Cold Snare Resection in the Colorectum: When to Choose it, When to Avoid it, and How to Do it.

Cold snaring is now the preferred resection method for the majority of colorectal polyps encountered during colonoscopy. A key advantage of cold resection over resection utilizing electrocautery is a substantially lower risk of delayed hemorrhage. Cold snare resection is preferred for all lesions ≤ 10 mm and for non-dysplastic sessile serrated lesions of any size, but should be avoided when lesions have a significant risk of submucosal invasion or fibrosis. Cold snare resection can be considered for certain lesions 11-19 mm in size and some lateral spreading lesions ≥ 20 mm. This review discusses tips and techniques to optimize cold snare resection.

AGA Clinical Practice Update on the Role of Artificial Intelligence in Colon Polyp Diagnosis and Management: Commentary.

DESCRIPTION: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert commentary on the current landscape of artificial intelligence in the evaluation and management of colorectal polyps. METHODS: This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This Expert Commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are experienced endoscopists with expertise in the field of artificial intelligence and colorectal polyps.

A colonial serrated polyp classification model using white-light ordinary endoscopy images with an artificial intelligence model and TensorFlow chart.

In this study, we implemented a combination of data augmentation and artificial intelligence (AI) model-Convolutional Neural Network (CNN)-to help physicians classify colonic polyps into traditional adenoma (TA), sessile serrated adenoma (SSA), and hyperplastic polyp (HP). We collected ordinary endoscopy images under both white and NBI lights. Under white light, we collected 257 images of HP, 423 images of SSA, and 60 images of TA. Under NBI light, were collected 238 images of HP, 284 images of SSA, and 71 images of TA. We implemented the CNN-based artificial intelligence model, Inception V4, to build a classification model for the types of colon polyps. Our final AI classification model with data augmentation process is constructed only with white light images. Our classification prediction accuracy of colon polyp type is 94%, and the discriminability of the model (area under the curve) was 98%. Thus, we can conclude that our model can help physicians distinguish between TA, SSA, and HPs and correctly identify precancerous lesions such as TA and SSA.

Colonoscopic-assisted laparoscopic wedge resection versus segmental colon resection for benign colonic polyps: a comparative cost analysis.

AIM: The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR. METHOD: A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period. RESULTS: Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001). CONCLUSION: Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.

Clinical Evaluation of Computer-Aided Colorectal Neoplasia Detection Using a Novel Endoscopic Artificial Intelligence: A Single-Center Randomized Controlled Trial.

INTRODUCTION: Computer-aided diagnostic systems are emerging in the field of gastrointestinal endoscopy. In this study, we assessed the clinical performance of the computer-aided detection (CADe) of colonic adenomas using a new endoscopic artificial intelligence system. METHODS: This was a single-center prospective randomized study including 415 participants allocated into the CADe group (n = 207) and control group (n = 208). All endoscopic examinations were performed by experienced endoscopists. The performance of the CADe was assessed based on the adenoma detection rate (ADR). Additionally, we compared the adenoma miss rate for the rectosigmoid colon (AMRrs) between the groups. RESULTS: The basic demographic and procedural characteristics of the CADe and control groups were as follows: mean age, 54.9 and 55.9 years; male sex, 73.9% and 69.7% of participants; and mean withdrawal time, 411.8 and 399.0 s, respectively. The ADR was 59.4% in the CADe group and 47.6% in the control group (p = 0.018). The AMRrs was 11.9% in the CADe group and 26.0% in the control group (p = 0.037). CONCLUSION: The colonoscopy with the CADe system yielded an 11.8% higher ADR than that performed by experienced endoscopists alone. Moreover, there was no need to extend the examination time or request the assistance of additional medical staff to achieve this improved effectiveness. We believe that the novel CADe system can lead to considerable advances in colorectal cancer diagnosis.

Liver Cirrhosis Increases the Risk of Developing Advanced Colon Polyps.

