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Fusco S, Bauer ME, Schempf U, Stüker D, Blumenstock G, Malek NP, Werner CR, Wichmann D. Analysis of Predictors and Risk Factors of Postpolypectomy Syndrome. Diagnostics (Basel) 2024; 14:127. [PMID: 38248004 PMCID: PMC10814321 DOI: 10.3390/diagnostics14020127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/26/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND AIMS Postpolypectomy syndrome (PPS) is a relevant adverse event that can appear after polypectomy. Several publications mention postpolypectomy syndrome using different criteria to define it. The aim of this study is to detect potential risk factors and predictors for developing PPS and to define the main criteria of PPS. METHODS In this retrospective monocentric study, 475 out of 966 patients who underwent colonoscopy with polypectomy from October 2015 to June 2020 were included. The main criterion of PPS is defined as the development of postinterventional abdominal pain lasting more than six hours. RESULTS A total of 9.7% of the patients developed PPS, which was defined as local abdominal pain around the polypectomy area after six hours. A total of 8.6% of the study population had abdominal pain within six hours postintervention. A total of 3.7% had an isolated triad of fever, leukocytosis, and increased CRP in the absence of abdominal pain. Increased CRP combined with an elevated temperature over 37.5 °C seems to be a positive predictor for developing PPS. Four independent risk factors could be detected: serrated polyp morphology, polypoid configurated adenomas, polyp localization in the cecum, and the absence of intraepithelial neoplasia. CONCLUSIONS Four independent risk factors for developing PPS were detected. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology. As expected, the increasing use of cold snare polypectomies will reduce the incidence of this syndrome. Key summary: Our monocentric study on 966 patients detected four independent risk factors for developing PPS: pedunculated polyp, resected polyps in the cecum, absence of IEN, and serrated polyp morphology. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology.
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Affiliation(s)
- Stefano Fusco
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Michelle E. Bauer
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Ulrike Schempf
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Dietmar Stüker
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology, Eberhard-Karls-University, 72076 Tübingen, Germany
| | - Nisar P. Malek
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Christoph R. Werner
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Dörte Wichmann
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
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2
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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3
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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4
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. [Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 76:282-296. [PMID: 33361705 DOI: 10.4166/kjg.2020.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/03/2022]
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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5
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Clin Endosc 2020; 53:663-677. [PMID: 33242928 PMCID: PMC7719428 DOI: 10.5946/ce.2020.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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6
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Garg R, Singh A, Ahuja KR, Mohan BP, Ravi SJK, Shen B, Kirby DF, Regueiro M. Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients. J Gastroenterol Hepatol 2020; 35:1381-1386. [PMID: 32003069 DOI: 10.1111/jgh.14996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited. METHODS Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses. RESULTS A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period. CONCLUSIONS Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.
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Affiliation(s)
- Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Keerat R Ahuja
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Babu P Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Shri J K Ravi
- Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Li F, Li K, Wu LJ, Fan YL, Liu TX. Role of Biogenic Amines in Oviposition by the Diamondback Moth, Plutella xylostella L. Front Physiol 2020; 11:475. [PMID: 32528307 PMCID: PMC7247421 DOI: 10.3389/fphys.2020.00475] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/17/2020] [Indexed: 11/13/2022] Open
Abstract
Oviposition is an important reproductive behavior that is triggered by mating in insects, and biogenic amines might be involved in its regulation. The effects of biogenic amines on oviposition have only been studied in a few insect species, and the findings to date have not been conclusive. In addition, there are few studies on the effects of biogenic amines on oviposition of the diamondback moth, Plutella xylostella L. Here, we tested how mating and biogenic amines regulate oviposition of P. xylostella by injecting amines and amine receptor antagonists into virgin and mated females and counting the number of eggs laid afterward. Biogenic amines of octopamine and tyramine could induce virgin adults of P. xylostella to lay eggs, while dopamine and serotonin had no such effect on oviposition. Furthermore, the octopamine antagonists mianserin, epinastine, and phentolamine inhibited oviposition by mated females. The tyramine antagonist yohimbine, dopamine antagonist SCH23390, and serotonin antagonist ketanserin did not block oviposition by mated females, and octopamine and tyramine-inducing oviposition by virgin females could be inhibited by the octopamine antagonists mianserin and epinastine instead of the tyramine antagonist yohimbine. We conclude that octopamine and its receptors are involved in mating-triggered oviposition in P. xylostella, while tyramine acts as a subsidiary. Further, the inducing effect of tyramine on oviposition is achieved via octopamine receptors instead of tyramine receptors. This experiment is helpful to further understand the role of biogenic amines in mating regulation and to provide a new strategy for controlling P. xylostella.
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Affiliation(s)
- Fan Li
- State Key Laboratory of Crop Stress Biology for Arid Areas and Key Laboratory of Integrated Pest Management on Crops in Northwestern Loess Plateau of Ministry of Agriculture, Northwest A&F University, Yangling, China
| | - Ke Li
- State Key Laboratory of Crop Stress Biology for Arid Areas and Key Laboratory of Integrated Pest Management on Crops in Northwestern Loess Plateau of Ministry of Agriculture, Northwest A&F University, Yangling, China
| | - Li-Juan Wu
- State Key Laboratory of Crop Stress Biology for Arid Areas and Key Laboratory of Integrated Pest Management on Crops in Northwestern Loess Plateau of Ministry of Agriculture, Northwest A&F University, Yangling, China
| | - Yong-Liang Fan
- State Key Laboratory of Crop Stress Biology for Arid Areas and Key Laboratory of Integrated Pest Management on Crops in Northwestern Loess Plateau of Ministry of Agriculture, Northwest A&F University, Yangling, China
| | - Tong-Xian Liu
- State Key Laboratory of Crop Stress Biology for Arid Areas and Key Laboratory of Integrated Pest Management on Crops in Northwestern Loess Plateau of Ministry of Agriculture, Northwest A&F University, Yangling, China
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Khalid M, Khalid M, Gayam V, Yeddi A, Adam O, Chakraborty S, Abdallah M, Abu-Heija A, Kaloti Z, Mukhtar O, Shereef H, Judd S. The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study. Gastroenterology Res 2020; 13:19-24. [PMID: 32095169 PMCID: PMC7011915 DOI: 10.14740/gr1234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/06/2019] [Indexed: 12/24/2022] Open
Abstract
Background Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce. Methods The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module. Results Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk. Conclusion Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.
