomy to conventional cold snare polypectomy for non-pedunculated colon polyps of size 5-10mm (COLDWATER study).

Colorectal cancer is internationally the third leading cause of death from a malignant disease. The aim of screening colonoscopy in adults > 45years of age is early diagnosis and treatment of precancerous polyps. Endoscopic polyp removal (polypectomy) can be achieved with various techniques depending on the size, morphology, and location of the polyp. According to current guidelines, small non-pedunculated polyps should be removed with a cold snare after the colorectal lumen has been insufflated with air (conventional cold snare polypectomy).In recent years, several studies have described the benefits of water aided colonoscopy, as well as the safety and efficacy of underwater cold snare polypectomy for large colon polyps. However, there are insufficient data on conventional and underwater techniques for small polyps, the most commonly diagnosed colorectal polyps. We have designed a prospective randomized double-blind clinical trial to compare the safety and efficacy of conventional and underwater cold snare polypectomy for non-pedunculated polyps 5-10mm in size. A total of 398 polyps will be randomized. Randomization will be carried out using the random numbers method of Microsoft Excel 2016. The primary endpoint is the muscularis mucosa resection rate. Secondary endpoints are the depth and percentage of R0 excisions, complications, and the recurrence rate at follow-up endoscopy 6-12months after polypectomy. We hypothesize underwater polypectomy will result in a higher muscularis mucosa resection rate. The results of our study will provide useful data for the development of guidelines in polypectomy techniques for non-pedunculated polyps 5-10mm in size. Clinicaltrials.gov, NCT05273697.

Measuring polyp size using a virtual scale endoscope: a video tutorial with clinical case demonstration.

Accurate real-time endoscopic assessment of colorectal polyp size plays a key role for selecting adequate post-polypectomy surveillance intervals or when choosing appropriate polypectomy techniques [1]. While visual estimation is the most commonly used method of measurement, there is marked interobserver variability. Biopsy forceps and ruler snares can be used as references for polyp size estimation, but are limited by being external devices that lengthen the duration of the endoscopy and increase the procedural cost [2] [3].

S1786 Pancreatic Metastasis Secondary to the Masters of Costumes, Renal Cell Carcinoma

Introduction: Renal cell carcinoma (RCC) has been one of the most studied cancers, and its metastatic capabilities are well documented in literature. RCC accounts for 80%-85% of primary renal neoplasm. Approximately 25% of individuals have distant metastases at the time of diagnosis. Its metastatic capabilities continue to be one of the most challenging aspects of the disease. Metastasis to the pancreas has been described in about 2%-5% of all malignant pancreatic tumors. Case Description/Methods: Case of an 80-year-old man with medical history of Stage IV RCC, treated with immunotherapy. Treatment was discontinued due to adverse effects. Patient presents to the ER with a complaint of intractable pruritus. On laboratory values, found with elevated liver enzymes and total bilirubin, with a mixed hepatocellular and cholestatic pattern, reason why gastroenterology service was consulted. Physical examination showed generalized jaundice. Abdominal CT scan showed multiple intrabdominal lesions, including in the pancreas, causing intra and extrahepatic ductal dilation. MRCP showed multiple intrabdominal masses encasing the common bile duct, causing intra and extrahepatic biliary tree and distal pancreatic duct dilation. Concern of a primary pancreaticobiliary malignancy arose. On EGD, multiple gastric and duodenal clean base ulcers and 2 large pedunculated polyps in the second portion of the duodenum removed using hot snare polypectomy technique, and random biopsies on gastric and duodenal ulcers taken. On EUS, a large hyperechoic vascular lesion was observed in the pancreatic head, infiltrating the intrapancreatic bile duct. Another large 3.3 cm x 3.0 cm vascular mass at the gastro-hepatic ligament was observed. Biopsies from duodenal ulcer, duodenal polyp, and pancreatic mass were consistent with metastatic clear cell neoplasm as seen in RCC. ERCP was made to place a fully covered metallic stent at CBD stricture caused by extrinsic compression. Discussion: RCC is the most common renal tumor. Up to 25% of cases present with advanced disease at diagnosis. Our patient presents with multiple intrabdominal masses causing biliary tree and pancreatic duct obstruction. Advanced endoscopic techniques and cross-sectional images play an essential role in the diagnosis and management of pancreaticobiliary pathologies. Other etiologies such as metastatic RCC may mimic primary pancreaticobiliary malignancies. In this case, advanced endoscopic modalities were used for tissue diagnosis and management of metastatic disease.