GOALS: To analyze our experience with adenoma detection rates in patients with liver cirrhosis in a community setting. BACKGROUND: Colorectal cancer (CRC) is the third most common cancer and leading cause of cancer death in men and women in the USA. The majority of CRCs arise from premalignant polyps (adenomas), which are typically detected and removed during colonoscopy. Data are limited on the risk of CRC in patients with various chronic liver diseases and the association between CRC and demographics, liver disease etiology and colonoscopy findings. STUDY RESULTS: A total of 351 colonoscopies were performed (2006 to 2019) in patients with liver cirrhosis. Mean age was 62.3 ± 9.4 years, there were 158 females and 193 males. Adenomas were found in 159 procedures (49.07%) and were more likely found in the right colon (76.73%) vs the left colon (18.87%). Left-sided adenoma occurrence was significantly lower in women (61% lower than men, p = 0.05). Neither indication for the procedure (p = 0.08) nor advancing age (p = 0.94) affected adenoma detection rates. No significant differences were observed in the findings of adenomas between different chronic liver diseases. CONCLUSIONS: Adenoma detection rates in patients with cirrhosis (49%) undergoing elective colonoscopy were higher than rates reported in the literature for LT candidates (22-42%) undergoing standardized screenings. Colonoscopy screenings should be expanded to all patients with cirrhosis, regardless of etiology.

Detection of High-Risk Sessile Serrated Lesions: Multitarget Stool DNA Versus CT Colonography.

BACKGROUND. The serrated pathway for colorectal cancer (CRC) development is increasingly recognized. Sessile serrated lesions (SSLs) that are large (≥ 10 mm) and/or have dysplasia (i.e., high-risk SSLs) are at higher risk of progression to CRC. Detection of SSLs is challenging given their predominantly flat and right-sided location. The yield of noninvasive screening tests for detection of high-risk SSLs is unclear. OBJECTIVE. The aim of this study was to compare noninvasive screening detection of high-risk SSLs between the multitarget stool DNA (mt-sDNA) test and CT colonography (CTC). METHODS. This retrospective study included 7974 asymptomatic adults (4705 women, 3269 men; mean age, 60.0 years) who underwent CRC screening at a single center by mt-sDNA from 2014 to 2019 (n = 3987) or by CTC from 2009 to 2019 (n = 3987). Clinical interpretations of CTC examinations were recorded. Subsequent colonoscopy findings and histology of resected polyps were also recorded. Chi-square or two-sample t tests were used to compare results between mt-sDNA and CTC using 6-mm and 10-mm thresholds for test positivity. RESULTS. The overall colonoscopy referral rate for a positive screening test was 13.1% (522/3987) for mt-sDNA versus 12.2% (487/3987; p = .23) and 6.5% (260/3987; p < .001) for CTC at 6-mm and 10-mm thresholds, respectively. The PPV for high-risk SSLs was 5.5% (26/476) for mt-sDNA versus 14.4% (66/457; p < .001) and 25.9% (63/243; p < .001) for CTC at the 6-mm and 10-mm thresholds, respectively. The overall screening yield of high-risk SSLs was 0.7% (26/3987) for mt-sDNA versus 1.7% (66/3987; p < .001) and 1.6% (63/3987; p < .001) for CTC at 6-mm and 10-mm thresholds, respectively. CONCLUSION. CTC at 6-mm and 10-mm thresholds had significantly higher yield and PPV for high-risk SSLs compared with mt-sDNA. CLINICAL IMPACT. The significantly higher detection of high-risk SSLs by CTC than by mt-sDNA should be included in discussions with patients who decline colonoscopy and opt for noninvasive screening.

Is inguinal hernia associated with an increased risk of colon cancer? A systematic review and meta-analysis.

