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

Prevalence of synchronous neoplasia in patients with large pedunculated colorectal polyps

BACKGROUND

 Large (≥ 20 mm) nonpedunculated colorectal lesions have high rates of synchronous neoplasia and advanced neoplasia. Synchronous neoplasia prevalence in patients with large pedunculated lesions is uncertain. We describe synchronous neoplasia in patients with large pedunculated colorectal polyps, using a cohort of patients with large nonpedunculated lesions as controls.

METHODS

 This study was a retrospective assessment of a prospectively recorded database listing synchronous findings in patients with ≥ 20 mm colorectal lesions referred to a tertiary center for endoscopic resection.

RESULTS

 At least one synchronous precancerous lesion was identified in 66/78 patients with large pedunculated index lesions (84.6 %, 95 %CI 74.9-91.1) and 726/814 patients with large nonpedunculated index lesions (89.2 %, 95 %CI 87.1-91.3). Patients with a large pedunculated index lesion had mean of 4.8 synchronous conventional adenomas, 56.4 % had ≥ 1 synchronous high risk lesion (advanced adenoma or advanced serrated lesion), 48.7 % had ≥ 1 synchronous advanced conventional adenoma, and 19.2 % had a synchronous neoplastic lesion ≥ 20 mm. Compared with patients with nonpedunculated index lesions, patients with large pedunculated index lesions had comparable rates of synchronous polyps, adenomas, and sessile serrated lesions, and higher rates of synchronous adenomas with villous elements (15.6 % [95 %CI 13.3-18.3] vs. 26.9 % [95 %CI 18.3-37.7]; P = 0.01) and synchronous pedunculated polyps (9.5 % [95 %CI 7.6-11.7] vs. 33.3 % [95 %CI 23.8-44.4]; P < 0.001).

CONCLUSION

 In patients with large (≥ 20 mm) pedunculated colorectal lesions, rates of synchronous neoplasia and advanced synchronous neoplasia were high and comparable to or higher than rates of synchronous neoplasia in patients with large nonpedunculated colorectal lesions.

Risk factors for delayed bleeding after endoscopic submucosal dissection of colorectal tumors

AIM

To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) for colorectal neoplasms.

METHODS

We retrospectively reviewed the medical records of 991 consecutive patients who underwent ESD for colorectal neoplasms at our hospital from January 2007 to November 2016. Delayed post-ESD bleeding was defined as bleeding within 6 h to 30 days after ESD that resulted in either of the three situations: overt hematochezia, bleeding spots confirmed by repeat colonoscopy, or the requirement of a blood transfusion. Delayed bleeding was furtherly separated into early and late delayed bleeding by the end of post-ESD day 2. We analyzed the relationship between delayed bleeding and candidate factors including patient-, lesion-, and treatment-related details.

RESULTS

Delayed post-ESD bleeding was found in 47 patients (4.7%), of which 18 cases were late delayed bleeding. Among all patients, 14 patients required a second colonoscopy, and 2 other patients were transferred to surgery. Univariate analysis revealed that patients with hypertension (p = 0.017) and using hot biopsy forceps for wound management (p = 0.028) were significantly associated with late delayed bleeding. Both risk factors remained significant after multivariate analysis: hypertension (OR 2.829, 95% CI 1.101-7.265, p = 0.031), hot biopsy forceps (OR 2.873, 95% CI 1.013-8.147, p = 0.047). Using hot biopsy forceps was also the significant risk factor for late delayed bleeding compared with early delayed bleeding.

CONCLUSION

Patient with hypertension and using hot biopsy forceps for wound management during procedure call for attention on high risk of delayed post-ESD bleeding. Therefore, additional perioperative treatment is recommended in patients with these risk factors.

Current strategies for malignant pedunculated colorectal polyps

Despite significant advances in imaging techniques, the incidence of colorectal cancer has been increasing in recent years, with many cases still being diagnosed in advanced stages. Early detection and accurate staging remain the main factors that lead to a decrease in the cost and invasiveness of the curative techniques, significantly improving the outcome. However, the diagnosis of pedunculated early colorectal malignancy remains a current challenge. Data on the management of pedunculated cancer precursors, apart from data on nonpolypoid lesions, are still limited. An adequate technique for complete resection, which provides the best long-term outcome, is mandatory for curative intent. In this context, a discussion regarding the diagnosis of malignancy of pedunculated polyps, separate from non-pedunculated variants, is necessary. The purpose of this review is to provide a critical review of the most recent literature reporting the different features of malignant pedunculated colorectal polyps, including diagnosis and management strategies.