Endoscopic management of large colorectal polyps

Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps

BACKGROUND & AIMS

Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance.

METHODS

We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon.

RESULTS

We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER, 19.53 QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was dominated by TEM. TEM became cost effective when the mortality from ER exceeded 0.63%, or if the loss to follow up rate exceeded 25.5%.

CONCLUSIONS

Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER.

Endoscopic resection of large colorectal adenomas - clinical experience of a tertiary referral centre

AIM

Colorectal cancer is a leading cause of cancer-related mortality. Adenomatous polyps are typically resected endoscopically to prevent cancer while giant and complex polyps are managed surgically. No criteria clearly define the indications for surgical vs endoscopic resection. Our aim was to evaluate factors associated with the short-term efficacy and safety of endoscopic resection of large (≥ 20 mm) and giant (≥ 40 mm) adenomas.

METHOD

Consecutive cases with colonic adenomas larger than 20 mm resected endoscopically were included. Endoscopic, clinical and histological details of polyps were recorded as well as the need for surgical resection.

RESULT

A total of 351 resections were included. The average adenoma diameter was 30.34 ± 10.66 mm. Surgery was recommended in 21 (5.98%) cases. In a multivariate analysis for efficacy, two variables were independent risk factors for surgery: adenoma size [OR 1.08 (95% CI: 1.04-1.12)] and caecal location [5.97(1.60-22.33)]. Postpolypectomy complications were documented in 85 (24.2%) cases: bleeding 69 (19.7%), perforations 8(2.3%) and significant discomfort 15(4.3%). Twenty-one patients (6.0%) developed serious complications requiring further hospitalization. In multivariate analysis for safety, independent risk factors for postpolypectomy complications included adenoma size [1.04 (1.06-1.01)], polyp morphology [sessile 2.55 (1.45-4.51), flat 2.40 (1.04-5.52)] and submucosal adrenaline injection [1.87 (1.11-3.20)]. Increments of 1 mm in adenoma diameter beyond 20 mm increased the need for surgery by 8% and the risk of complications by 4%.

CONCLUSION

Resection of large or giant adenomas is generally a safe procedure. Although adenoma size and morphology are significant predictors of efficacy and safety, each case should be individually evaluated in a specialist unit for feasibility of endoscopic resection.

Management of early colonic neoplasia: where are we now and where are we heading?

There have been considerable advances in the endoscopic treatment of colorectal neoplasia. The development of endoscopic submucosal dissection and full thickness resection techniques is changing the way benign disease and early cancers are managed. This article reviews the evidence behind these new techniques and discusses where this field is likely to move in the future. Areas covered: A PubMed literature review of resection techniques for colonic neoplasia was performed. The clinical and cost effectiveness of endoscopic mucosal resection (EMR) is examined. The development of endoscopic submucosal dissection (ESD) and knife assisted resection is described and issues around training reviewed. Efficacy is compared to both EMR and transanal endoscopic microsurgery. The future is considered, including full thickness resection techniques and robotic endoscopy. Expert commentary: The perceived barriers to ESD are falling, and views that such techniques are only possible in Japan are disappearing. The key barriers to uptake will be training, and the development of educational programmes should be seen as a priority. The debate between TEMS and ESD will continue, but ESD is more flexible and cheaper. This will become less significant as the number of endoscopists trained in ESD grows and some TEMS surgeons may shift across towards ESD.

Insulated-tip knife endoscopic polypectomy for difficult pedunculated colorectal polyps: a prospective pilot study

BACKGROUND

Endoscopic polypectomy is widely used for colorectal polyps. However, for giant pedunculated colorectal polyps (≥3 cm), conventional techniques are so difficult with en bloc resection that patients had to be transferred to surgery. We had firstly reported our first experience with an insulated-tip knife to successfully remove a giant pedunculated polyp in the sigmoid colon. In this study, our aim was to explore safety and feasible of insulated-tip knife endoscopic polypectomy (IT-EP) for difficult pedunculated colorectal polyps.