BACKGROUND: The presence of an inguinal hernia has been associated with an increased risk of identifying colon cancer, and therefore colonoscopy is recommended prior to inguinal hernia repair. However, the evidence on the association between the presence of an inguinal hernia and colon cancer is conflicting and uncertain. We performed a systematic review and meta-analysis to synthesize all available evidence on this topic. METHODS: A comprehensive search of PubMed and EMBASE was performed. Any comparative study (case-control or cohort study) comparing the rate of colon cancer detection in patients with and without inguinal hernias who underwent screening colonoscopy or flexible sigmoidoscopy was eligible for inclusion. Data were extracted and pooled under a random effects model. RESULTS: The initial search identified 692 references, of which 4 comparative studies (1462 patients) met the inclusion criteria. The overall risk of bias in the included studies was low. Pooled results showed a statistically non-significant difference in the incidence of detection of colon cancer, with patients with inguinal hernia having a 1.26 times increased likelihood of colon cancer diagnosis compared with patients without inguinal hernia (odds ratio (OR) 1.26; 95% confidence interval (CI) 0.63-2.51; P = 0.51). Although patients with inguinal hernia were also 1.23 times more likely to be diagnosed with colon polyps compared to patients without inguinal hernia, this difference was statistically non-significant (OR 1.23; 95% CI 0.94-1.60; P = 0.12). CONCLUSION: The findings from this first systematic review and meta-analysis show that there is no difference in the incidence of either colon cancer or colon polyps in patients presenting with inguinal hernias compared to those without. Nevertheless, larger prospective studies are needed to further investigate the relationship between the risk of colon cancer or polyps and the presence of inguinal hernia.

Trends of Colonic Neoplasia in US Outpatient Endoscopy Centers.

BACKGROUND: A variety of studies have shown rising trends in the occurrence of colorectal cancer in younger patients as opposed to falling trends among older patients aged 55 years or more. We hypothesized that the time trends of benign colonic precursor lesions would reveal similar patterns. AIMS: The present study was designed to test this hypothesis in a large nationwide sample of the US population undergoing colonoscopy in community-based endoscopy centers. METHODS: The Inform Diagnostics database is an electronic repository of histopathologic records of patients distributed throughout the USA. A cross-sectional study analyzed the detection rates of sessile serrated adenomas (SSA), hyperplastic polyps (HP), tubular adenomas (TA), traditional serrated adenomas (TSA), or adenocarcinomas (colorectal cancer, CRC) in 2,910,174 colonoscopies done 2008-2020. RESULTS: During the 13-year time period, the rate of SSA showed a significant rise, both in patients younger and older than 55 years. HP and TA both showed a significant decline during the same time period. The trends of CRC in the older age group decreased significantly between 2008 (or its peak in 2012) and 2020. The trends of CRC in the younger age group increased significantly between 2008 and its peak in 2017. CONCLUSIONS: The age-specific time trends of benign and malignant colonic neoplasia are characterized by dissimilar temporal patterns. Such dissimilarity could suggest that besides a set of shared risk factors that affect all types of colonic neoplasia alike, there is yet another set of environmental risk factors that specifically influence malignant transformation.

Are the current colonoscopy recommendations for interval surveillance in patients with polyps enough? Machine learning-augmented propensity score cohort analysis of 1840 patients.

BACKGROUND: Colonoscopy remains the gold standard for screening and surveillance of colorectal neoplasms, and is associated with a lower risk of colorectal cancer (CRC)-related mortality. The current interval surveillance recommendations in patients with previous adenomas lack sufficient evidence. The prevalence of subsequent adenomas, and especially high-risk adenomas, during surveillance is not well known. METHODS: The primary outcome of this study was to determine the prevalence of polyps upon surveillance colonoscopy in patients who have a history of adenomas on initial average-risk-screening colonoscopy, but then have a normal initial surveillance (second) colonoscopy between 2003 and 2017. This is the first known retrospective cohort study of adenoma detection rate (ADR) with sub-group analysis of patients with serial surveillance colonoscopies by abnormal and high-risk surveillance findings separately by prior abnormal colonoscopies and correct surveillance strategies based on the recent March 2020 updated guidelines. After ADR calculation, machine learning-augmented propensity score adjusted multivariable regression with augmented inverse-probability weighting propensity (AIPW) score analysis was used to assess the relationship between guideline adherence, as well as abnormal and high-risk surveillance findings. RESULTS: A total of 1840 patients with pathologically confirmed adenomas or cancer on an initial average-risk-screening (first) colonoscopy met study criteria. 837 (45.5%) had confirmed adenomas on second colonoscopy, and 1003 (54.5%) had normal findings. Of 837 patients with polyps on both first and second colonoscopy, 423 (50.5%) had adenomas on third colonoscopy. Of the 1003 patients without polyps on second colonoscopy, 406 (40.5%) had confirmed adenomas on third colonoscopy. Guideline adherence was low at 9.18%, though was associated in propensity score adjusted multivariable regression with increased odds of an abnormal third (but not high-risk) colonoscopy, with comparable AIPW results. CONCLUSION: This 14-year study demonstrates the ADR to be > 40% on the third colonoscopy for patients with adenomas on initial screening colonoscopy, who then have a normal second colonoscopy. Through advanced machine learning and propensity score analysis, we showed that correct adherence is associated with higher odds of abnormal, but not high-risk abnormal 3rd colonoscopy, with evidence that high-risk surveillance findings are reduced by providers shortening the time between surveillance colonoscopies in contrast to the guidelines for those for whom there is presumed greater clinical suspicion of eventual cancer. Larger prospective trials are needed to guide optimal surveillance for these patients.