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Affiliation(s)
- Mowyad Khalid
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Mazin Khalid
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Vijay Gayam
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Ahmed Yeddi
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Omeralfaroug Adam
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | | | - Mohamed Abdallah
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Ahmad Abu-Heija
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Zaid Kaloti
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Osama Mukhtar
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Hammam Shereef
- Department of Internal Medicine, Beaumont Hospital, Dearborn, MI, USA
| | - Stephanie Judd
- Department of Gastroenterology, Wayne State University/John D. Dingell VA Medical Center, Detroit, Michigan, USA
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Holley J, Seibert D, Moss A. Peritonitis following Colonoscopy and Pol Ypectomy: A Need for Prophylaxis? Perit Dial Int 2020. [DOI: 10.1177/089686088700700211] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- J. Holley
- Sections of Nephrology and Gastroenterology West Virginia University
| | - D. Seibert
- Sections of Nephrology and Gastroenterology West Virginia University
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10
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Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, Ng M, Chan TM, Lai KN, Lo WK. Risks and Outcomes of Peritonitis after Flexible Colonoscopy in CAPD Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080702700517] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective The ISPD 2005 guidelines for peritonitis recommend antibiotic prophylaxis for patients undergoing colonoscopy with polypectomy while on continuous ambulatory peritoneal dialysis (CAPD) but there is little literature to support this recommendation. This study aimed to look into the risks and outcomes of peritonitis after colonoscopy in CAPD patients. Patients and Methods All records of flexible colonoscopy performed on our CAPD patients from January 1994 to January 2006 were retrieved. Demographic and clinical data, use of antibiotics before colonoscopy, endoscopic findings, procedure performed, and peritonitis data were analyzed. Results 77 CAPD patients underwent 97 colonoscopies. No peritonitis developed in the 18 cases where antibiotics were given before colonoscopy. Among those without antibiotic prophylaxis, 4 episodes of peritonitis occurred within 24 hours after the procedure and 1 occurred 5 days later. All responded to intraperitoneal antibiotics. Colonic biopsy and polypectomy were not associated with more peritonitis (2 in 41 with biopsy vs 3 in 38 without biopsy, p = 0.67; 1 in 30 with polypectomy vs 4 in 49 without polypectomy, p = 0.64). Conclusion The risk of peritonitis after colonoscopy without antibiotic prophylaxis was 6.3%. All peritonitis episodes responded to intraperitoneal antibiotics. Colonic biopsy or polypectomy did not appear to increase the risk of peritonitis. Although statistically not significant when compared with patients without antibiotic prophylaxis, we observed no peritonitis after colonoscopy in patients that were given antibiotics for prophylactic purposes or for other reasons. The efficacy of prophylactic antibiotics would be better defined by large randomized trials.
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Affiliation(s)
- Terence Yip
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Kai Chung Tse
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Man Fai Lam
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Suk Wai Cheng
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Sing Leung Lui
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Sydney Tang
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Matthew Ng
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Tak Mao Chan
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Kar Neng Lai
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
| | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, University of Hong Kong, Hong Kong
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Pugliese V, Gatteschi B, Aste H, Nicolò G, Munizzi F, Giacchero A, Bruzzi P. Value of Multiple Forceps Biopsies in Assessing the Malignant Potential of Colonic Polyps. TUMORI JOURNAL 2018; 67:57-62. [PMID: 7245356 DOI: 10.1177/030089168106700111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fifty-nine colo-rectal polyps were detected at endoscopy and repeatedly biopsied before removal by endoscopic snare polypectomy. The aim of the present paper was to evaluate the reliability of multiple forceps biopsies in assessing both the malignant potential and the presence or absence of invasive cancers (IC) in colo-rectal adenomas (CRA). In order to achieve the first objective, the histologic types and the degree of dysplasia have been defined. The data obtained by means of multiple biopsies examination, compared with those of polyp in toto study, show that fractional biopsies were of value in the histologic classification of only the smallest 41 polyps (agreement 88.09 %), whilst no reliability of biopsies was demonstrated in the 18 largest polyps (agreement 27.68 %). In the field of dysplasia grading, the agreement was 55 % and 61 % for the smallest and the largest CRA respectively. These last figures are hardly acceptable. Biopsies examination gave also under- and overestimation of the histologic severity and of dysplasia as well as a significant incidence of false negative results in IC detection. It is concluded that polypectomy is the only method which provides adequate material for precise diagnosis, no matter how large a polyp. Therefore it should be performed whenever possible. Finally the authors discuss the management of small sessile adenomas.
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Heublein V, Pannach S, Daschkow K, Tittl L, Beyer-Westendorf J. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry. J Gastroenterol 2018; 53:236-246. [PMID: 28493007 DOI: 10.1007/s00535-017-1346-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients receiving direct-acting, non-vitamin K oral anticoagulants (NOAC) frequently undergo gastrointestinal endoscopies (GIE) but little is known on the management and outcome of these interventions. METHODS With use of data from an ongoing, prospective, noninterventional registry of NOAC patients, the management and outcome of GIE were evaluated with use of standard event definitions. Patients undergoing GIE were categorized into two subgroups: (1) scheduled GIE (scheduled appointment, no acute bleeding) and (2) unscheduled GIE (unscheduled including management of acute gastrointestinal bleeding). The rates of major bleeding complications, cardiovascular complications, and all-cause death within 30 days after the procedure were evaluated. RESULTS Between October 1, 2011, and March 31, 2015, 492 patients underwent a total of 713 GIE (44.5% gastroscopies, 53.0% colonoscopies, 2.5% endoscopic retrograde cholangiopancreatography procedures), with 70.0% being scheduled procedures and 30.0% being unscheduled procedures. Endoscopies were performed within 24 h after the last NOAC intake in 45 of 713 cases (6.3%), between 24 and 48 h after the last intake in 336 cases (47.1%), and after NOAC therapy interruption for more than 48 h in 213 cases (29.9%). Heparin bridging therapy was used in 180 of 713 procedures (25.3%) and predominantly (170/180; 94.4%) in cases of NOAC therapy interruption for longer than 72 h. Until day 30 after the procedure, the event rates were 1.4% for cardiovascular events and 0.7% for major bleeding events. CONCLUSION Continuation or short-term interruption of NOAC therapy seems to be a safe strategy for GIE. Heparin bridging therapy is predominantly used in cases of prolonged NOAC therapy interruption.