METHODS

A total of seven consecutive patients with giant pedunculated colorectal polyps (≥3 cm) were prospectively enrolled. IT-EP was conducted with the help of clips for all the seven patients, and data of them was recorded and analyzed.

RESULTS

Of seven patients, five were men and two were women with a mean age 61 years (49-72 years). The mean diameter of polyp head and stalk was 36.4 ± 4.9 mm (30-42 mm) and 14.6 ± 3.6 mm (10-20 mm), respectively. All the polyps were successfully removed with IT-EP, with a mean operation time of 14.9 ± 3.5 min (11-20 min). No serious bleeding or perforation was experienced, and no surgery was needed. There was no recurrence or residual of polyps at a mean 8.1-month follow-up.

CONCLUSIONS

Insulated-tip knife endoscopic polypectomy is a safe and feasible alternative for difficult pedunculated colorectal polyps.

Scope or scalpel? A matched study of the treatment of large colorectal polyps

BACKGROUND

Large colorectal polyps can be treated either endoscopically or by formal resection. The aim of this study was to clarify the relative advantages and disadvantages of surgical resection and colonoscopic snaring as means of treating large colorectal polyps.

METHODS

This is a matched cohort study, comparing cases of surgical resection of benign colorectal polyps with endoscopic resection. Cases drawn from pathology and endoscopy databases were matched for the size and site of polyps, and the groups were compared for the end points of complications, length of hospital stay and completeness of the removal of the polyp.

RESULTS

There were 78 patients in each group, with mean ages of 65.6 years (colonoscopy) and 66.8 years (surgery). A total of 39 of the surgery group and 47 of the colonoscopy group were men. Mean polyp size was 34.1 mm (colonoscopy) and 32.1 mm (surgery). There was an exact match for polyp location. Complications occurred in eight colonoscopy patients (10.3%) and 42 surgery patients (56.0%) (P < 0.001, chi-square). Length of hospital stay was 0 days for colonoscopy patients and 7.3 ± 4.7 days for surgery (P < 0.001). The surgery group was separated into laparoscopic (n = 35) and open (n = 43) surgery. There was no difference in complication rates (42.4 versus 53.5%, respectively) but laparoscopic had shorter length of stay (5.8 days ± 4.9 SD versus 8.4 days ± 4.3 SD). Recurrence of surgically resected polyps was zero; at last follow-up 13% of snared polyps persisted.

CONCLUSION

Although resection is a more certain and absolute way of treating benign polyps, endoscopic polypectomy is preferable.

Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of endoscopic resection of large colorectal polyps.

DESIGN

Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed.

RESULTS

50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%).

CONCLUSIONS

Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.

Large Colorectal Lesions: Evaluation and Management

In the last years, a distinctive interest has been raised on large polypoid and non-polypoid colorectal tumors, and specially on flat neoplastic lesions ≥20 mm tending to grow laterally, the so called laterally spreading tumors (LST). Real or virtual chromoendoscopy, endoscopic ultrasound or magnetic resonance should be considered for the estimation of submucosal invasion of these neoplasms. Lesions suitable for endoscopic resection are those confined to the mucosa or selected cases with submucosal invasion ≤1000 μm. Polypectomy or endoscopic mucosal resection remain a first-line therapy for large colorectal neoplasms, whereas endoscopic submucosal dissection in high-volume centers or surgery should be considered for large LSTs for which en bloc resection is mandatory.

Clinical characteristics and STK11 gene mutations in Chinese children with Peutz-Jeghers syndrome

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant inherited disease characterized by gastrointestinal hamartomatous polyps and mucocutaneous melanin spots. Germline mutation of the serine/threonine kinase 11 (STK11) gene are responsible for PJS. In this study, we investigated the clinical characteristics and molecular basis of the disease in Chinese children with PJS.

METHODS

Thirteen children diagnosed with PJS in our hospital were enrolled in this study from 2011 to 2015, and their clinical data on polyp characteristics, intussusceptions events, family histories, etc. were described. Genomic DNA was extracted from whole-blood samples from each subject, and the entire coding sequence of the STK11 gene was amplified by polymerase chain reaction and analyzed by direct sequencing.