Clinician based decision tool to guide recommended interval between colonoscopies: development and evaluation pilot study.

BACKGROUND: Optimal intervals between repeat colonoscopies could improve patient outcomes and reduce costs. We evaluated: (a) concordance between clinician and guideline recommended colonoscopy screening intervals in Winnipeg, Manitoba, (b) clinician opinions about the utility of an electronic decision-making tool to aid in recommending screening intervals, and (c) the initial use of a decision-making smartphone/web-based application. METHODS: Clinician endoscopists and primary care providers participated in four focus groups (N = 22). We asked participating clinicians to evaluate up to 12 hypothetical scenarios and compared their recommended screening interval to those of North American guidelines. Fisher's exact tests were used to assess differences in agreement with guidelines. We developed a decision-making tool and evaluated it via a pilot study with 6 endoscopists. RESULT: 53% of clinicians made recommendations that agreed with guidelines in ≤ 50% of the hypothetical scenarios. Themes from focus groups included barriers to using a decision-making tool: extra time to use it, less confidence in the results of the tool over their own judgement, and having access to the information required by the tool (e.g., family history). Most were willing to try a tool if it was quick and easy to use. Endoscopists participating in the tool pilot study recommended screening intervals discordant with guidelines 35% of the time. When their recommendation differed from that of the tool, they usually endorsed their own over the guideline. CONCLUSIONS: Endoscopists are overconfident and inconsistent with applying guidelines in their polyp surveillance interval recommendations. Use of a decision tool may improve knowledge and application of guidelines. A change in practice may require that the tool be coupled with continuing education about evidence for improved outcomes if guidelines are followed.

Detecting colon polyps in endoscopic images using artificial intelligence constructed with automated collection of annotated images from an endoscopy reporting system.

BACKGROUND: Artificial intelligence (AI) has made considerable progress in image recognition, especially in the analysis of endoscopic images. The availability of large-scale annotated datasets has contributed to the recent progress in this field. Datasets of high-quality annotated endoscopic images are widely available, particularly in Japan. A system for collecting annotated data reported daily could aid in accumulating a significant number of high-quality annotated datasets. AIM: We assessed the validity of using daily annotated endoscopic images in a constructed reporting system for a prototype AI model for polyp detection. METHODS: We constructed an automated collection system for daily annotated datasets from an endoscopy reporting system. The key images were selected and annotated for each case only during daily practice, not to be performed retrospectively. We automatically extracted annotated endoscopic images of diminutive colon polyps that had been diagnosed (study period March-September 2018) using the keywords of diagnostic information, and additionally collect the normal colon images. The collected dataset was devised into training and validation to build and evaluate the AI system. The detection model was developed using a deep learning algorithm, RetinaNet. RESULTS: The automated system collected endoscopic images (47,391) from colonoscopies (745), and extracted key colon polyp images (1356) with localized annotations. The sensitivity, specificity, and accuracy of our AI model were 97.0%, 97.7%, and 97.3% (n = 300), respectively. CONCLUSION: The automated system enabled the development of a high-performance colon polyp detector using images in endoscopy reporting system without the efforts of retrospective annotation works.

[The ways of developing organizational principles of coloproctologic care of patients with large intestine neoplasms].

The colorectal cancer remains one of leading problems of modern coloproctology and oncology. The polyps are one of pathology of colon widespread in population and predictor of colorectal cancer. Their timely detection and removal is considered as only effective measure of prevention of colon malignant neoplasms. The morbidity of colon malignant neoplasms in the Perm Kray was monitored in 2004-2018. Its structure and dynamics were evaluated. The software is described that allows both physicians and patients to evaluate probability of detecting colon neoplasms that contributes to expansion of the research database of coloproctologic studies. The ways of increasing effectiveness of predicting incidence of colorectal cancer and colon polyps were proposed on the basis of neural networks, that permit to increase detection of corresponding pathology by personalizing screening.