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Affiliation(s)
- Vera Heublein
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sven Pannach
- Division of Gastroenterology, Department of Medicine I, Carl Gustav Carus University Hospital, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Katharina Daschkow
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Luise Tittl
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany.
- Kings Thrombosis Service, Department of Hematology, Kings College London, London, UK.
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Tullavardhana T, Akranurakkul P, Ungkitphaiboon W, Songtish D. Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies. Ann Med Surg (Lond) 2017; 19:65-73. [PMID: 28652912 PMCID: PMC5476974 DOI: 10.1016/j.amsu.2017.05.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Bleeding is the most common major complication following colonoscopic polypectomy. The purpose of this study is to evaluate whether submucosal epinephrine injections could prevent the occurrence of postpolypectomy bleeding. Method The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for appropriate randomized controlled studies published before April 2015. A meta-analysis was conducted to investigate the preventative effect of submucosal epinephrine injection for overall, early, and delayed postpolypectomy bleeding. Results The final analysis examined the findings of six studies, with data from 1388 patients. The results demonstrated that prophylactic treatment with epinephrine injection significantly reduced the occurrence of overall (OR = 0.38, 95% CI: 0.21, 0.66; p = 0.0006) and early bleeding (OR = 0.38, 95% CI: 0.20, 0.69; p = 0.002). However, for delayed bleeding complications, epinephrine injections were not found to be any more effective than treatment with saline injection or no injection (OR = 0.45, 95% CI: 0.11, 1.81; p = 0.26). Moreover, for patients with polyps larger than 20 mm, mechanical hemostasis devices (endoloops or clips) were found to be more effective than epinephrine injection in preventing overall bleeding (OR = 0.33, 95% CI: 0.13, 0.87; p = 0.03) and early bleeding (OR = 0.29, 95% CI: 0.08, 1.02; p = 0.05). This was not established for delayed bleeding. Conclusion The routine use of prophylaxis submucosal epinephrine injection is safe and beneficial preventing postpolypectomy bleeding.
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Affiliation(s)
- Thawatchai Tullavardhana
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Prinya Akranurakkul
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Withoon Ungkitphaiboon
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Dolrudee Songtish
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
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Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
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Verres needle desufflation as an effective treatment option for colonic perforation after colonoscopy. Surg Laparosc Endosc Percutan Tech 2016; 25:e61-4. [PMID: 24752169 DOI: 10.1097/sle.0000000000000058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND This study aimed to assess the incidence of colonoscopic perforation and the efficacy of minimal invasive management by Verres needle desufflation. MATERIALS AND METHODS All colonoscopies performed between January 2007 and January 2012, at the Maastricht University Medical Centre, were reviewed. RESULTS During the study period, 18,449 colonoscopies were performed. Fourteen colonoscopic perforations were diagnosed. Seven patients underwent immediate surgery, whereas the remaining 7 patients were initially managed conservatively: 5 of these patients also underwent Verres needle desufflation. One of the patients who received Verres needle desufflation underwent secondary surgery because of failure of nonsurgical treatment. Conservative management of colonoscopic perforation, including treatment with Verres needle desufflation, was associated with lower complication rates and shorter hospital stays compared with immediate surgical intervention. CONCLUSIONS Verres needle desufflation in combination with nil per os and antibiotic treatment is a safe option for managing colon perforation after colonoscopy in selected patients lacking clinical signs of peritonitis or sepsis.
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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Abstract
AIM Adequate colonic imaging is generally an invasive procedure with attendant risks, particularly perforation. Endoscopy, barium enema and computed tomographic colonography (CTC) are the main techniques for investigating patients with symptoms of, or screening for, colorectal cancer. The potential complications of these investigations have to be weighed against the benefits. This article reviews the literature on the incidence, presentation and management of iatrogenic colonic perforation at colonic imaging. METHOD A literature review of relevant studies was undertaken using PubMed, Cochrane library and personal archives of references. Manual cross-referencing was performed, and relevant references from selected articles were reviewed. Studies reporting complications of endoscopy, barium enema and CT colonography were included in this review. RESULTS Twenty-four studies were identified comprising 640,433 colonoscopies, with iatrogenic perforation recorded in 585 patients (0.06%). The reported perforation rate with double-contrast barium enema was between 0.02 and 0.24%. Serious complications with CTC were infrequent, though nine perforations were reported in a case series of 24,365 patients (0.036%) undergoing CTC. CONCLUSION Perforation remains an infrequent and almost certainly under-reported, complication of all colonic imaging modalities. Risk awareness, early diagnosis and active management of iatrogenic perforation minimizes an adverse outcome.
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Affiliation(s)
- J S Khan
- Queen Alexandra Hospital, Portsmouth, UK.
