Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients

Delphi consensus statement for the management of delayed post-polypectomy bleeding

Background

Delayed post-polypectomy bleeding (DPPB) is the most common adverse event following colonic polypectomy, yet its management remains highly heterogeneous and lacks standardization. A considerable number of colonoscopies performed for DPPB may be unnecessary and do not result in hemostatic intervention.

Objectives

To develop evidence-based statements to guide clinical decision-making in DPPB.

Design

Multidisciplinary Delphi consensus statement.

Methods

A panel of 29 experts in gastroenterology, hematology, radiology, and surgery was assembled. Through a systematic review of the literature and a modified Delphi process, consensus statements were developed through iterative rounds of anonymous voting. Statements were revised following anonymous voting and feedback at each round. Those achieving 80% agreement were accepted.

Results

The expert panel reached a consensus on 36 statements, covering areas such as antithrombotic management, bowel preparation, colonoscopy indications, and therapeutic hemostatic modalities. Key recommendations include guidance for managing self-limited bleeding and risk stratification to reduce the rate of unnecessary colonoscopies, as well as recommendations for hemodynamically unstable patients who may require primary angioembolization. A practical clinical algorithm is proposed.

Conclusion

This document provides a consensus-based framework for managing DPPB. These recommendations aim to improve patient outcomes and optimize healthcare resources while fostering a standardized approach to this common adverse event.

Clinical Trial: Precise Administration of Sucralfate Powder in Prevention of Delayed Postpolypectomy Bleeding. A Randomized Controlled Trial

INTRODUCTION

Delayed postpolypectomy bleeding occurs in approximately 1%-2% of all patients undergoing colonoscopic polypectomy, and this rate increases to 6% in patients with large (>2 cm) colon polyps. Sucralfate can protect the mucosa and promote its healing. This study was conducted to investigate whether colonoscopic spraying of sucralfate powder on polypectomy wounds can prevent delayed postoperative bleeding.

METHODS

This randomized controlled trial included patients with polyps (size ≥0.5 cm) who had undergone colonoscopic polypectomy at our hospital between May 2023 and January 2024. After polypectomy, the patients received standard treatment for immediate bleeding. Then, they were randomly allocated to either a sucralfate group (prophylactic spraying of sucralfate powder [3 g] on polypectomy wounds) or a control group. All patients were monitored for delayed bleeding within 28 days after colonoscopy.

RESULTS

A total of 160 patients were divided into the sucralfate and control groups (80 per group). The baseline characteristics were balanced between the groups. The rate of delayed postpolypectomy bleeding (0% vs 6.3%, respectively; P = 0.029) and postpolypectomy overt bloody stool (2.4% vs 18.8%, respectively; P = 0.001) were lower in the sucralfate group than in the control group. The duration of freedom from delayed bleeding was longer in the sucralfate group than in the control group ( P = 0.024). Multivariate Cox regression analysis confirmed the additional sucralfate spray as an independent factor against postpolypectomy overt bloody stool (relative risk, 0.03; 95% confidence interval, 0.003-0.43; P = 0.009).

DISCUSSION

Colonoscopic spraying of sucralfate powder is a safe approach with potential to reduce the risk of delayed postpolypectomy bleeding. Trial registration: NCT05817656.

Colonoscopy-Related Adverse Events in the 21st Century: An Updated Systematic Review and Meta-Analysis

INTRODUCTION

Colonoscopy is one of the most commonly performed endoscopic procedures and is generally considered low-risk. However, when adverse events (AEs) occur, they can present significant challenges in clinical practice. The aim of this study was to estimate the global incidence of colonoscopy-related AEs.

METHODS

We searched multiple databases for population-based studies reporting the incidence of colonoscopy-related AEs up to December 22, 2024. Meta-analyses were conducted for both gastrointestinal and nongastrointestinal AEs. Subgroup analyses were performed based on factors including World Health Organization region, publication year, sample size, data collection method, and study design.

RESULTS

Among the 30,818 records identified, 82 population-based studies from 24 countries were included, involving a total of 38.5 million colonoscopies. The estimated incidence per 10,000 colonoscopies was as follows: gastrointestinal AEs, including perforation (5.15; 95% confidence interval [CI] 4.19-6.34, I2 = 99%), bleeding (18.39; 95% CI 13.53-24.99, I2 = 100%), and splenic injury (0.61; 95% CI 0.43-0.85, I2 = 93%); nongastrointestinal AEs, including cardiovascular events (52.11; 95% CI 18.67-144.59, I2 = 100%), respiratory events (4.26; 95% CI 0.73-24.99, I2 = 100%), and deaths related to colonoscopy (0.18; 95% CI 0.10-0.34, I2 = 74%). Subgroup analyses yielded partially divergent findings. The majority of the included studies exhibited a low to moderate risk of bias.