[The analysis of impact of medical social and economic factors on regional coloproctological morbidity of adult population].

Actually, there is constant increase of number of patients with coloproctological diseases, including corresponding malignant neoplasms. At that, issues of improving organization of specialized care of patients of this kind still remain unresolved in many positions. The retrospective analysis of regional coloproctological morbidity of adult population was carried out as exemplified by the Perm Kray. To forecast onset of colorectal cancer multiple logistic regression analysis was applied. To assess relationship of particular factors and morbidity, the Spearman rank correlation method was implemented. The ROC-analysis was applied using MedCalc software. The study established strong relationship between the presence of colorectal cancer and colon polyps (87.2%, Somers' D = 0.868). According to ROC analysis data, colon polyps are risk factor of development of colorectal cancer in 93.4% of cases. The pronounced relationship is demonstrated for presence of colon polyps and colorectal cancer detectability (OR 225.85, CI 61.5 - 829.15, p <0.0001). The results of analysis of regional coloproctological morbidity of adult population in 45 municipalities of the Perm Kray testify significant variability of territorial features. The study revealed that level of coloproctological morbidity in municipalities depends on such indices as provision of physicians and hospital beds and average salary. The study results testify necessity to consider territorial characteristics of Perm Kray in planning complex coloproctological care of population. The identified interrelationships of population morbidity, activities and resource support are to be taken into account in planning organizational measures to modernize treatment and preventive care of coloproctological patients, including early diagnosis of coloproctological cancer in combination with other measures to reduce overall level of coloproctological morbidity on territory of Perm Kray and to improve quality of life of patients.

Transcriptome of CD8+ tumor-infiltrating T cells: a link between diabetes and colorectal cancer.

There is an increased risk of colorectal cancer (CRC) development in patients with non-insulin-dependent type 2 diabetes. CD8+ T cells have been implicated in diabetes and are crucial for anti-tumor immunity. However, transcriptomic profiling for CD8+ T cells from CRC diabetic patients has not been explored. We performed RNA sequencing and compared transcriptomic profiles of CD8+ tumor-infiltrating T lymphocytes (CD8+ TILs) in CRC diabetic patients with CRC nondiabetic patients. We found that genes associated with ribogenesis, epigenetic regulations, oxidative phosphorylation and cell cycle arrest were upregulated in CD8+ TILs from diabetic patients, while genes associated with PI3K signaling pathway, cytokine response and response to lipids were downregulated. Among the significantly deregulated 1009 genes, 342 (186 upregulated and 156 downregulated) genes were selected based on their link to diabetes, and their associations with the presence of specific CRC pathological parameters were assessed using GDC TCGA colon database. The 186 upregulated genes were associated with the presence of colon polyps history (P = 0.0007) and lymphatic invasion (P = 0.0025). Moreover, CRC patients with high expression of the 186 genes were more likely to have poorer disease-specific survival (DSS) (Mantel-Cox log-rank P = 0.024) than those with low score. Our data provide novel insights into molecular pathways and biological functions, which could be altered in CD8+ TILs from CRC diabetic versus nondiabetic patients, and reveal candidate genes linked to diabetes, which could predict DSS and pathological parameters associated with CRC progression. However, further investigations using larger patient cohorts and functional studies are required to validate these findings.

External validation of blue light imaging (BLI) criteria for the optical characterization of colorectal polyps by endoscopy experts.