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How Should Patients Requiring Dual Antiplatelet Therapy be Managed When Undergoing Elective Endoscopic Gastrointestinal Procedures? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 13:46-56. [PMID: 21136215 DOI: 10.1007/s11936-010-0107-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OPINION STATEMENT The following are general guidelines for the management of patients on dual antiplatelet therapy as they undergo gastrointestinal procedures with potential for bleeding complications: Avoid cessation of all antiplatelet therapies after percutaneous coronary intervention (PCI) with stent placement when possible. Avoid cessation of clopidogrel (even when aspirin is continued) within the first 30 days after PCI and either drug-eluting stent (DES) or bare metal stent placement. Defer elective endoscopic procedures, possibly up to 12 months, if clinically acceptable from the time of PCI and DES placement. Perform endoscopic procedures, particularly those associated with bleeding risk, 5 to 7 days after thienopyridine drug cessation. Aspirin should be continued when possible. Resume thienopyridine and aspirin drug therapy after the procedure once hemostasis is achieved. A loading dose of the former should be considered among patients at risk for thrombosis. Continue platelet-directed therapy in patients undergoing elective endoscopy procedures associated with a low risk for bleeding.
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Rotholtz NA, Laporte M, Lencinas S, Bun M, Canelas A, Mezzadri N. Laparoscopic approach to colonic perforation due to colonoscopy. World J Surg 2010; 34:1949-53. [PMID: 20372899 DOI: 10.1007/s00268-010-0545-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Iatrogenic perforation due to colonoscopy is the most serious complication of this procedure. Usually, resolution of this event requires segmental resection. The laparoscopic approach could be an option to minimize the outcome of this complication. The aim of the present study was to assess the effectiveness of the laparoscopic approach in treating colonic perforations due to colonoscopy. METHODS Between July 1997 and November 2008 data were collected retrospectively on all patients who underwent colonoscopy and had a perforation caused by the procedure. Patients with other complications after colonoscopy as well as other colonic perforations were excluded. According to the method employed for the approach, the series was divided in two groups: those treated by the laparoscopic approach (group I; GI) and those treated via laparotomy (group II; GII). Morbidity and recovery parameters were compared between the two groups. Statistical analysis was performed using Student's t-test and the chi square test. RESULTS A total of 14,713 colonoscopies were performed during the study period. Of these, 10,299 (73 %) were diagnostics and 4,414 (27%) were therapeutics. There were 20 (0.13%) iatrogenic perforations (GI = 14 versus GII = 6). The mean age of the patients was 62 +/- 12.1 years. There were no differences in patient demographics, co-morbidities, and American Society of Anesthesiologists (ASA) grades between the groups. Seventeen patients had segmental colectomy with primary anastomosis (GI: 13 versus GII: 4). One patient in each group had simple suture with diverting ileostomy, and one patient from GII underwent a Hartmann's procedure. Patients from GI had a shorter hospital stay (GI: 4.2 +/- 2.06 days versus GII 11.5 +/- 8.8 days; P = 0.007) and there were no differences in complication rate compared with GII (GI: 3 versus GII: 5; P = 0.058). CONCLUSIONS Laparoscopic colectomy is effective in resolving colonic perforation due to colonoscopy, and it might offer benefits over the open approach.
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Affiliation(s)
- Nicolas A Rotholtz
- Colorectal Surgery Section, General Surgery Department, Hospital Alemán de Buenos Aires, Av Pueyrredón 1640 (1118), Buenos Aires, Argentina.
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Becker RC, Scheiman J, Dauerman HL, Spencer F, Rao S, Sabatine M, Johnson DA, Chan F, Abraham NS, Quigley EMM. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol 2010; 54:2261-76. [PMID: 19942393 DOI: 10.1016/j.jacc.2009.09.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 09/09/2009] [Accepted: 09/15/2009] [Indexed: 01/02/2023]
Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
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Affiliation(s)
- Richard C Becker
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27705, USA.
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Becker RC, Scheiman J, Dauerman HL, Spencer F, Rao S, Sabatine M, Johnson DA, Chan F, Abraham NS, Quigley EMM. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Am J Gastroenterol 2009; 104:2903-17. [PMID: 19935784 DOI: 10.1038/ajg.2009.667] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
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Affiliation(s)
- Richard C Becker
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina 27705, USA.
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Hsieh TK, Hung L, Kang FC, Lan KM, Poon PWF, So EC. Anesthesia Does Not Increase the Rate of Bowel Perforation During Colonoscopy: A Retrospective Study. ACTA ACUST UNITED AC 2009; 47:162-6. [DOI: 10.1016/s1875-4597(09)60049-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Is endoscopic closure with clips effective for both diagnostic and therapeutic colonoscopy-associated bowel perforation? Surg Endosc 2009; 24:1177-85. [PMID: 19915907 DOI: 10.1007/s00464-009-0746-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 10/12/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Colonic perforation is an uncommon but serious colonoscopy-associated complication. This study assessed the effectiveness of conservative management with endoscopic clipping for colonoscopy-associated perforations. METHODS Clinical manifestations and management outcomes were assessed for 38 patients with colonoscopy-associated colonic perforations that occurred between January 2001 and April 2008 at the Asan Medical Center, Seoul, Korea. These perforations were classified as endoscopically evident, endoscopically suspected, and radiologically proven. RESULTS Of the 38 perforations, 19 were endoscopically evident, 9 were endoscopically suspected, and 10 were radiologically proven but without endoscopic evidence. Of the 19 patients with endoscopically evident perforations, 13 (68.4%) underwent endoscopic closure with clips, and all improved without surgery. All nine patients with endoscopically suspected perforations underwent endoscopic closure, and eight (88.9%) improved without surgery. Of the 10 radiologically proven perforations, 7 were detected within 1 day after colonoscopy. All the patients improved without surgery. However, two of the three patients with delayed perforations required emergency laparotomy. Consequently, of the 38 patients with perforations, 29 (76.3%) improved without surgery. Of the 28 patients with endoscopically evident or suspected perforations, conservative management was successful for 21 (95.5%) of the 22 patients with effective clipping, but for none (0%) of the 6 patients without clipping. CONCLUSIONS Conservative management by immediate endoscopic closure with clips can be effective for the treatment of colonic perforations detected during colonoscopy. Conservative management also may be tried cautiously for stable patients who have radiologically proven colonoscopy-associated perforations without endoscopic evidence.