RESULTS

The median age at the onset of symptoms was 2 years and 4 months. To date, these children have undergone 40 endoscopy screenings, 17 laparotomies and 9 intussusceptions. Polyps were found in the stomach, duodenum, small bowel, colon and rectum, with large polyps found in 7 children. Mutations were found in eleven children, including seven novel mutations (c.481het_dupA, c.943_944het_delCCinsG, c.397het_delG, c.862 + 1G > G/A, c.348_349het_delGT, and c.803_804het_delGGinsC and c.121_139de l19insTT) and four previously reported mutations (c.658C > C/T, c.890G > G/A, c.1062 C > C/G, and c.290 + 1G > G/A). One PJS patient did not have any STK11 mutations.

CONCLUSIONS

The polyps caused significant clinical consequences in children with PJS, and mutations of the STK11 gene are generally the cause of PJS in Chinese children. This study expands the spectrum of known STK11 gene mutations.

Malignancy in large colorectal lesions

CONTEXT

The size of colorectal lesions, besides a risk factor for malignancy, is a predictor for deeper invasion objectives: To evaluate the malignancy of colorectal lesions ≥20 mm.

METHODS

Between 2007 and 2011, 76 neoplasms ≥20 mm in 70 patients were analyzed.

RESULTS

The mean age of the patients was 67.4 years, and 41 were women. Mean lesion size was 24.7 mm ± 6.2 mm (range: 20 to 50 mm). Half of the neoplasms were polypoid and the other half were non-polypoid. Forty-two (55.3%) lesions were located in the left colon, and 34 in the right colon. There was a high prevalence of III L (39.5%) and IV (53.9%) pit patterns. There were 72 adenomas and 4 adenocarcinomas. Malignancy was observed in 5.3% of the lesions. Thirty-three lesions presented advanced histology (adenomas with high-grade dysplasia or early adenocarcinoma), with no difference in morphology and site. Only one lesion (1.3%) invaded the submucosa. Lesions larger than 30 mm had advanced histology (P = 0.001). The primary treatment was endoscopic resection, and invasive carcinoma was referred to surgery. Recurrence rate was 10.6%.

CONCLUSIONS

Large colorectal neoplasms showed a low rate of malignancy. Endoscopic treatment is an effective therapy for these lesions.

Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions

BACKGROUND

Endoscopic resection of large colorectal lesions is associated with high complication rates.

OBJECTIVE

To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions.

DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications.

MAIN OUTCOME MEASUREMENTS

Delayed hemorrhage, postpolypectomy syndrome, and perforation.

RESULTS

There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding.

LIMITATION

Retrospective design.

CONCLUSIONS

Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted.

Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?

BACKGROUND

Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.

METHODS

Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.

RESULTS

A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.

CONCLUSIONS

The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.

Snaring large serrated polyps

BACKGROUND

Serrated polyps of the large bowel are potentially premalignant, difficult to see, but important to remove. Few studies describe the technique or outcomes of serrated polypectomy. We sought to present outcomes of a series of polypectomies of large serrated polyps in comparison to a series of endoscopic resections of large adenomas.

METHODS

This retrospective, comparative, single endoscopist study was performed in an outpatient colonoscopy department of a tertiary referral medical center. Patients had outpatient colonoscopy where a large (≥2 cm) serrated polyp or adenoma was removed. Outcomes were completeness of excision and complications of polypectomy. A database of endoscopic polypectomies was reviewed. Polypectomy of large serrated polyps was compared with polypectomy of large adenomas.

RESULTS

There were 132 large serrated polyps in 112 patients and 563 adenomas in 428 patients. More serrated polyps were right sided (120 of 130, 92.3 %, vs. 379 of 563, 67 %) (p < 0.0001). The serrated polyps were smaller than the adenomas (mean 25.5 ± 7.9 mm standard deviation) versus 36.8 ± 16.9 mm standard deviation (p < 0.001). There were four complications of serrated polypectomy in four patients (4 % of polyps, 5 % of patients): three postpolypectomy bleeds and one postpolypectomy syndrome. There were 33 complications of adenoma removal (31 postpolypectomy bleeding and two postpolypectomy syndrome) (6.9 % of polyps, p = 0.376, 8.4 % of patients, p = 0.371). On follow-up, 36 of 51 patients (71 %) with serrated polyps had metachronous lesions compared to 133 of 298 patients (45 %) with adenomas (p < 0.0001). There were fewer residual polyps in the serrated group (4 of 47 vs. 64 of 298, p = 0.001).