BACKGROUND AND AIM: Recently, the BLI Adenoma Serrated International Classification (BASIC) system was developed by European experts to differentiate colorectal polyps. Our aim was to validate the BASIC classification system among the US-based endoscopy experts. METHODS: Participants utilized a web-based interactive learning system where the group was asked to characterize polyps using the BASIC criteria: polyp surface (presence of mucus, regular/irregular and [pseudo]depressed), pit appearance (featureless, round/non-round with/without dark spots; homogeneous/heterogeneous distribution with/without focal loss), and vessels (present/absent, lacy, peri-cryptal, irregular). The final testing consisted of reviewing BLI images/videos to determine whether the criteria accurately predicted the histology results. Confidence in adenoma identification (rated "1" to "5") and agreement in polyp (adenoma vs non-adenoma) identification and characterization per BASIC criteria were derived. Strength of interobserver agreement with kappa (k) value was reported for adenoma identification. RESULTS: Ten endoscopy experts from the United States identified conventional adenoma (vs non-adenoma) with 94.4% accuracy, 95.0% sensitivity, 93.8% specificity, 93.8% positive predictive value, and 94.9% negative predictive value using BASIC criteria. Overall strength of interobserver agreement was high: kappa 0.89 (0.82-0.96). Agreement for the individual criteria was as follows: surface mucus (93.8%), regularity (65.6%), type of pit (40.6%), pit visibility (66.9%), pit distribution (57%), vessel visibility (73%), and being lacy (46%) and peri-cryptal (61%). The confidence in diagnosis was rated at high ≥4 in 67% of the cases. CONCLUSIONS: A group of US-based endoscopy experts have validated a simple and easily reproducible BLI classification system to characterize colorectal polyps with >90% accuracy and a high level of interobserver agreement.

Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial.

BACKGROUND AND AIM: Prophylactic clipping (PC) after polypectomy has the potential to prevent post-polypectomy bleeding (PPB). We aimed to evaluate the effectiveness of PC in preventing PPB for < 20-mm polyps. METHODS: This multicenter, open-label, randomized controlled trial conducted from December 2013 to June 2017 at 10 institutions randomly assigned 1080 patients with < 20-mm colon polyps to the non-PC and PC groups. Allocation factors were institution, antiplatelet drug use, and polyp number. The primary endpoint was differences in PPB rates between the groups. The severity of PPB and post-procedural abdominal symptoms were also investigated. These endpoints in intention-to-treat and per-protocol (PP) analyses were evaluated. RESULTS: We investigated 1039 patients with 2960 lesions. There was no significant difference between the groups in characteristics including age, sex, hypertension, diabetes, hyperlipidemia, antiplatelet drug use, and lesion characteristics such as type and size. Excluding the clip used in the non-PC group, intraoperative bleeding, and deviation of protocol, 903 patients were investigated in PP analysis. There was no significant difference in the PPB rate between the non-PC and PC groups (2.7% vs 2.3%, P = 0.6973 [intention-to-treat analysis]; 3.0 vs 2.4%, P = 0.7353 [PP analysis]). Severe PPB (≥ grade 3) was similar between the groups. Total procedure time was significantly shorter in the non-PC group than in the PC group (31 vs 36 min, P = 0.0002). Post-procedural abdominal fullness was less common in the non-PC group than in the PC group (20.8% vs 25.6%, P = 0.0833). CONCLUSION: Prophylactic clipping is not effective in preventing PBB for < 20-mm colon polyps (UMIN000012163).

Laparoscopic wedge resection as an alternative to laparoscopic oncological colon resection for benign endoscopically unresectable colon polyps.

AIM: The aim of this study was to investigate, by comparing clinical and histological outcomes, whether laparoscopic (hybrid) wedge resection (LWR) could be a less invasive and safe alternative to laparoscopic oncological colon resection (OCR) for patients with an endoscopically unresectable, suspected benign, colon polyp. METHOD: All patients with an endoscopically unresectable colon polyp who were referred for surgery between 2009 and 2018 and without biopsy-proven colon cancer were identified from a prospectively maintained database. Patients with macroscopic features of malignancy during endoscopy were excluded. Clinical and histological results for patients who underwent OCR or LWR were reviewed. RESULTS: One hundred-and-twenty-two patients were included. Ninety-seven patients underwent OCR and 25 LWR. Major complications occurred in 16.7% (n = 16) of the OCR group compared with 4.0% (n = 1) of the LWR group (p = 0.06). In the OCR group the anastomotic leakage rate was 6.3% (n = 6) and the mortality rate 3.1% (n = 3). No anastomotic leakage or deaths occurred in the LWR group. The median length of hospital stay after OCR was 5 days [interquartile range (IQR) 5-9 days)] compared with 2 days (IQR 2-4 days) after LWR (p < 0.0001). Definite pathology showed a malignancy rate of 4.2% (n = 4) in the OCR group and 4.0% (n = 1) (without high-risk features) in the LWR group. CONCLUSION: This study shows that LWR was associated with significantly lower complication rates and acceptable oncological risks compared with OCR. Therefore we suggest that LWR is a safe alternative treatment, next to other endoscopic options. The treatment that is most suitable for an individual patient should be discussed in a multidisciplinary meeting.