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Kamal A. Learning from our virtual mistakes. Gastrointest Endosc 2009; 70:846-8. [PMID: 19879400 DOI: 10.1016/j.gie.2009.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 07/19/2009] [Indexed: 12/10/2022]
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Yao MD, von Rosenvinge EC, Groden C, Mannon PJ. Multiple endoscopic biopsies in research subjects: safety results from a National Institutes of Health series. Gastrointest Endosc 2009; 69:906-10. [PMID: 19136110 PMCID: PMC5050003 DOI: 10.1016/j.gie.2008.05.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Accepted: 05/05/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Routine endoscopic mucosal biopsies are generally considered safe. However, the outcomes of performing large numbers of biopsies in subjects enrolled in research protocols have not been reported. OBJECTIVE Our purpose was to assess the safety of taking numerous mucosal biopsy specimens during endoscopic procedures (eg, >20/endoscopic procedure) in research subjects. DESIGN Single-center retrospective chart review. SETTING Research hospital: National Institutes of Health (NIH) Clinical Center. PATIENTS Volunteers who underwent research protocol endoscopies with large numbers of biopsies during 2001 to 2008 at the NIH. MAIN OUTCOME MEASUREMENTS Charts were reviewed for the occurrence of procedure-related major/minor complications. RESULTS A total of 253 research endoscopies were performed on 133 patients: 169 colonoscopies, 64 sigmoidoscopies, and 20 upper endoscopies. A total of 9,661 biopsy specimens were obtained for research and histopathologic examination (mean 38.2 +/- 15.6 per procedure). No major complications were identified. Minor complications occurred with 13 (5.1%) lower endoscopic procedures and included self-limited bleeding (4), pain (5), or both (4). There was no statistically significant association between the number of biopsies, type of procedure, location of research biopsies, operator, polypectomy, or the use of nonsteroidal anti-inflammatory drugs and the risk of complications. LIMITATIONS Retrospective design, modest sample size. CONCLUSIONS This is the first report on the safety of performing large numbers of endoscopic biopsies in research subjects. This practice is well tolerated and appears to have no more than minimal risk without appreciably increasing the risk of otherwise routine endoscopy.
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Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos G. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009; 69:654-64. [PMID: 19251006 DOI: 10.1016/j.gie.2008.09.008] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 09/05/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies that reported the incidence of perforation from a colonoscopy are limited by small sample sizes, restricted age groups, or single-center data. OBJECTIVE To determine the incidence and risk factors of colonic perforation from a colonoscopy in a large population cohort. DESIGN Retrospective, population-based, cohort study, followed by a nested case-control study. SETTING California Medicaid program claims database. PATIENTS A total of 277,434 patients (aged 18 years and older) who underwent a colonoscopy during 1995 to 2005, age, sex, and time matched to 4 unique general-population controls. MAIN OUTCOME MEASUREMENTS Perforation incidence in the 7 days after colonoscopy (or matched index date for controls) with odds ratio (OR); multivariate logistic regression to calculate adjusted ORs for subsequent analysis of risk factors. RESULTS A total of 228 perforations were diagnosed after 277,434 colonoscopies, which corresponded to a cumulative 7-day incidence of 0.082%. The OR of getting a perforation from a colonoscopy compared with matched controls (n = 1,072,723) who did not undergo a colonoscopy was 27.6 (95% CI, 19.04-39.92), P < .001. On multivariate analysis, when comparing the group that had a perforation after a colonoscopy (n = 216) with those who did not (n = 269,496), increasing age, significant comorbidity, obstruction as an indication for the colonoscopy, and performance of invasive interventions during colonoscopy were significant positive predictors. Performance of biopsy or polypectomy did not affect the perforation risk. The rate of perforation did not change significantly over time. LIMITATIONS Validity of coding and capturing of all perforation diagnoses may possibly be deficient. CONCLUSION The risk of perforation from a colonoscopy is low, but, despite increased experience with the procedure, it remains unchanged over time.
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Affiliation(s)
- Gaurav Arora
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305-5187, USA
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Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc 2007; 22:1500-4. [DOI: 10.1007/s00464-007-9682-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Revised: 08/30/2007] [Accepted: 10/03/2007] [Indexed: 12/16/2022]
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Kisloff B, Peele PB, Sharam R, Slivka A. Quality of patient referral information for open-access endoscopic procedures. Gastrointest Endosc 2006; 64:565-9. [PMID: 16996351 DOI: 10.1016/j.gie.2006.02.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Accepted: 02/11/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Increased demand for endoscopic procedures has led to the provision of these services without prior consultation (open access). The need for accurate medical referral information for these patients is vital for patient safety. OBJECTIVE To assess the accuracy of endoscopic referral information. DESIGN Over a 4-month study period, patient referral forms were evaluated to determine the accuracy of medical information on patient referral forms by using direct interview with the patient and/or the caregiver. Inconsistencies were validated against medical records. SETTING Large academic medical clinic. PATIENTS A total of 868 open-access patient referrals for upper endoscopy and colonoscopy services. MAIN OUTCOME MEASUREMENTS Referral information about medical diagnoses, medications, allergies, need for antibiotic administration, and current coagulopathies. RESULTS Inaccurate medical referral information was provided to the endoscopist in 8.8% of referrals (n = 76). Among referrals containing errors, there were a total of 95 significant medical information errors, which, if left undetected by preprocedure review, could have resulted in serious adverse consequences for patients undergoing endoscopy. LIMITATIONS Study limited to an academic clinical setting. CONCLUSIONS Patient referrals for endoscopic services in an open-access referral system contain unacceptably high numbers of errors, which place patients at risk for adverse outcomes from endoscopic procedures.
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Affiliation(s)
- Barry Kisloff
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pennsylvania 15261, USA
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Tulchinsky H, Madhala-Givon O, Wasserberg N, Lelcuk S, Niv Y. Incidence and management of colonoscopic perforations: 8 years’ experience. World J Gastroenterol 2006; 12:4211-3. [PMID: 16830377 PMCID: PMC4087376 DOI: 10.3748/wjg.v12.i26.4211] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To review the experience of a major medical teaching center with diagnostic and therapeutic colonoscopies and to assess the incidence and management of related colonic perforations.