DISCUSSION

This comprehensive meta-analysis provides valuable insights into the global incidence of colonoscopy-related AEs and underscores the imperative need for continuous efforts to enhance the safety of this procedure.

Use of Snare Tip Endoscopic Submucosal Dissection in the Endoluminal Management of Complex Colon Lesions

BACKGROUND

Endoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions.

OBJECTIVE

This study aimed to assess patient outcomes after endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip.

DESIGN

A retrospective review of a prospectively maintained database at a single tertiary care center was conducted.

SETTINGS

This study was conducted at a single tertiary care center.

PATIENTS

Adult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that were lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded.

MAIN OUTCOME MEASURES

En bloc resection rates, operative time, perioperative complications, and short-term outcomes, such as length of stay and lesion recurrence on follow-up colonoscopy, were evaluated.

RESULTS

A total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8%, with an average procedure time of 37.1 ± 29.8 minutes. There were 2 perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy.

LIMITATIONS

This study was retrospective, conducted by 2 skilled endoscopists with experience in endoscopic resection, and had short-term follow-up.

CONCLUSIONS

Snare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing the adoption of endoscopic resection and improving patient accessibility. See Video Abstract .

USO DE LA DISECCIN SUBMUCOSA ENDOSCPICA CON PUNTA DE ASA EN EL TRATAMIENTO ENDOLUMINAL DE LESIONES COMPLEJAS DEL COLON

ANTECEDENTES:La disección submucosa endoscópica para lesiones avanzadas del colon generalmente se realiza con bisturíes endoscópicos especializados y costosos, lo que potencialmente limita la accesibilidad y aumenta el costo del procedimiento. Alternativamente, la punta de asa endoscópica, que es económica y está disponible universalmente, ha demostrado su uso seguro y eficiente en lesiones gástricas, pero carece de datos suficientes para su uso en lesiones de colon.OBJETIVO:Evaluar los resultados de los pacientes después de la disección submucosa endoscópica de lesiones avanzadas del colon utilizando la punta del asa endoscópica.DISEÑO:Revisión retrospectiva de una base de datos mantenida prospectivamente en un único centro de atención terciaria.AJUSTE:Estudio realizado en un único centro de atención terciaria.PACIENTES:Pacientes adultos con lesiones de colon no susceptibles a polipectomía con asa, fueron evaluados para disección submucosa endoscópica. La resección con punta del asa se realizó en pacientes seleccionados con lesiones que se levantaron adecuadamente después de la inyección submucosa. Se excluyeron pacientes sometidos a resecciones híbridas con disección endoscópica de la mucosa.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron las tasas de resección en bloque, tiempo operatorio, complicaciones perioperatorias y resultados a corto plazo, como la duración de la estancia hospitalaria y la recurrencia de la lesión en la colonoscopia de seguimiento.RESULTADOS:Un total de 121 pacientes se sometieron a disección submucosa endoscópica con punta de asa, con un tamaño medio de lesión de 28,8 ± 9,84 mm. La mayoría de los procedimientos se realizaron en la sala de endoscopia (81,8%). La tasa de resección en bloque fue del 81,8% con un tiempo medio de procedimiento de 37,1 ± 29,8 min. Hubo dos perforaciones (1,70%), una de las cuales fue manejada quirúrgicamente. La recurrencia se observó en 6 pacientes (7,89%) durante la colonoscopia de seguimiento.LIMITACIONES:Estudio retrospectivo, realizado por dos endoscopistas expertos con experiencia en resección endoscópica y el seguimiento de corto plazo.CONCLUSIONES:La disección submucosa endoscópica con punta de asa para lesiones avanzadas del colon demuestra resultados satisfactorios a corto plazo, lo que sugiere su potencial como una alternativa segura y accesible a los bisturíes especializados, lo que posiblemente mejore la adopción de la resección endoscópica y la accesibilidad del paciente. (Traducción - Dr. Fidel Ruiz Healy ).