S2133 Suck and Snare: A Technique for Rapid, Complete, and Safe Cold Snare Polypectomy of Sessile Polyps Greater Than One Centimeter

Introduction: Snare polypectomy of flat colon polyps may be challenging when boarders are indistinct or if the snare wire slides over the flat mucosal surface as the snare closes. Current guidelines suggest cold or hot snare polypectomy with or without submucosal injection for the removal of polyps between 1 and 1.9 centimeters (cm). Injection lift polypectomy and hot snare endoscopic mucosal resection of flat lesions can be time intensive and carries risks of perforation, post polypectomy syndrome, and bleeding. Cold snare technique has become increasingly utilized for Paris class 1s and 1sp polyps of any size. We propose an adaptation of the “suction polypectomy technique,” previously described for the removal of less than 1 cm sessile polyps, for use in cold snare polypectomy of sessile polyps greater than 1 cm. Case Description/Methods: Technique: Olympus high definition colonoscopes (CF-HQ190L/I) were used to identify sessile polyps between 10-15 mm (Table). The snare was passed though the instrument and pulled back slightly into the channel. Polyps were then suctioned using the tip of endoscope for 1-2 seconds. This technique was repeated over the surface of the entire lesion until the polyps puckered up, developing a more polypoid shape. The polyps were then immediately resected via cold snare polypectomy (Figure). All polyps were completely resected and there were no procedural complications. Discussion: This series shows that the “suction polypectomy” technique using a cold snare for polyps 1 cm or greater is feasible and safe with the benefits of not requiring the use of lifting agents, injection needles, or significant technical expertise. Future studies are required to determine the feasibility of suction polypectomy in lesions greater than 1.5 cm and the safety and efficacy of the technique in larger prospective cohorts.Figure 1.: Endoscopic images of the technique. Images labeled “A” show the polyp before suction. Images labeled “B” show the polyp after suction. Images labeled “C” show post-polypectomy. Table 1. - Characteristics of Polyps Removed Patient # Polyp Size Location Pathology Diagnosis En Bloc versus Piecemeal Complications (Immediate/Delayed Bleeding or Perforation) 1 10 mm Descending Colon Tubular Adenoma in Fragments En Bloc None 2 10 mm Ascending Colon Sessile Serrated Adenoma En Bloc None 3 12 mm Ascending Colon Sessile Serrated Adenoma En Bloc None 4 12 mm Ascending Colon Tubular Adenoma in Fragments En Bloc None 5 11 mm Transverse Colon Tubular Adenoma En Bloc None

Novel Endoscopic Polypectomy Surveillance Technique for Fundic Gland Polyps in Familial Adenomatous Polyposis Can Improve Early Detection of Dysplasia and Gastric Cancer.

Fundic gland polyps (FGPs) are commonly found in patients with familial adenomatous polyposis (FAP) and are considered benign. Biopsies are not routinely performed, and conventional forceps may be time-consuming and/or yield nonrepresentative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, in the incidence of dysplasia and gastric cancer (GC) in FAP. This is a retrospective longitudinal cohort of patients with FAP referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 and 2019. Demographic, endoscopic, and clinicopathologic information was reviewed. Thirty-five patients with FAP were identified at initial endoscopy by the mean age of 43.4 years (±12.8). One hundred thirteen surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial esophagogastroduodenoscopy in 7 patients (20%), and 13 additional patients (46.4%) progressed to low-grade dysplasia. Three patients (15%) who subsequently had progression to GC were found to have signet ring cell cancer within the foci of FGPs through EPS. One patient presented as metastatic GC. Progression from nondysplastic FGP to low-grade dysplasia occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10 mm in size ( P < 0.001) and carpeting of polyps ( P < 0.001). The 5-year cumulative incidence of developing dysplasia was 35.7%. We identified that the incidence of dysplasia and GC is higher than previously reported in patients with FAP. Our study used a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and GC.

Endoscopic resection of superficial bowel neoplasia: The unmet needs in the Egyptian practice.

