Polyp and endoscopist-related factors influencing complication rates in difficult colonic polypectomies: results of a multicenter observational study.

BACKGROUND: Current polypectomy practices are highly variable. Endoscopists report increased size, nonpolypoid lesion type and unfavorable position as characteristic of difficult polypectomies. We studied reported difficult colonic polypectomies to determine polyp-related and operator-dependent factors influencing complication rates. PATIENTS AND METHODS: We conducted an international multicenter observational prospective study of difficult colonic polypectomies. Endoscopists reported difficult cases of colonic polypectomies, techniques and complication rates. Per-polyp and per-endoscopist analyses were performed. RESULTS: Ninety procedures were reported at 4 participating centers by 19 endoscopists. 43% of the lesions were pedunculated, 39% were sessile and 18% were flat. Lesion size ranged between 5-60 mm. Bleeding occurred in 18 out of 90 procedures (17 immediate, 1 delayed); no perforations were reported. Bleeding rate was independent of patient age or sex, polyp type, size and histology or resection method. Procedures were deemed difficult due to polyp size (37/90), unfavorable position (23/90), bleeding risk (12/90), lesion type (12/90) or other reasons (6/90) with no statistically significant difference between expert and beginner endoscopists (p = 0.14). CONCLUSION: Difficult colonic polypectomies are unpredictable with a complication rate independent of polyp type or size. There was no difference between experts and beginners with regard to technical aspects of resection or complication rates.

Hydroxy-propyl-methyl-cellulose is a safe and effective lifting agent for endoscopic mucosal resection of large colorectal polyps.

BACKGROUND: Endoscopic mucosal resection (EMR) is today the treatment of choice for flat and sessile colorectal lesion, the only concern being completeness of resection. One of the major issues is the choice of the infiltrating substance to enable a long-lasting cushion under the lesion. The aim of this study was to prospectively evaluate safety and efficacy of hydroxy-propyl-methyl-cellulose (HPMC) injection for this purpose. PATIENTS: All flat and sessile lesions of the colon and rectum larger than 20 mm and considered suitable for EMR were included. In all cases 0.8% HPMC solution was injected through a 23G needle, in quantity according to the endoscopist's indication. Primary endpoints of the study were: (1) ability to perform en bloc resection of the lesions by using this new injection means, (2) complete resection rate, and (3) early and late complication rate. RESULTS: We resected 27 flat, sessile, or laterally spreading lesions up to 60 mm (28 mm average). Mean dose of HPMC injected was 10.2 ml (range 8-40 ml). Median procedure time was 32 min (range 15-105 min). En bloc resection was achieved in up to 21 cases (78%). Histologically detected complete tumour removal was achieved in 23 lesions, whereas lateral margins could not be properly evaluated in 4 cases due to coagulation artefacts. No perforation was observed. Procedural spurting bleeding was managed by epinephrine injection in one case and clip application in the remaining. Two case of local recurrence of adenomatous tissue were observed at 3 and 12 months, and treated by EMR. No complication related to the use of HPMC was observed. CONCLUSIONS: Injection of HPMC for EMR resulted safe and effective, allowing en bloc resection in the majority of cases with a limited number of complications. Continued progress in the field will include more outcomes research and techniques simplification.

Endoclipping for gastric perforation secondary to second session of EMRC in locally residual early gastric cancer: a case report.

A 72-year-old woman underwent gastric endoscopic mucosal resection with a cap-fitted endoscope for an adenocarcinoma in situ. She was scheduled for endoscopic follow-up at 1 and 3 months after the procedure. By the third month of follow up, biopsies of a slightly depressed scar area showed an high grade epithelial dysplasia. For this reason a second endoscopic resection (ER) was performed using the oblique soft cap. A perforation in the site of endoscopic resection was immediately observed. The complication was treated successfully by the application of seven clips.

Management of aortic dissection that involves the right coronary artery.

A report on the follow-up of 11 patients who suffered from aortic dissection involving the right coronary artery and who underwent surgical treatment is reported. In two patients, the left coronary ostia was also affected. In seven patients, the dissection was acute and in four, chronic. The ascending aorta was substituted by a Dacron graft in all patients, and right coronary artery saphenous vein bypass or Gore-Tex graft to the coronary ostia or right coronary artery was performed in nine, and reimplantation of both dissected coronary in two. There were three early postoperative deaths (27.3%) caused by low-output syndrome and myocardial infarction. There were two late deaths. The six surviving patients were followed-up from 78 to 96 months (mean 83 months). This experience suggests that although carrying a high risk, the involvement of the coronary ostia in aortic dissection can be successfully managed if made before irreversible complications arise.