Effect of Cold Versus Hot Snare Polypectomy on Colon Postpolypectomy Bleeding in Patients with End-Stage Renal Disease: A Retrospective Cohort Study

BACKGROUND

Patients with end-stage renal disease (ESRD) who undergo polypectomy may experience postpolypectomy bleeding. To reduce the risk of delayed postpolypectomy bleeding among the general population, cold snare polypectomy (CSP) is recommended for removing colon polyps smaller than 1 cm. Nevertheless, only few studies have examined the effect of CSP on patients with ESRD.

METHODS

We retrospectively analyzed the data of patients with ESRD who underwent colonoscopic polypectomy for polyps larger than 5 mm at a Taiwanese university hospital from January 2014 to January 2023. The main outcome was delayed postpolypectomy bleeding within 30 days. Multivariate analysis was conducted to adjust for major confounders.

RESULTS

A total of 557 patients with ESRD underwent colonoscopic polypectomy during the study period: 201 underwent CSP and 356 underwent hot snare polypectomy (HSP). Delayed postpolypectomy bleeding occurred in 27 patients (4.8%). The rate of delayed postpolypectomy bleeding was lower in patients with ESRD who underwent CSP than in those who underwent HSP (1.9% vs. 6.4%, P = 0.022). The percentage of patients who did not experience postpolypectomy bleeding within 30 days after CSP remained lower than that observed after HSP (P = 0.019, log-rank test). Multivariate analysis demonstrated immediate postpolypectomy bleeding and HSP to be independent risk factors for delayed postpolypectomy bleeding. A nomogram prognostic model was used to predict the potential of delayed postpolypectomy bleeding within 30 days in patients with ESRD.

CONCLUSIONS

Compared with HSP, CSP is more effective in mitigating the risk of delayed postpolypectomy bleeding in patients with ESRD.

Efficacy and Safety of Cold Snare Endoscopic Mucosal Resection (CS-EMR) for Nonampullary Duodenal Polyps: Systematic Review and Meta-Analysis

INTRODUCTION

There is an increasing interest in cold snare endoscopic mucosal resection (CS-EMR), and studies have shown its safety and efficacy for colonic polyps. This meta-analysis aims to assess the safety and efficacy of CS-EMR for the removal of duodenal adenomas.

METHODS

We conducted a comprehensive literature search of several databases, from inception through February 2023, for studies that addressed outcomes of CS-EMR for nonampullary duodenal adenomas. We used the random-effects model for the statistical analysis. The weighted pooled rates were used to summarize the technical success, polyp recurrence, bleeding, and perforation events. Cochran Q test and I2 statistics adjudicated heterogeneity.

RESULTS

Six studies were included in the analysis. In all, 178 duodenal polyps were resected using CS-EMR. The pooled rates were 95.8% (95% CI 89.1-98.5%, I2 =21.5%) for technical success and 21.2% (95% CI 8.5-43.6%, I2 =78%) for polyp recurrence. With regards to CS-EMR safety, the pooled rates were 4.2% (95% CI 1.6-10.5%, I2 =12%) for immediate bleeding, 3.4% (95% CI 1.5-7.6%, I2 =0%) for delayed bleeding, 2.8% (95% CI 1.1-6.7%, I2 =0%) for perforation, and 2% (95% CL 0.5-7.5%, I2 =0%) for post-polypectomy syndrome. Rates were not significantly different for large adenomas. Three studies reported data on CS-EMR and conventional EMR. Compared with conventional EMR, CS-EMR had lower odds of delayed bleeding, OR 0.11 (CI 0.02-0.62, P value 0.012, I2 =0%).

CONCLUSION

Our findings suggest that CS-EMR is a safe and effective strategy for the resection of nonampullary duodenal adenomas, with an acceptable recurrence rate. Data from larger randomized controlled studies are needed to validate our findings.