BACKGROUNDManagement of superficial bowel neoplasia (SBN) in early stages is associated with better outcomes. The last few decades experienced a paradigm shift in the management of SBN with the introduction of advanced endoscopic resection techniques (ERTs). However, there are no clear data about the aspects of ERTs in Egypt despite the growing gastroenterology practice.AIMTo investigate the knowledge, attitude, and practice of ERTs toward management of SBN among Egyptian practitioners and the suitability of the endoscopy units’ infrastructures toward these techniques.METHODSAn online 2-pages questionnaire was used. The first page comprised demographic data, and questions for all physicians, about the knowledge (11 questions) of and attitude (5 questions) toward ERTs as a therapeutic option for SBN. The second page investigated the practice of ERTs by endoscopists (6 questions) and the infrastructures of their endoscopy units (14 questions). The survey was disseminated through July 2021 and the data were collected in an excel sheet and later analyzed anonymously.RESULTSThe complete responses were 833/2300 (36.2%). The majority of the participants were males (n = 560, 67.2%), middle-aged (n = 366, 43.9%), consultants (n = 464, 55.7%), gastroenterologists (n = 678, 81.4%), spending ≥ 15 years in practice (n = 368, 44.2%), and were working in university hospitals (n = 569, 68.3%). The majority correctly identified the definition of SBN (88.4%) and the terms polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) (92.1%, 90.2%, and 89.1% respectively). However, 26.9%, 43.2% and 49.5% did not recognize the clear indication of polypectomy, EMR, and ESD respectively. Although 68.1% of physicians are convinced about the ERTs for management of SBN; only 8.9% referred all candidate cases for ERTs. About 76.5% of endoscopists had formal training in the basic polypectomy techniques while formal training for EMR and ESD was encountered only in 31.9% and 7.2% respectively. About 71.6% and 88.4% of endoscopists did not perform EMR or ESD in the last one year. Consequently, the complication rate reported by endoscopists was limited to 18.1% (n = 103) of endoscopists. Only 25.8% of endoscopists feel confident in the management of ERTs-related complications and a half (49.9%) were not sure about their competency. Regarding the endoscopy units’ infrastructures, only 4.2% of the centers had their endoscopes 100% armed with optical enhancements and 54.4% considered their institutions ready for managing ERTs-related complications. Only 18.3% (n = 104) of endoscopists treated their complicated cases surgically because the most frequent ERTs-related complications were procedural bleeding (26.7%), and perforations (17%).CONCLUSIONA significant deficiency was reported in the knowledge and attitude of Egyptian practitioners caring for patients with SBN toward ERTs. The lack of trained endoscopists in both EMR and ESD in part is due to unsuitable infrastructures of many endoscopy units.

Adherence to European Society of Gastrointestinal Endoscopy Quality Performance Measures for Upper and Lower Gastrointestinal Endoscopy: A Nationwide Survey From the Italian Society of Digestive Endoscopy.

BackgroundThe quality of gastrointestinal (GI) endoscopy has been recently identified as a major priority being associated with many outcomes and patient's experience.ObjectiveTo assess adherence of endoscopists to the European Society of Gastrointestinal Endoscopy (ESGE) quality performance measures for upper and lower GI endoscopy in Italy.MethodsAll endoscopist members of the Italian Society of Digestive Endoscopy (SIED) were invited from October 2018 to December 2018 to participate to a self-administered questionnaire-based survey. The questionnaire included questions on demographics and professional characteristics, and the recent ESGE quality performance measures for upper and lower GI endoscopy.ResultsA total of 392 endoscopists participated in the study. Only a minority (18.2%) of participants recorded the duration of esophagogastroduodenoscopy (EGD) and 51% provided accurate photo documentation in the minimum standard of 90% of cases. Almost all endoscopists correctly used Prague and Los Angeles classifications (87.8% and 98.2%, respectively), as well as Seattle and Management of precancerous conditions and lesions in the stomach (MAPS) biopsy protocols (86.5% and 91.4%, respectively). However, only 52.8% of participants monitored complications after therapeutic EGD, and 40.8% recorded patients with a diagnosis of Barrett's esophagus (BE). With regard to colonoscopy, almost all endoscopists (93.9%) used the Boston Bowel Preparation Scale for measuring bowel preparation quality and reported a cecal intubation rate ≥90%. However, about a quarter (26.2%) of participants reported an adenoma detection rate of <25%, only 52.8% applied an appropriate polypectomy technique, 48% monitored complications after the procedure, and 12.4% measured patient's experience.ConclusionThe adherence of endoscopists to ESGE performance measures for GI endoscopy is sub-optimal in Italy. There is a need to disseminate and implement performance measures and endorse educational and scientific interventions on the quality of endoscopy.

