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Canakis A, Chandan S, Bapaye J, Canakis J, Twery B, Mohan BP, Ramai D, Facciorusso A, Bilal M, Adler DG. Cold Snare Polypectomy in Small (<10 mm) Pedunculated Colorectal Polyps: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:370-377. [PMID: 38289665 DOI: 10.1097/mcg.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/24/2023] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Endoscopic removal techniques for colorectal polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). Although HSP is recommended for pedunculated polyps (PPs) larger than 10 mm, data regarding use of CSP for PPs <10 mm continues to emerge. We aimed to investigate outcomes of these techniques in small (<10 mm) pedunculated colorectal polyps. METHODS Multiple databases were searched till June 2022 to identify studies involving the removal of small PPs with CSP and HSP. Random effects model was used to calculate outcomes and 95% CI. Primary outcome was the pooled rate of successful en-bloc resection. Secondary outcomes were immediate and delayed bleeding with CSP and HSP as well as prophylactic and post resection clip placement. RESULTS Six studies including 1025 patients (1111 polyps with a mean size 4 to 8.5 mm) were analyzed. 116 and 995 polyps were removed with HSP and CSP, respectively. The overall pooled rate of successful en-bloc resection with CSP was 99.7% (CI 99.1-99.9; I2 0%). Pooled immediate and delayed bleeding after CSP was 49.8% (CI 46.8-52.91; I2 98%) and 0% (CI 0.00-0.00; I2 0%), respectively. Delayed bleeding was higher with HSP, relative risk 0.05 (CI 0.01-0.43; I2 0%), P =0.006, whereas immediate bleeding was higher with CSP, relative risk 7.89 (CI 4.36-14.29; I2 0%), P <0.00001. Pooled rates of prophylactic clip placement and post-procedure clip placement (to control immediate bleeding) were 55.3% and 47.2%, respectively. Finally, right colon polyp location significantly correlated with frequency of immediate bleeding. CONCLUSION Our analysis shows that CSP is safe and effective for resection of small PPs.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Justin Canakis
- Department of Internal Medicine, George Washington University School of Medicine, Washington, DC
| | - Benjamin Twery
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota and Minneapolis VA Health Care System, Minneapolis, MN
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, CO
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Stark EM, Lahr RE, Shultz J, Vemulapalli KC, Guardiola JJ, Rex DK. Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit. Endosc Int Open 2024; 12:E579-E584. [PMID: 38654968 PMCID: PMC11039037 DOI: 10.1055/a-2284-9739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/26/2024] [Indexed: 04/26/2024] Open
Abstract
Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.
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Affiliation(s)
- Easton M. Stark
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Rachel E. Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Jeremiah Shultz
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Krishna C. Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - John J. Guardiola
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Douglas K. Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
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Rex DK, Gallagher JA, Lahr RE, Vemulapalli KC, Sharma P, Hassan C. One-device colonoscopy: feasibility, cost savings, and plastic waste reduction by procedure indication, when performed by a high detecting colonoscopist. Endoscopy 2024; 56:102-107. [PMID: 37816393 DOI: 10.1055/a-2189-2679] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND Cold forceps and snares are each effective for removing polyps of 1-3 mm, while snares are more effective for polyps of 4-10 mm in size. If, in the same patient, polyps of 1-3 mm are removed with forceps and those of 4-10 mm with snares, two devices are used. If cold snares are used to resect all lesions of 1-10 mm (one-device colonoscopy), there is a potential for lower costs and less plastic waste. METHODS A single high detecting colonoscopist prospectively measured the feasibility of cold snaring all colorectal lesions of ≤10 mm in size, along with the associated costs and plastic waste reduction. RESULTS 677 consecutive lower gastrointestinal endoscopies (not for inflammatory bowel disease) were assessed. Of 1430 lesions of 1-3 mm and 1685 lesions of 4-10 mm in size, 1428 (99.9%, 95%CI 99.5%-100%) and 1674 (99.3%, 95%CI 98.8%-99.7%), respectively, were successfully resected using cold snaring. Among 379 screening and surveillance patients, universal cold snaring of lesions ≤10 mm saved 35 and 47 cold forceps per 100 screening and surveillance patients, respectively. CONCLUSION Cold snare resection of all lesions ≤10 mm (one-device colonoscopy) was feasible, and reduced costs and plastic waste.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Jackson A Gallagher
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Prateek Sharma
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, United States
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, United States
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
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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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Anderson JC, Rex DK. Performing High-Quality, Safe, Cost-Effective, and Efficient Basic Colonoscopy in 2023: Advice From Two Experts. Am J Gastroenterol 2023; 118:1779-1786. [PMID: 37463252 DOI: 10.14309/ajg.0000000000002407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023]
Abstract
Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, and cost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparation using a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferred method for all polyps < 10 mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations.
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Affiliation(s)
- Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- Division of Gastroenterology, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Zhu XJ, Yang L. Progression in clinical application of cold snare resection technique in colorectal polyps. Shijie Huaren Xiaohua Zazhi 2022; 30:950-955. [DOI: 10.11569/wcjd.v30.i21.950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The cold snare resection technique has been recommended by European and American societies and gradually applied in clinical practice. However, due to the operating habits of endoscopists and the insufficient understanding of the cold resection technique, it has not been fully used in colorectal polyps. In this paper, we review the application status of cold snare resection technique, its use in patients treated with antithrombotic drugs, and postoperative histological changes.
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Affiliation(s)
- Xiao-Jia Zhu
- Department of Gastroenterology, Third People's Hospital of Jingdezhen, Jingdezhen 333000, Jiangxi Province, China
| | - Li Yang
- Department of Gastroenterology, Third People's Hospital of Jingdezhen, Jingdezhen 333000, Jiangxi Province, China
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