Comparing efficacy and factors of postoperative bleeding in endoscopic mucosal resection vs coagulation for intestinal polyps

This study aimed to assess the effectiveness of Endoscopic Mucosal Resection (EMR) and Argon Plasma Coagulation (APC) as therapeutic approaches for intestinal polyps in patients, and to examine the factors associated with postoperative bleeding. This study included 132 patients diagnosed with colorectal polyps (188 polyps) who underwent endoscopic surgery at our hospital between January 2022 and December 2022. Based on the surgical method employed, the patients were divided into 2 groups: EMR (68 cases, 97 polyps) and APC (64 cases, 91 polyps). Comparative analyses were conducted to assess the clinical efficacy, surgery-related indicators, and quality of life the 2 groups. Furthermore, an investigation was carried out to identify the factors associated with postoperative bleeding. The analysis revealed no statistically significant difference in the cure rate of flat and superficial raised polyps between the EMR group and the APC (P > .05). However, it was found that the EMR group exhibited a significantly higher cure rate for subpedunculated and raised-pedunculated polyps compared to the APC group (P < .05). The results of logistics analysis showed that patients with hypertension (OR = 2.876, 95% CI: 1.119-7.393), patients with diabetes (OR = 5.278, 95% CI: 1.388-20.064), patients with hyperlipidemia (OR = 2.594, 95% CI: 1.054-6.380), the polyps of right hemicolon (OR = 2.743, 95% CI: 1.003-7.504), rectal polyps (OR = 5.143, 95% CI: 1.728-7.504), pedunculated polyps (OR = 4.758, 95% CI: 1.322-17.129), adenomatous polyps (OR = 3.152, 95% CI: 1.018-9.757) were independent risk factors for postoperative bleeding in patients with colorectal polyps (P < .05). The findings suggest that for subpedunculated and pedunculated-raised polyps, EMR can be a suitable treatment approach. On the other hand, flat and superficial-raised polyps can be effectively managed with either EMR or APC. The presence of hypertension, diabetes, hyperlipidemia, polyps of the right hemicolon, rectal polyps, pedunculated polyps, and adenomatous polyps has been established as independent risk factors for postoperative bleeding in patients with colorectal polyps.

Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics

Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.

Outcomes of thin versus thick-wire snares for cold snare polypectomy: a systematic review and meta-analysis

BACKGROUND/AIMS

Cold snare polypectomy (CSP) is commonly used for the resection of colorectal polyps ≤10 mm. Data regarding the influence of snare type on CSP effectiveness are conflicting. Hence, this meta-analysis aimed to compare the outcomes and safety of thin- and thick-wire snares for CSP.

METHODS

A comprehensive search of the literature published between 2000 and 2021 was performed of various databases for comparative studies evaluating the outcomes of thin- versus thick-wire snares for CSP.

RESULTS

Five studies with data on 1,425 polyps were included in the analysis. The thick-wire snare was comparable to the thin-wire snare with respect to complete histological resection (risk ratio [RR], 1.03; 95% confidence interval [CI], 0.97-1.09), overall bleeding (RR, 0.98; 95% CI, 0.40-2.40), polyp retrieval (RR, 1.01; 95% CI, 0.97-1.04), and involvement of submucosa in the resection specimen (RR, 1.28; 95% CI, 0.72-2.28). There was no publication bias and a small study effect, and the relative effects remained the same in the sensitivity analysis.

CONCLUSION

CSP using a thin-wire snare has no additional benefit over thick-wire snares in small colorectal polyps. Factors other than snare design may play a role in improving CSP outcomes.

Establishment of a model for predicting delayed post-polypectomy bleeding: A real-world retrospective study

Background

Delayed post-polypectomy bleeding (DPPB) is the most common complication which occurs within 30 days after polypectomy, it has become rather common with the widespread of colorectal cancer screening. It is important to clarified predictors of DPPB and identify patients at high risk.

Materials and methods

This was a real-world retrospective study based on medical records from The First Affiliated Hospital of Nanjing Medical University. Cases of patients who underwent colonoscopic polypectomy between January 2016 and December 2020 were reviewed to identify risk factors of DPPB. We use the LASSO-Logistic regression analysis model to identify independent predictors and create a predictive model. The model finally got visualized by developing a nomogram.

Results

Colonoscopic polypectomy was done on 16,925 patients in our study. DPPB occurred in 125 (0.74%) of these instances. In multivariate analysis, age, sex, hypertension, polyp location, polyp size, and operative modality were found to be independent risk factors and were integrated for the construction of a nomogram. The model’s C-index is 0.801 (95%CI: 0.761–0.846). We also found polyps located at the right semicolon and polyp ≥ 1 cm associated with active bleeding under the therapeutic colonoscopy.

Conclusion

Young age, male, hypertension, polyp ≥ 1 cm, proximal colon location and operative modality were finally identified as significant predictors of DPPB. We developed and validated a nomogram which performs well in predicting the incidence of DPPB, the model we established can be used as a valuable screening tool to identify patients who are at high risk of bleeding.