Clinical guidance on endoscopic management of colonic polyps in Singapore.

Colonoscopy with endoscopic resection of detected colonic adenomas interrupts the adenoma-carcinoma sequence and reduces the incidence of colorectal cancer and cancer-related mortality. In the past decade, there have been significant developments in instruments and techniques for endoscopic polypectomy. Guidelines have been formulated by various professional bodies in Europe, Japan and the United States, but some of the recommendations differ between the various bodies. An expert professional workgroup under the auspices of the Academy of Medicine, Singapore, was set up to provide guidance on the endoscopic management of colonic polyps in Singapore. A total of 23 recommendations addressed the following issues: accurate description and diagnostic evaluation of detected polyps; techniques to reduce the risk of post-polypectomy bleeding and delayed perforation; the role of specific endoscopic resection techniques; the histopathological criteria for defining endoscopic cure; and the role of surveillance colonoscopy following curative resection.

EMR and ESD: Indications, techniques and results

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are two well-known endoscopic resection procedures used for advance gastrointestinal lesions. As compared to standard polypectomy techniques, EMR and ESD provide wider and deeper resection margins and allow en bloc removal of lesions for more detailed pathology with curative intent for early neoplastic gastrointestinal lesions. Both procedures have their advantages and disadvantages which will be discussed in detail in this review article. Recently there have been advancements in the techniques of EMR and ESD with addition in new equipment. We will also discuss current guidelines recommending use of EMR and/or ESD in various clinical scenarios.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends.

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

A novel polypectomy technique: the "ropeway method" for resection of large pedunculated polyps.

A novel polypectomy technique: the "ropeway method" for resection of large pedunculated polyps.

Prospective evaluation of the effectiveness of colonoscopic polyp resection

Background: Colon cancer incidence is on the rise and despite having undergone a colonoscopy to screen and remove all visible polyps as a preventive measure, nearly 1 in 110 patients will develop colon cancer within 3 years. The three main possible explanations for this are missing polyps, incompletely removed polyps, or rapidly growing tumors. Objective: To determine the proportion of colonic polyps ≤ 3 cm in size that show evidence of residual polyp tissue following colonoscopy and polypectomy. Methods: Patients who presented for colonoscopy at a community center were invited to participate in this study. Those who had confirmed adenoma were invited to repeat the procedure in 2 to 6 months with biopsies at the resection site to check for the presence of residual polyp tissue. Exclusion criteria included the absence of adenoma in the resected lesion, contraindication to polypectomy or follow-up colonoscopy, refusal to participate in follow-up examination, and other conditions increasing colon cancer risk. If polyps between 5 mm and 30 mm were found, the endoscopist resected them using the hot snare polypectomy technique or endoscopic mucosal resection (EMR). Results: Ninety-one patients completed the study protocol, with 105 lesions being studied. The second procedure was performed between 2 and 24 months. All analyzed lesions were adenoma, and three of them were associated with intramucosal adenocarcinoma. Others included 60 tubular lesions, 37 tubulovillous lesions, and 5 serrated lesions. Thirty-two lesions were flat and were removed by EMR; polypectomy was performed for 73 lesions. There was no residual tissue in the polypectomy group. The EMR group presented three cases of incomplete resection without adenocarcinomas. Conclusion: Our study showed that flat lesions might be an important cause of incomplete resection. In addition, we documented the complete resection of pedunculated lesions in all studied patients. This study provides more evidence to validate the empirical perception in the medical field that assumes the complete resection of pedunculated polyps. Therefore, we suggest that patients who undergo snare removal of pedunculated polyps should follow the regular protocol for colon cancer screening, with colonoscopy every 5 to 10 years. Meanwhile, the surveillance scheme should be reviewed for patients who undergo removal of flat lesions smaller than 30 mm.

The Cost of Guideline Adherence: A Multicenter Analysis of the Financial Implications of Adopting the US Multi-Society Task Force Polypectomy Guidelines.