METHODS: All colonoscopies performed between January 1994 and December 2001 were studied. Data on patients, colonoscopic reports and procedure-related complications were collected from the departmental computerized database. The medical records of the patients with post procedural colonic perforation were reviewed.
RESULTS: A total of 12 067 colonoscopies were performed during the 8 years of the study. Seven colonoscopic perforations (4 females, 3 males) were diagnosed (0.058%). Five occurred during diagnostic and two during therapeutic colonoscopy. Six were suspected during or immediately after colonoscopy. All except one had signs of diffuse tenderness and underwent immediate operation with primary repair done in 4 patients. No deaths were reported.
CONCLUSION: Perforation rate during colonoscopy is low. Nevertheless, it is a serious complication and its early recognition and treatment are essential to optimize outcome. In patients with diffuse peritonitis early operative intervention makes primary repair a safe option.
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Affiliation(s)
- Hagit Tulchinsky
- Department of Surgery B, Sourasky Medical Center, 6 Veizman St., Tel Aviv 64239, Israel.
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Averbach M, Hashiba K, Corrêa P, Cutait R, Rossini G, Paccos JL, Hasegawa R, Yoza M. Use of a Homemade Nylon Loop for the Prevention of Postpolypectomy Bleeding of Large Pedunculated Polyps. Surg Laparosc Endosc Percutan Tech 2005; 15:275-8. [PMID: 16215486 DOI: 10.1097/01.sle.0000183255.89184.e5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To avoid bleeding after colonoscopic polypectomy, several procedures are being used. We describe a new method that consists of a homemade nylon loop that is applied and tied to the stalk of the pedunculated polyp and after which a conventional polypectomy is done. We have used this method in 15 patients and no complication was observed. The procedure is simple; the loop may be opened to large diameters to make it easier to use for large polyps. It has a low cost and seems to be safe and effective to prevent bleeding after endoscopic polypectomy.
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Abstract
Self-propelling endoscopes offer exciting possibilities for improving access to colon cancer screening, safety of colonoscopy, and efficiency in endoscopy. From an operational perspective, efficiency in endoscopy may be increased or decreased by the introduction of a self-propelling endoscope, depending on the instrument's technical performance characteristics and capabilities, its safety profile, ease of use, the physician time required to review the endoscopic findings, and requirements for sedation, if any. In addition, patient acceptance of such new technology will be a driving force determining its potential for success in the competition for a niche in the diagnostic armamentarium of colon cancer screening.
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Affiliation(s)
- Yang K Chen
- University of Colorado Hospital, Division of Gastroenterology and Hepatology, Anschutz Centers for Advanced Medicine, 1635 N. Ursula Street, Box F-735, Aurora, CO 80010, USA.
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Ker TS, Wasserberg N, Beart RW. Colonoscopic Perforation and Bleeding of the Colon Can be Treated Safely without Surgery. Am Surg 2004. [DOI: 10.1177/000313480407001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The incidence of colonoscopic perforation of colon is about 0.3 per cent. The incidence of colonoscopic bleeding is about 0.6 per cent. Many of those patients undergo unnecessary operations. In order to assess the outcome of nonoperative management of those patients with postcolonoscopic perforation and bleeding, the records of 5120 patients who underwent colonoscopies from September 1, 1988 to June 30, 2003 were retrospectively reviewed with attention paid to colonoscopic perforation and bleeding. Their symptoms, management, and outcome were reviewed. There were 2765 male and 2355 female patients. Ages ranged from 9 to 91 years. A total of 1902 patients (37.1%) had polyps removed. Six patients (0.1%) had colonoscopic perforation. All of them presented with abdominal pain 1 to 4 days after colonoscopic polypectomy. All had subphrenic free air or subcutaneous emphysema on the radiogram. All were treated nonoperatively with nothing by mouth and intravenous fluids and antibiotics in the hospital and recovered uneventfully. Six patients (0.1%) had colonic bleeding that occurred 1 to 14 days after colonoscopic polypectomy. All of them were managed by repeat colonoscopy with injection of epinephrine. All recovered without further bleeding. Therefore, postcolonoscopic perforation and bleeding can be treated nonoperatively. It is safe and cost effective. The mortality and morbidity are very low.
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Affiliation(s)
- Tim S. Ker
- From the Department of Colon and Rectal Surgery, University of Southern California, Los Angeles, California
| | - Nir Wasserberg
- From the Department of Colon and Rectal Surgery, University of Southern California, Los Angeles, California
| | - Robert W. Beart
- From the Department of Colon and Rectal Surgery, University of Southern California, Los Angeles, California
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Dominitz JA, Eisen GM, Baron TH, Goldstein JL, Hirota WK, Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Raddawi HM, Vargo JJ, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO. Complications of colonoscopy. Gastrointest Endosc 2003; 57:441-5. [PMID: 12665750 DOI: 10.1016/s0016-5107(03)80005-6] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Colonoscopy and polypectomy, when performed by adequately trained physicians, is a safe and effective procedure that can decrease deaths resulting from colorectal cancer.
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Affiliation(s)
- Douglas Nelson
- Department of Gastroenterology, Veterans Affairs Medical Center, Minneapolis, MN 55417, USA.
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Nelson DB. Technical assessment of direct colonoscopy screening: procedural success, safety, and feasibility. Gastrointest Endosc Clin N Am 2002; 12:77-84. [PMID: 11916163 DOI: 10.1016/s1052-5157(03)00059-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Colonoscopy, when performed by adequately trained physicians, is a safe and effective procedure for colorectal cancer screening. To realize the benefits of colonoscopic screening of the general population for colorectal cancer, it is imperative that physicians performing this procedure receive appropriate training to maintain the highest standards of patient care.
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Affiliation(s)
- Douglas B Nelson
- Minneapolis Veterans Affairs Medical Center, and the Department of Medicine, University of Minnesota, 55417, USA.
