Efficacy and safety of cold versus hot snare polypectomy for small (5-9 mm) colorectal polyps: a multicenter randomized controlled trial.

BACKGROUND: Resection techniques for small polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). This study compared CSP and HSP in 5-9 mm polyps in terms of complete resection and adverse events. METHODS: This was a multicenter, randomized trial conducted in seven Spanish centers between February and November 2019. Patients with ≥ 1 5-9 mm polyp were randomized to CSP or HSP, regardless of morphology or pit pattern. After polypectomy, two marginal biopsies were submitted to a pathologist who was blinded to polyp histology. Complete resection was defined as normal mucosa or burn artifacts in the biopsies. Abdominal pain was only assessed in patients without < 5 mm or > 9 mm polyps. RESULTS: 496 patients were randomized: 237 (394 polyps) to CSP and 259 (397 polyps) to HSP. Complete polypectomy rates were 92.5 % with CSP and 94.0 % with HSP (difference 1.5 %, 95 % confidence interval -1.9 % to 4.9 %). Intraprocedural bleeding occurred during three CSPs (0.8 %) and seven HSPs (1.8 %) (P = 0.34). One lesion per group (0.4 %) presented delayed hemorrhage. Post-colonoscopy abdominal pain presented similarly in both groups 1 hour after the procedure (CSP 18.8 % vs. HSP 18.4 %) but was higher in the HSP group after 5 hours (5.9 % vs. 16.5 %; P = 0.02). A higher proportion of patients were asymptomatic 24 hours after CSP than after HSP (97 % vs. 86.4 %; P = 0.01). CONCLUSIONS: We observed no differences in complete resection and bleeding rates between CSP and HSP. CSP reduced the intensity and duration of post-colonoscopy abdominal pain.

Findings in the distal and proximal colon in colonoscopy screening after positive FIT and related pre-procedure factors.

BACKGROUND: Colonoscopy is the gold standard method for the early diagnosis and prevention of colorectal cancer (CRC). Screening programs include immune determination of blood in feces. Regardless of the method used, proximal colon lesions appear to be detected less frequently. OBJECTIVE: Analyze the characteristics of proximal and distal lesions and possible predisposing factors. METHODS: A cross-sectional study was performed of 692 patients from the CRC screening program with FIT ≥ 100ngHb/ml (October 2017 - October 2018). The right colon was examined twice as patients were participating in a randomized clinical trial to re-evaluate the right colon by forward-viewing endoscope or proximal retroflexion. The adenoma detection rate (ADR), advanced neoplasia (AN) and CRC in the proximal and distal colon, the histological and morphological characteristics in each section were analyzed. RESULTS: 52.9% of the patients were male, with a mean age of 59.5 years (SD: 7.6). 1490 polyps were found and the ADR was 57.7% (distal 42% and proximal 37%). Detection rates were 45.8% for AN, 40.9% for advanced adenomas, 5.2% for advanced SSL and CRC was diagnosed in 4.8% of patients. Males had more AN than females. The mean age of patients with AN was significantly higher. AN were associated with smoking and alcohol consumption (p=0.0001). Globally, FIT levels were higher in patients with AN (p=0.003). Sixty-six per cent of cancers were distally located and 61.3% of CRC were diagnosed in the early stages. CONCLUSIONS: In an average-risk asymptomatic population undergoing colonoscopy after positive FIT, AN were more common in the distal colon in males, older patients, smokers and those with alcohol intake.

The role of endoscopic ultrasound guidance for biliary and pancreatic duct access and drainage to overcome the limitations of ERCP: a retrospective evaluation.

BACKGROUND: Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. METHODS: Consecutive duct access procedures (n = 2205; 95 % biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as "index" in patients without prior endoscopic duct access and "combined" when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates. RESULTS: EUS-DAD was performed in 7.7 % (170/2205) of overall procedures: 9.1 % (116/1274) index and 5.8 % (54/931) follow-up. Most index EUS-DADs were performed following (46 %) or anticipating (39 %) ERCP failure, whereas 15 % followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically altered anatomy (58.2 % [39 /67)] vs. 6.4 % [77/1207]); PTBD was required in 0.2 % (3/1274). Among follow-up procedures, ERCP represented 85.7 %, cholangiopancreatography through mature transmural fistulas 8.5 %, and EUS-DAD 5.8 %; no patient required PTBD. The secondary PTBD rate was 0.1 % (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4 % [9/2205]). CONCLUSIONS: EUS-DAD was required in 7.7 % of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1 %. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases.

Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses.