The goal of this study was to determine the financial impact of adopting the US Multi-Society Task Force (USMSTF) polypectomy guidelines on physician reimbursement and disposable equipment costs for gastroenterologists in the academic medical center and community practice settings. In 2020, USMSTF guidelines on polypectomy were introduced with a strong recommendation for cold snare rather than cold forceps technique for removing diminutive and small polyps. Polypectomy with snare technique reimburses physicians at a higher rate compared with cold forceps and also requires different disposable equipment. The financial implications of adopting these guidelines is unknown. Patients that underwent screening colonoscopy where polypectomy was performed at an academic medical center (Loma Linda University Medical Center) and community practice medical center (Ascension Providence Hospital) between July 2018 and July 2019 were identified. The polypectomy technique performed during each procedure was determined (forceps alone, snare alone, forceps plus snare) along with the number and size of polyps as well as disposable equipment. Actual and projected provider reimbursement and disposable equipment costs were determined based on applying the new polypectomy guidelines. A total of 1167 patients underwent colonoscopy with polypectomy. Adhering to new guidelines would increase estimated physician reimbursement by 5.6% and 12.5% at academic and community practice sites, respectively. The mean increase in physician reimbursement per procedure was significantly higher at community practice compared with the academic setting ($29.50 vs. $14.13, P <0.00001). The mean increase in disposable equipment cost per procedure was significantly higher at the community practice setting ($6.11 vs. $1.97, P <0.00001). Adopting new polypectomy guidelines will increase physician reimbursement and equipment costs when colonoscopy with polypectomy is performed.

The quality of colorectal polypectomy. Is it enough to have just a visual assessment of the site?

Introduction: Performing a colonoscopy allows the examination of the entire colon and the assessment of polyps. Patients, Materials and Methods: We performed a retrospective analysis of prospectively collected data from January 2018 until February 2020 (two years), in which we enrolled a number of 210 patients performing colonoscopy in the Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Romania. We performed 326 polypectomies. Results: We classified the polyps into diminutive (n=169), small (n=103) and large polyps (n=54). Regarding the polypectomy technique, our results indicated that 40 out of 48 (83.3%) polypectomies with the biopsy forceps were complete, as well as 27 out of 31 (87.1%) cold snare polypectomies and 12 out of 14 (85.7%) hot snare polypectomies. The differences were not statistically significant (p=0.116). Regarding the number of incomplete polypectomies, our data suggests that the high expertise endoscopist had two incomplete resections (5.1% of total), the medium expertise endoscopist 1 had also two incomplete resections (11.1% of total), the medium expertise endoscopist 2 had three incomplete resections (15% of total), the limited expertise endoscopist 1 had three incomplete resections (27.27% of total) and the limited expertise endoscopist 2 had four incomplete resections (30.76% of total). Analyzing the data, the differences were statistically significant (p=0.006). Conclusions: Our study is able to suggest that high-definition white-light endoscopy (HD–WLE) macroscopic visualization of the polyp resection site is not enough to assess complete polyp resection and follow-up colonoscopy should be performed for cases with incomplete margins of resection.

GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary thatis presented in this document of the "top 10" endoscopic advances of2020.

A Pilot Randomized Trial of Polypectomy Techniques for 4 to 6 mm Colonic Polyps.

There is variation in polypectomy techniques for resection of small polyps. Aim was to compare techniques for 4 to 6 mm polyps for recurrent adenoma, efficiency, and adverse events and to establish methodological factors for definitive trial. The study was a randomized controlled trial. Outpatients with ≥1, 4 to 6 mm polyps were randomized to cold forceps (CF), cold snare (CS), and hot snare (HS). Polypectomy site was marked with SPOT to assess for recurrence at the original polypectomy site during surveillance colonoscopy. To assess feasibility of a definitive trial we measured (1) rates of patient refusal, participation, ineligibility; (2) retention; (3) recurrent neoplasia; and (4) sample size for a definitive trial. Three hundred fifty-three patients were randomized to 1 of the 3 polypectomy techniques, of whom 260 (73.6%) completed the initial colonoscopy (mean age 57 y, 50.4% women), with 91, 87, and 82 patients randomized to CF, CS, and HS polypectomy, respectively. Mean time for polyp resection for CF, CS, and HS were 198.8, 58.5, and 96.8 seconds, respectively, with CS and HS requiring less time than CF (P<0.001). One hundred sixty-four (63.1%) completed surveillance colonoscopy. Polyp recurrences were 9 (14.5%) with CF, 5 (9.6%) with CS, and 0 (0%) with HS. Although the recurrence relative risks with CF and CS polypectomy were 1.84 and 1.65 as compared with HS, respectively, neither was statistically significant. CS and HS polypectomy require less time than CF. HS polypectomy may have a lower risk for recurrent neoplasia. High attrition rate is a challenge in conducting randomized controlled trial with polyp recurrence as endpoint.