Endoscopic resection reduces morbidity when compared to surgery in veterans with large and complex colorectal polyps.

INTRODUCTION: Data supporting endoscopic resection (ER) over surgical resection (SR) for large and complex polyps come from high-volume centers. The aim of this study was to determine whether these favorable outcomes can be replicated among endoscopists at tertiary Veterans Affairs Medical Centers (VAMCs) who perform 25 to 30 ER cases a year. METHODS: Patients with adenomatous polyps or intra-mucosal cancers ≥ 2 cm in size who underwent ER or SR were identified from prospectively maintained databases at the 2 tertiary VAMCs in Veterans Integrated Service Network 6 (VISN6). The primary outcome was the rate of serious complications in the ER and SR groups. RESULTS: 310 ER and 81 SR patients met the inclusion criteria. ER was successful in 97% of all polyps, and 93% of polyps ≥ 4 cm. The rate of serious complications was significantly lower with ER compared to SR (0.6% vs. 22%, p = 0.00001). These findings persisted even after limiting the analysis to polyps ≥ 4 cm and after propensity score matching. If all ER patients had instead undergone laparoscopic surgery, the estimated risk of a serious complication was still higher than ER for all patients (8% vs. 0.6%, p < 0.0001) but not significantly higher for polyps ≥ 4 cm (8% vs 2%, p = 0.17). CONCLUSIONS: This study documents high success rates for ER in veterans with colorectal polyps ≥ 2 cm and ≥ 4 cm. When compared to a historical cohort of surgical patients, a strategy of attempting ER first reduced morbidity. A randomized trial is warranted to compare ER to laparoscopic surgery for polyps ≥ 4 cm.

Evaluation of a progressive algorithmic approach for the treatment of unresectable colon polyps using colon conservation techniques.

BACKGROUND: The majority of endoscopically unresectable colon polyps (EUCP) are treated by segmental colectomy. However, up to 90% of EUCP do not harbor malignancy, making colectomy an unnecessary procedure. To minimize unnecessary segmental colectomy, we established a progressive treatment algorithm utilizing colon conservation techniques (CCT). In our progressive CCT algorithm, patients with EUCP first underwent endoscopic submucosal dissection (ESD). If unsuccessful, they progressed to combined endo-laparoscopic surgery (CELS) and ultimately to segmental colectomy, if necessary. METHODS: We performed a retrospective analysis of all patients treated by our progressive CCT algorithm from August 2015 to April 2019. Demographic information, polyp characteristics, and clinical outcomes were analyzed. We also compared the outcomes of our CCT algorithm group to 156 patients undergoing segmental colectomy for EUCP at related institutions from August 2015 to August 2018. RESULTS: A total of 102 EUCP in 97 patients were treated with our progressive CCT algorithm. Of these, 76 of 102 (75.5%) EUCP were removed without requiring segmental colectomy, with 42 EUCP removed via ESD and 34 via CELS. Interval surveillance colonoscopy confirmed that 72 of 97 (74.2%) patients with EUCP treated by CCT completely avoided segmental colectomy. Polyps > 5 cm in size was a significant predictor of CCT failure (OR 3.83, P = 0.03). When compared to an external cohort of patients undergoing segmental colectomy for EUCP, the CCT algorithm was associated with longer operative time, but shorter length of stay, with no difference in postoperative complications. The estimated total healthcare cost of the CCT algorithm was lower than segmental colectomy ($10,956.77 versus $16,692.94), with more dramatic cost savings seen in ESD ($4,492.70) and CELS ($8,507.06). CONCLUSIONS: An established progressive CCT algorithm can result in high colon conservation rate and decrease associated health care costs compared to segmental colectomy. It is a reasonable treatment strategy for patients with EUCP.