CONCLUSIONS

Removal of large serrated colorectal polyps is no more complicated than polypectomy of similarly sized adenomas. However, large serrated polyps have a higher rate of metachronous polyps than similarly sized adenomas and surveillance should be adapted to reflect these findings.

Quality of polyp resection during colonoscopy: are we achieving polyp clearance?

BACKGROUND AND STUDY AIM

Currently colonoscopy quality indicators emphasize our ability to improve polyp detection (e.g., preparation quality, withdrawal times of ≥6 min). The completeness of a polyp resection may also be an important determinant of quality and efficient colonoscopy. The primary aim of this study was to determine the incidence of an incomplete polyp resection despite a perceived complete polypectomy.

PATIENTS AND METHODS

This was a retrospective quality assurance project conducted at the San Diego Veterans Affair Medical Center and University of California San Diego Medical Center from July 2007 to April 2008. The patients recruited to this study were undergoing surveillance and screening colonoscopy. The resection quality was evaluated in 65 polyps of 47 patients. Twenty-two polyps were removed with standard biopsy forceps, jumbo forceps (18), hot snare (18), and cold snare (7). Biopsies were taken from the post-polypectomy site base and perimeter for histologic examination in order to confirm histologic absence of all polypoid appearing mucosa.

RESULTS

The post-polypectomy sites of ten polyps (15%) were found to have residual polypoid tissue. Six were removed by standard biopsy forceps, jumbo forceps (2), hot snare (1), and cold snare (1). When compared to other polypectomy devices, standard biopsy forceps were more likely to result in an incomplete resection (27 vs. 9%; P = 0.076).

CONCLUSIONS

The endoscopist may not be visually accurate in determining when a polyp is completely resected, and alternative devices and techniques for polyp resection should be considered.

Transanal endoscopic video-assisted (TEVA) excision

BACKGROUND

Transanal endoscopic video-assisted (TEVA) excision represents an alternative approach for the surgical treatment of middle and upper rectal lesions not amenable to colonoscopic removal. Utilizing principles of single-incision laparoscopic surgery, this novel minimally invasive approach optimizes access for safe and complete removal of these lesions without the need for a formal rectal resection. We describe our technique and early outcomes with TEVA excision.

METHODS

Between March 2010 and September 2011, TEVA excision was performed for patients presenting for management of rectal lesions not amenable to colonoscopic or standard transanal removal. Patients were selected if they presented with benign disease or superficial adenocarcinoma, and the proximal extent of the lesion extended beyond 8 cm from the anal verge. Demographic, intraoperative, and postoperative data were assessed. A SILS™ port was placed in the anal canal for access in all cases. Standard laparoscopic instruments were utilized for visualization, full-thickness transanal excision, and primary closure.

RESULTS

Twenty patients (50% male) with a mean age of 64.6 ± 10.9 years, mean body mass index of 28.2 ± 4.9 kg/m(2), and median American Society of Anesthesiologist score of 2 underwent TEVA excision. Fourteen patients (70%) presented with benign disease and six patients (30%) presented with malignant disease. The mean size of the lesions was 3.0 ± 1.4 cm, and the mean distance from the anal verge was 10.6 ± 2.4 cm. All excisions were successfully completed with a mean operative time of 79.8 ± 25.1 (range, 45-135) min. The mean length of hospital stay was 1.1 ± 0.7 (range, 0-3) days.

CONCLUSIONS

TEVA excision is a safe and feasible approach for local excision of rectal lesions not otherwise amenable to standard techniques. Continued investigation and development will be important to establish its role in minimally invasive colorectal surgery.