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Dafnis G, Ekbom A, Pahlman L, Blomqvist P. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden. Gastrointest Endosc 2001; 54:302-9. [PMID: 11522969 DOI: 10.1067/mge.2001.117545] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Colonoscopy, introduced in the late 1960s, has become the principal method for diagnosis, treatment, and follow-up of colorectal diseases. Being invasive, colonoscopy is associated with a risk of complications. The aim of this study was to analyze the rate of complications of diagnostic and therapeutic colonoscopy in a population-based setting. METHODS All colonoscopy records for 1979 to 1995 in 1 Swedish county (population 258,000) were retrieved. Information was obtained about patients' demographics, date of examination, endoscopist, indications, findings, colonoscopy type, completion level, and complications. Records were linked to the Cause of Death Register and the Swedish Hospital Discharge Register to ascertain mortality and morbidity. RESULTS In 6066 colonoscopies, the overall morbidity was 0.4% (diagnostic 0.2%, therapeutic 1.2%). The most frequent complications were bleeding (0.2%) and perforation (0.1%), with no colonoscopy-related mortality. Bleeding was confined to therapeutic colonoscopy and occurred immediately, mainly after removal of large polyps with thick stalks. Perforations at diagnostic colonoscopy occurred in the left colon; they were diagnosed sooner than perforations associated with therapeutic colonoscopy where the cecum was the most frequent site. The bleeding rate was correlated to the experience of the endoscopists. CONCLUSIONS Colonoscopy is a safe procedure, and the rate of adverse events in this population-based setting was low.
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Affiliation(s)
- G Dafnis
- Department of Surgery, University Hospital, Uppsala, Sweden
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Abstract
PURPOSE This study was designed to assess the medical and surgical treatment of colonoscopic perforations. METHODS A retrospective review of colonoscopic perforations from 1970 to 1999 was performed. RESULTS In 30 years, 34,620 colonoscopies resulted in 31 (0.09 percent) perforations. Eighteen (58 percent) resulted from therapeutic colonoscopies, whereas 13 (42 percent) occurred after diagnostic colonoscopies. Sixteen perforations (52 percent) were identified during the procedure, 13 (42 percent) within 24 hours, and two (6 percent) within 48 hours. Twenty patients (65 percent) underwent surgical therapy, and 11 (35 percent) were treated medically with intestinal rest and intravenous antibiotics. In the medically treated group, one patient required rehospitalization for percutaneous drainage of an intra-abdominal abscess, and one patient died after requesting no further treatment because of an underlying terminal medical condition. Three patients failed medical treatment and required surgical intervention. One underwent repair with proximal diversion, whereas the remaining two received a colorrhaphy without resection or diversion. In the surgical treatment group, nine patients received colorrhaphy without diversion, seven underwent resection with primary anastomosis, and four had resection with diversion. CONCLUSION Selected patients with colonoscopic perforation may be safely treated nonoperatively. Surgical treatment is reserved for patients with a large perforation or diffuse peritonitis.
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Affiliation(s)
- F Y Araghizadeh
- Department of Colon and Rectal Surgery, Ochsner Clinic, New Orleans, Louisiana, USA
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40
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Hartke RH, Gonzalez-Rothi RJ, Abbey NC. Midazolam-associated alterations in cardiorespiratory function during colonoscopy. Gastrointest Endosc 2001; 35:232-8. [PMID: 2759400 DOI: 10.1016/s0016-5107(89)72764-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Twenty patients undergoing clinically indicated elective colonoscopy were prospectively monitored noninvasively for alterations in cardiorespiratory function. Most of the patients were elderly and many had either cardiac or pulmonary disease. All subjects were premedicated with intramuscular meperidine and continuously monitored with ECG, blood pressure, earlobe pulse oximetry, nasal air flow by thermistor probe, and impedance pneumography. Any use of additional analgesic or sedative was determined by the endoscopist, who was blinded to the physiologic tracings, and dosages of medications given were titrated to each patient's tolerance of the procedures as assessed by the endoscopist. Seventeen patients (85%) required additional sedation with the benzodiazepine, midazolam. These patients exhibited frequent episodes of hypotension (reductions in mean arterial blood pressure of 23 +/- 12 mm Hg from baseline, means +/- SD) and respiratory depression (as noted by the greater number of apneas and arterial oxygen desaturation as low as 7.1 +/- 2% from baseline, means +/- SD). In addition, elderly patients and patients with an underlying history of cardiac or pulmonary disease had a greater incidence of potentially untoward cardiorespiratory events.
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Affiliation(s)
- R H Hartke
- Division of Pulmonary Medicine and Research Service, Veterans Administration Medical Center, Gainesville, Florida 32602
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Wexner SD, Garbus JE, Singh JJ. A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc 2001; 15:251-61. [PMID: 11344424 DOI: 10.1007/s004640080147] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2001] [Accepted: 11/09/2000] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines. METHODS A prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed. RESULTS Between April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001). CONCLUSIONS This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe" colonoscopies.
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Affiliation(s)
- S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, FL 33309, USA.
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Affiliation(s)
- J M Edmonson
- Dittrick Museum of Medical History, Case Western Reserve University, USA
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Cappell MS, Abdullah M. Management of gastrointestinal bleeding induced by gastrointestinal endoscopy. Gastroenterol Clin North Am 2000; 29:125-67, vi-vii. [PMID: 10752020 DOI: 10.1016/s0889-8553(05)70110-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.
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Affiliation(s)
- M S Cappell
- Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA
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ASGE guidelines for clinical application. The role of colonoscopy in the management of patients with colonic polyps neoplasia. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1999; 50:921-4. [PMID: 10644192 DOI: 10.1016/s0016-5107(99)70196-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
The authors investigated the incidence of unplanned work absence the day following outpatient colonoscopy and examined factors associated with missing work. A total of 250 patients were studied. Patient demographic information, the length of the procedure, time of day the exam was performed, and the amount and type of sedation medication used was obtained at the time of the procedure. The incidence and reasons for missing work were elicited via a phone survey 7 days postprocedure. Ten patients (4%) had an unplanned work absence the day after their colonoscopy. No complications were noted. Feeling sleepy and weak or abdominal pain and bloating were the most common reasons for missing work. In univariate analyses, patients with an unplanned work absence were more likely to be younger (p = 0.009), and female (p = 0.02) compared with patients who returned to work. No statistically significant differences were found with regard to the amount of sedation medication used, the length of the procedure, or whether the procedure was performed in the morning or afternoon. Unplanned work absence is low following outpatient colonoscopy in a community-based practice. Female gender and younger age are associated with a higher likelihood of missing work. Postprocedure work absence may have a greater economic impact than procedure-related complications.