BACKGROUND AND AIM: Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) has become the standard treatment for peripancreatic fluid collections. Its use in other intra-abdominal abscesses has been reported, although there is limited evidence. METHODS: We carried out a single-center retrospective cohort study comparing percutaneous drainage (PCD) and EUS-D of upper abdominal abscesses between January 2012 and June 2017. Pancreatic fluid collections and liver transplant recipients were excluded. Primary endpoints were technical and clinical success rates. RESULTS: We included 18 EUS-D (nine hepatic and nine intraperitoneal abscesses) and 62 PCD. There were no differences regarding age, gender and etiology. Size was larger in the PCD group (80 vs 65.5 mm, P = 0.04) and perivesicular location was more frequent in the PCD group (24.2% vs 11.1%, P = 0.003). In the EUS-D group, metal stents were deployed in 16 (88.9%) subjects (eight lumen-apposing metal stents and eight self-expandable metal stents), coaxial double-pigtail plastic stents in six (33.3%) and lavage/debridement was carried out in five (27.8%). There were no significant differences in technical success (EUS-D: 88.9%, PCD: 96.8%, P = 0.22) or clinical success (EUS-D: 88.9%, PCD: 82.3%, P = 0.50), with no relapses in the EUS-D group and 10 (16.1%) in the PCD group (P = 0.11). There were four (22.2%) adverse events in the EUS-D group, none of them severe, and 13 (21%) in the PCD group (P = 0.91). CONCLUSIONS: EUS-D is an alternative to PCD in the treatment of upper abdominal abscesses, reaching similar success, relapse and adverse events rates.

Proximal retroflexion versus second forward view of the right colon during screening colonoscopy: A multicentre randomized controlled trial.

BACKGROUND: Colonoscopy is the gold standard investigation for the detection of colorectal cancer, but the right colon is more difficult to examine than the left colon. A second examination of the proximal colon has the potential to reduce rates of missed pathology. OBJECTIVE: To determine whether proximal retroflexion improves the adenoma detection rate or other outcomes in the right colon compared with the forward view. METHODS: We performed a multicentre randomized controlled trial of patients from the colorectal cancer screening programme with a positive faecal immunochemical test. Patients were randomized to a second right colon examination using proximal retroflexion or forward view. RESULTS: A total of 692 patients were included. A second examination of the right colon, with an average additional procedure time of 1.62 min, increased the adenoma detection rate by 11%, regardless of the method used (9% proximal retroflexion vs. 12% second forward view, p = 0.21). The adenoma miss rate was 19% (17% proximal retroflexion vs. 20% forward view, p = 0.28) The success rate of retroflexion was 83%, without secondary complications. In the 15.6% of patients in whom lesions were detected during the second pass, endoscopic follow-up was modified by reducing the time of the next colonoscopy. CONCLUSIONS: A second examination of the right colon, either from retroflexion or second forward view, can increase adenoma detection rate and shorten surveillance intervals in patients undergoing screening colonoscopy. This should be emphasized during colonoscopy training and integrated into diagnostic colonoscopy practice.

Safety and clinical outcomes of endoscopic ultrasound-guided gallbladder drainage with lumen-apposing metal stents in patients with dwell time over one year.

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has proved effective in patients with cholecystitis at high surgical risk. The long-term risks of gallstone-related disease and stent-related adverse events are unknown. METHODS: We performed a retrospective evaluation of a case series including subjects who underwent EUS-GBD using lumen-apposing metal stents (LAMS). Patients were identified from a prospective LAMS registry at a single tertiary center. Patients with a stent indwell time <1 year were excluded. Data regarding stent deployment and adverse events were retrieved from the prospective LAMS registry, while emergency room visits, admissions and causes of death were retrieved from electronic medical records. RESULTS: We included 22 patients with a median age of 88.3 years (interquartile range [IQR]: 82.6-92.7), 14 (63.6%) were male. Median follow up was 24.4 months (IQR: 18.2-42.4) and median time to the last available imaging procedure was 607 days (IQR: 463-938). No LAMS-related adverse events were identified beyond the first year of follow up. During follow up, 12 patients (54.5%) visited the emergency room 34 times (1 visit/patient, IQR: 0-3) and a total of 36 hospital admissions were required, with a median of 1 admission/patient (IQR: 0-3). Fourteen (63.6%) patients died during follow up. Only 1 patient (4.5%) required new hospital admissions for gallstone-related disease. CONCLUSIONS: There were no adverse events beyond the first year after stent deployment, with only 4.5% of subjects requiring gallstone-related admissions. Permanent EUS-GBD with LAMS may be a definitive treatment for acute cholecystitis in patients ineligible for cholecystectomy.

Increased risk of thiopurine-related adverse events in elderly patients with IBD.

BACKGROUND: Thiopurines are the most widely used immunosuppressants in IBD although drug-related adverse events (AE) occur in 20%-30% of cases. AIM: To evaluate the safety of thiopurines in elderly IBD patients METHODS: Cohort study including all adult patients in the ENEIDA registry who received thiopurines. Patients were grouped in terms of age at the beginning of thiopurine treatment, specifically in those who started thiopurines over 60 years or between 18 and 50 years of age. Thiopurine-related AEs registered in the ENEIDA database were compared. RESULTS: Out of 48 752 patients, 1888 started thiopurines when over 60 years of age and 15 477 under 50 years of age. Median treatment duration was significantly shorter for those who started thiopurines >60 years (13 [IQR 2-55] vs 32 [IQR 5-82] months; P < .001). Patients starting >60 years had higher rates of all types of myelotoxicity, digestive intolerance and hepatotoxicity. Thiopurines were discontinued due to AEs (excluding malignancies and infections) in more patients starting >60 years (67.2% vs 63.1%; P < .001). Elderly age and female sex were independent risk factors for most AEs. CONCLUSION: In elderly IBD patients, thiopurines are associated with an increased risk of non-infectious, non-neoplastic, AEs.