Subacute reaction to endoscopic mucosal resection mimicking perforation

A 25-year-old woman underwent routine day-case endoscopic mucosal resection (EMR) of two ascending colonic polyps. Six hours later she re-presented with severe abdominal pain. On examination she was tachycardic with tenderness and peritonism in the right lower quadrant. Urgent abdominal computed tomography (CT) did not reveal any signs of free intra-abdominal gas or fluid but did detect transmural thickening and oedema in the ascending colon and caecum. As there was no radiological evidence of perforation, the patient was managed conservatively and made a full recovery. The exact aetiology of this patient's symptoms is not known. She may have developed post-polypectomy electrocoagulation (a transmural diathermy injury), localised ischaemia of the colonic wall (secondary to the adrenaline used during EMR) or an allergic reaction to the dye used during EMR. As EMR is an increasingly used treatment modality in the management of colonic polyps, clinicians should have an awareness of the complications of treatment. We would advocate a low threshold for prompt CT investigation in any patient presenting with abdominal pain after EMR to detect any evidence of free intraperitoneal air. Patients without signs of perforation may be managed conservatively, as in this case.

Routine and advanced polypectomy techniques

The performance of colon polypectomy has proven to be one of the most impactful services provided by today's endoscopist. Advancements in instrumentation and endoscopic techniques have been studied intensely by endoscopists over the past decade in order to expand their extent of resection capabilities to large and complex polyps. Much of the research in the past year has focused on the safety and efficacy of performing endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and combined laparascopic-endoscopic resections (CLER). Experts have published case-series, multicenter studies, and even nationwide results on the use of these methods for complex polypectomy. Because of the novelty and increased risk of these procedures, recent research has also focused on the prevention, identification and management of complications related to polypectomy, particularly bleeding and perforation. This manuscript will review the recent literature addressing basic and advanced colon polypectomy techniques.

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

CONTEXT: Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. OBJECTIVES: To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. METHODS: A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique. Complications and recurrence were analyzed. Patients were followed up for 18 months. RESULTS: There were 83 (48.2%) superficial lesions, 57 (33.1%) depressed lesions, 44 (25.6%) laterally spreading tumors, and 45 (26.2%) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0%) lesions were located in the rectum, 68 (39.5%) in the left colon, and 80 (46.5%) in the right colon (transverse, ascending, and cecum). There were 167 (97.1%) neoplasms: 142 (82.5%) adenomatous lesions, 24 (14.0%) intramucosal carcinomas, and 1 (0.6%) invasive carcinoma. En bloc resection was performed in 158 (91.9%) cases and piecemeal resection in 14 (8.1%). Bleeding occurred in 5 (2.9%) cases. Recurrence was observed in 4.1% (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). CONCLUSIONS: Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.

Laparo-endoscopic resection for extensive and inaccessible colorectal polyps: a feasible and safe procedure

INTRODUCTION

Polypectomy at colonoscopy may be difficult or dangerous. In such instances colonic resection may be indicated. Novel combined laparoscopic-endoscopic procedures have the potential to allow safe extensive extramucosal resection, thus avoiding resection. Laparoscopic colon mobilisation provides a more favourable orientation for endoscopic mucosal resection and facilitates identification of possible perforation sites with immediate laparoscopic repair or resection if necessary. This study aimed to assess the efficacy and safety of laparo-endoscopic resection (LER) of colonic polyps.

PATIENTS AND METHODS

Data were collected prospectively on consecutive patients undergoing LER. The mode of presentation, referral pattern, lesion site and size, hospital stay, procedural details, complications, histology and further treatment were recorded.

RESULTS

A total of 13 patients underwent attempted LER (16 polyps in total) and this was completed for 10, with a median hospital stay of 2 days. Five polyps were removed whole and eight piecemeal. Excision was clinically complete in all cases. Three procedures were converted to colonic resection. One lesion appeared malignant, indicating a conversion to laparoscopic right hemicolectomy. Two polyps were not amenable to LER and resection was performed. One patient underwent subsequent colonic resection based on the histological findings. There were no perforations or serious complications.

CONCLUSIONS

LER is a safe and effective treatment for large and inaccessible colonic polyps that would otherwise be treated by colonic resection.