Mucosal defect size predicts the adequacy of resection of ≤10 mm nonpedunculated colorectal polyps using a new cold snare polypectomy technique.

There is still room for improvement in the methods used to achieve complete polyp resection. The aim of this study was to develop a cold snare polypectomy technique that will reliably result in resections containing the muscularis mucosae and the lateral polyp margins. Nonpedunculated polyps ≤10 mm were resected using a dedicated cold snare with the goal of creating a mucosal defect approximately 1 cm in dia. The completeness of resection of the lateral and vertical polyp margins was examined histologically. The cases of 201 patients (mean age 67 ± 13 years; 115 men) with 500 eligible polyps were enrolled. The mean polyp size was 6.1 ± 1.8 mm (range 1-10 mm). The mean mucosal defect size immediately after resection was 7.7 ± 2.5 mm (range 3-15 mm). Overall, the complete resection rate in which the lateral and vertical margins were free from the neoplasia tissue was 92% (417/454, 95% CI, 89-94); in the remaining 8% of cases, the vertical margins showed complete resection but the lateral margins could not be evaluated due to the fragmentation of resected polyps. A mucosal defect ≥7 mm predicted complete resection of the mucosal layer containing the muscularis mucosae. Complete mucosal layer resection of nonpedunculated colorectal polyps ≤10 mm was reliably achieved using a cold snare technique that produced a mucosal defect ≥7 mm in dia.

Overutilization of surgical resection for benign colorectal polyps: analysis from a tertiary care center.

Background and study aims Adequate removal of precancerous polyps is an independent factor in colorectal cancer prevention. Despite advances in polypectomy techniques, there is an increasing rate of surgery for benign polyps. We assessed whether surgical resection is properly utilized for benign colorectal polyps. Patients and methods We identified 144 patients with surgical resection for benign colorectal polyps. Polyp location, size and the indication for and type of surgery were obtained. For the purposes of this analysis, we assumed that gastroenterologists should assess polyp size accurately, endoscopically resect polyps < 2 cm, and treat incompletely excised polyps on follow-up. Results A total of 118 patients (82 %) were referred to surgery without attempted endoscopic removal. In 26 (22 %) of 118, the macroscopic polyp size was < 2 cm (23 in right, 3 in the left colon) and 18 (15 %; 14 in the right, four in the left colon) were found to have had size overestimation during endoscopy. Twenty-two (15 %) of 144 underwent surgical resection for incomplete endoscopic resection of adenomas (16 in the right, 6 in the left colon); 12 (54.5 %) had a residual polyp size of < 2 cm (10 in the right colon; 2 in the left colon). In-hospital mortality was 0.7 % and morbidity was 20.1 %. Conclusions Of the patients, 41 % could have potentially avoided surgical intervention (37 polyps < 2 cm and/or size overestimations precluding endoscopic polypectomy and 22 incomplete resections). When including polyps with size ≥ 2 to < 4 cm, the percentage of patients with avoidable surgery reached 80 %. This confirms the need to develop standardized quality metrics for endoscopic polypectomies and for better overall training of endoscopists performing these procedures. Given the risks of surgery, referral to an experienced gastroenterologist should be considered as a first step.

Underwater endoscopic mucosal resection of a rectal adenoma in the nondistensible rectum from severe fecal incontinence

In a patient with severe fecal incontinence, polypectomy of rectal adenomas may be difficult if the patient cannot retain gas in the rectum. Existing literature does not include reports of the optimal polypectomy technique in these patients. We describe a challenging case of difficult polypectomy in the nondistensible rectum from severe fecal incontinence (Video 1, available online at www.giejournal.org).