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Affiliation(s)
- M K Newcomer
- Health Research Center, Park Nicollet Clinic, Institute for Research and Education, Health System Minnesota, Minneapolis 55416, USA
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Abstract
Cold biopsy of the gastric mucosa is useful in many gastroduodenal disorders. Antral biopsies are done with increasing frequency to confirm Helicobacter pylori infection and to determine the type and content of gastritis. Gastrointestinal bleeding after gastric cold biopsy is rare. We report two patients who developed melena after cold biopsy of the gastric antrum. Repeat gastroscopies excluded lesions other than the biopsied sites as the source of bleeding. Colonoscopies in both cases did not reveal any evidence of lower GI bleed. Relevant medications include amlodipine, in case 1, and brufen, which was used in case 2 but discontinued before biopsy. Literature review has shown the rarity of clinically significant hemorrhage resulting from gastric cold biopsy. Nevertheless, all patients undergoing gastroscopy should be informed of this potential complication.
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Affiliation(s)
- C K Vu
- Monash Medical Centre Gastroenterology Unit, Clayton, Victoria, Australia
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Balsells F, Wyllie R, Kay M, Steffen R. Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review. Gastrointest Endosc 1997; 45:375-80. [PMID: 9165318 DOI: 10.1016/s0016-5107(97)70147-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the past decade, many pediatric endoscopists have replaced general anesthesia with conscious sedation. Sedation is commonly used to minimize discomfort. METHODS To evaluate the safety and efficacy of conscious sedation we reviewed 2711 reports of lower and upper gastrointestinal endoscopic examinations performed in 2026 patients between July 1981 and December 1992. RESULTS Intravenous sedation was accomplished using meperidine and diazepam (914 examinations, 35%) or meperidine and midazolam (1427 examinations, 55%). Single agents were used for 83 examinations (3%), and 96 examinations (3.5%) were performed with the patient under general anesthesia. In the lower endoscopy group sedated intravenously (n = 713), the cecum was reached in 82% of examinations. The procedure could not be completed in 17 cases in which patients were uncooperative despite sedation. In the upper endoscopy group sedated intravenously (N = 1653), all but 91 endoscopies were completed to the descending duodenum. Esophagoscopy had been planned in 76% of these procedures. Minor complications occurred in 7 patients (0.3%). This included two episodes of significant oxygen desaturation that responded to oxygen administration and narcotic reversal. A major complication occurred in 1 patient (0.04%) who had a gastric perforation during esophageal dilation over a defective guide wire. There were no deaths, episodes of cardiorespiratory arrest, or pulmonary aspirations in our series. The combined major and minor complication rate was 0.3%. CONCLUSIONS Intravenous conscious sedation is safe and effective in children undergoing endoscopic examination of the gastrointestinal tract. Selected patients will require general anesthesia.
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Affiliation(s)
- F Balsells
- Pediatric Gastroenterology and Nutrition, Cleveland Clinic Foundation, OH 44195, USA
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Damore LJ, Rantis PC, Vernava AM, Longo WE. Colonoscopic perforations. Etiology, diagnosis, and management. Dis Colon Rectum 1996; 39:1308-14. [PMID: 8918445 DOI: 10.1007/bf02055129] [Citation(s) in RCA: 162] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since its introduction into clinical medicine, flexible fiberoptic colonoscopy has had a great impact on diagnosis and management of diseases of the colon and rectum. There are three mechanisms responsible for colonoscopic perforation: specifically, mechanical perforation directly from the colonoscope or a biopsy forceps, barotrauma from overzealous air insufflation, and, finally, perforations that occur during therapeutic procedures. Perforation of the colon, which requires surgical intervention more frequently than bleeding, occurs in less than 1 percent of patients undergoing diagnostic colonoscopy and may be seen in up to 3 percent of patients undergoing therapeutic procedures such as polyp removal, dilation of strictures, or laser ablative procedures. Management of colonic perforation secondary to colonoscopy remains a controversial issue in that it can be effectively managed by operative and nonoperative measures. If a perforation does occur, signs and symptoms that the patient will experience will be related to both the size and site of the perforation, adequacy of the bowel preparation, amount of peritoneal soilage, underlying colonic pathology (where a thin walled colon from colitis or ischemia, for example, may result in a larger perforation than a healthy colon), and, finally, overall clinical condition of the patient. Radiology often establishes diagnosis. Plain films of the abdomen and an upright chest x-ray may reveal extravasated air confined to the bowel wall, free intraperitoneal air, retroperitoneal air, subcutaneous emphysema, or even a pneumothorax. A localized perforation may demonstrate lack of pneumoperitoneum. Some surgeons recommend surgery for all colonoscopic perforations; however, there does appear to be a role for conservative management in a select group of patients such as those with silent asymptomatic perforations and those with localized peritonitis without signs of sepsis that continue to improve clinically with conservative management. Finally, conservative management works well in those patients with postpolypectomy coagulation syndrome. Surgery is most definitely indicated in the presence of a large perforation demonstrated either colonoscopically or radiographically and in the setting of generalized peritonitis or ongoing sepsis. The presence of concomitant pathology at time of colonoscopic perforation such as a large sessile polyp likely to be a carcinoma, unremitting colitis, or perforation proximal to a nearly obstructing distal colonic lesion may force immediate surgery. Finally, in the patient who deteriorates with conservative management, one should proceed to surgery.
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Affiliation(s)
- L J Damore
- Department of Surgery, Saint Louis University Health Sciences Center, Missouri 63110-0250, USA
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