Endoscopic colorectal imaging and therapy

PURPOSE OF REVIEW

Colorectal cancer screening and prevention is a pivotal element in every gastroenterologist practice. Recent advances in imaging technology and treatment opened the field for endoscopic management of large flat colorectal polyps and early cancer.

RECENT FINDINGS

High-definition white light colonoscopy allowed for better characterization of colon polyps, particularly flat lesions. Chromoendoscopy facilitated the identification of colon polyps as well as better endoscopic polyp characterization, with strong correlation with final pathological diagnosis, opening the field of 'virtual' biopsy. One particular technology, confocal endomicroscopy can magnify an image approximately 1000 times resembling optical microscopy with very good correlation with histology. Endoscopic mucosal resection has gained great acceptance to manage flat colorectal polyps with the two major complications being bleeding and perforation, both now under 5% in experienced hands. Endoscopic submucosal resection was developed to increase en-bloc resection (less residual disease) of a flat colorectal lesion but one has to accept a higher perforation rate around 10%.

SUMMARY

Current technology allows for better polyp identification and characterization, which can be managed endoscopically.

Colonoscopic polypectomy and associated techniques

Polypectomy of colonic polyps has been shown to reduce the risk of colon cancer development and is considered a fundamental skill for all endoscopists who perform colonoscopy. A variety of polypectomy techniques and devices are available, and their use can vary greatly based on local availability and preferences. In general, cold forceps and cold snare have been the polypectomy methods of choice for smaller polyps, and hot snare has been the method of choice for larger polyps. The use of hot forceps has mostly fallen out of favor. Polypectomy for difficult to remove polyps may require the use of special devices and advanced techniques and has continued to evolve. As a result, the vast majority of polyps today can be removed endoscopically. Since electrocautery is frequently used for polypectomy, endoscopists should be thoroughly familiar with the basic principles of electrosurgery as it pertains to polypectomy. Tattooing of a polypectomy site is an important adjunct to polypectomy and can greatly facilitate future surgery or endoscopic surveillance. The two most common post-polypectomy complications are bleeding and perforation. Their incidence can be decreased with the use of meticulous polypectomy techniques and the application of some prophylactic maneuvers. This review will examine the technique of polypectomy and its complications from the perspective of the practicing gastroenterologist.

Endoscopic treatment of a large colonic polyp as a cause of colocolonic intussusception in a child

Colocolonic intussusception is an uncommon cause of intestinal obstruction in children. The most common type is idiopathic ileocolic intussusception. However, pathologic lead points occur approximately in 5% of cases. In pediatric patients, Meckel's diverticulum is the most common lead point, followed by polyps and duplication. We present a case of recurrent colocolonic intussusception which caused colonic obstruction in a 10-year-old boy. A barium enema revealed a large polypoid mass at the transverse colon. Colonoscopy showed a colonic polyp, 3.5 centimeters in diameter, which was successfully removed by endoscopic polypectomy.

A new serrated snare for improved tissue capture during endoscopic snare resection

Endoscopic snare resection of gastrointestinal polyps and neoplasm is a standard procedure in interventional endoscopy. Due to technical and procedural improvements the removal of large sessile polyps can be achieved by endoscopic mucosal resection either in one single specimen or by piecemeal resection. In this experimental study a new snare with special teeth attached to the distal part of the wire loop was evaluated and compared to a conventional snare. Seventy artificial sessile tumors were created in a standardized manner in a porcine ex vivo colon. Thirty-five polyps were resected with the new serrated snare, whilst the other 35 polyps were removed using an identical snare without teeth. The weight measurement of the resected polyps showed that when using the new serrated snare 31% more tissue could be removed with a single snare resection in comparison with the conventional snare without teeth (mean 454 mg vs. 347 mg, +/-202 mg vs. +/-165 mg). The teeth obviously increased the effectiveness of snare resection by avoiding the accidental loss of entrapped tissue from the loop. The new snare hopes to faciliate the removal of flat polyps and to reduce the number of specimens during piecemeal resection to a minimum, allowing a better histopathological assessment.