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.

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.