Safety and efficacy of low-power pure-cut hot snare polypectomy for small nonpedunculated colorectal polyps compared with conventional resection methods: A propensity score matching analysis.

Objectives: Cold snare polypectomy (CSP) is widely performed for small colorectal polyps. However, small colorectal polyps sometimes include high-grade adenomas or carcinomas that require endoscopic resection with electrocautery. This study aimed to evaluate the efficacy and safety of a novel resection technique, hot snare polypectomy with low-power pure-cut current (LPPC-HSP) for small colorectal polyps, compared with CSP and conventional endoscopic mucosal resection (EMR). Methods: Records of patients who underwent CSP, EMR, or LPPC-HSP for nonpedunculated colorectal polyps less than 10 mm between April 2021 and March 2022 were retrospectively evaluated. We analyzed and compared the treatment outcomes of CSP and EMR with those of LPPC-HSP using propensity score matching. Results: After propensity score matching of 396 pairs, an analysis of CSP and LPPC-HSP indicated that LPPC-HSP had a significantly higher R0 resection rate (84% vs. 68%; p < 0.01). Delayed bleeding was observed in only two cases treated with CSP before matching. Perforation was not observed with either treatment. After propensity score matching of 176 pairs, an analysis of EMR and LPPC-HSP indicated that their en bloc and R0 resection rates were not significantly different (99.4% vs. 100%, p = 1.00; 79% vs. 81%, p = 0.79). Delayed bleeding and perforation were not observed with either treatment. Conclusions: The safety of LPPC-HSP was comparable to that of CSP. The treatment outcomes of LPPC-HSP were comparable to those of conventional EMR for small polyps. These results suggest that this technique is a safe and effective treatment for nonpedunculated polyps less than 10 mm.

Cold sub-mucosal injection versus traditional cold snare polypectomy for diminutive and small colorectal polyps: A systematic review and meta-analysis.

BACKGROUND: The guidelines recommend conventional cold snare polypectomy (C-CSP) for diminutive and small colorectal polyps (≤ 10 mm). However, it remains unclear whether CSP with sub-mucosal injection (SI-CSP) achieves comparable efficacy to C-CSP for managing these lesions. This study compares SI-CSP with C-CSP for patients with diminutive and small colorectal polyps. METHODS: An electronic literature search was conducted to retrieve articles comparing resection outcomes between SI-CSP and C-CSP in diminutive and small colorectal polyps (registration number INPLASY2023100096). Our primary outcomes of interest were the complete resection rate (CRR), complications (namely immediate bleeding, delayed bleeding and perforation) and polypectomy time. Mean differences with 95% confidence intervals (CI) were employed for continuous variables, while odds ratios (OR) with 95% CI were calculated for categorical variables. Data was analyzed using a random effects model and the I2 test was utilized to assess heterogeneity. RESULTS: Eight studies involving 1470 patients with 2223 polyps were included in our analysis. The CRR was not significantly higher in the SI-CSP group, with an OR of 95% CI 0.50 (0.22, 1.15). The incidences of immediate bleeding (OR 95% CI 0.60 [0.26-1.40]) and delayed bleeding (OR 95% CI 0.88 [0.32-2.42]) did not differ significantly between the two groups. On average, the mean polypectomy time was 64.75 seconds shorter in the C-CSP group (95% CI, - 102.96 to - 26.53). Notably, no perforation events were reported in the included studies. CONCLUSIONS: The use of SI-CSP was not superior to C-CSP in managing diminutive and small colorectal polyps and the procedure required significantly more time.

Different endometrial preparation protocols on first frozen-thawed embryo transfer outcomes after hysteroscopic polypectomy: A retrospective cohort study.

OBJECTIVE: To evaluate the optimal endometrial preparation protocol for frozen-thawed embryo transfer (FET) following hysteroscopic polypectomy. METHODS: This was a retrospective clinical cohort study involving 464 patients who underwent their first FET after polyp resection between January 2021 and July 2023. The cohorts were categorized into three groups: the natural cycle (NC) group (n = 139), the ovarian induction (OI) group (n = 117), and the hormone replacement therapy (HRT) group (n = 208). RESULTS: In the initial unadjusted analysis, both NC and OI cycles exhibited similar pregnancy rates but were associated with significantly higher implantation rate (56.5%, 57.1% vs 42.0%, P < 0.001), clinical pregnancy rate (73.4%, 74.4% vs 57.2%, P = 0.001), and ongoing pregnancy rate (OPR; 67.6%, 63.2% vs 51.0%, P = 0.005) compared to the HRT group. Additionally, the three groups demonstrated comparable abortion rate (7.8%, 14.9% vs 10.9%, P = 0.299). After adjusting for potential confounders in the multiple logistic regression model, the HRT protocol resulted in a 54% significantly lower OPR compared to the NC protocol (adjusted odds ratio [aOR] = 0.46, 95% confidence interval [CI]: 0.28-0.77; P = 0.003). Meanwhile, the OPR difference between the OI protocol and the NC protocol remained insignificant (OI vs NC: aOR = 0.62, 95% CI: 0.35-1.12; P = 0.112). CONCLUSION: The ovulatory-FET scheme (NC and OI) following hysteroscopic polyp resection displayed promising clinical outcomes compared with HRT-FET scheme. The regimen without exogenous estrogen administration should be prioritized for endometrial preparation protocol after polypectomy.

Risk factors and prediction model for delayed bleeding after cold snare polypectomy: a retrospective study.

BACKGROUND: Delayed bleeding (DB) is a serious complication after cold snare polypectomy (CSP) for polyps in the colon. The present study aimed to investigate the incidence and risk factors of DB after CSP and to develop a risk-scoring model for predicting DB. METHODS: A retrospective study was conducted in four Chinese medical institutions. 10650 patients underwent CSP from June 2019 to May 2023. The study analyzed the rate of DB and extracted the general clinical information and polyp-related information of patients with postoperative DB. As a control, non-DB patients who received CSP at the same 4 hospitals were analyzed. A multivariate Cox regression analysis was performed to develop the prediction model. The model was further validated using a Kaplan-Meier log-rank analysis, receiver operating characteristic curve (ROC) plot and risk plot. RESULTS: In our study, we found a 0.24% rate of DB and the risk factors were history of hypertension, hyperlipidemia, antithrombotics use, antiplatelet use, anticoagulant use, abdominal operation, sigmoid colon lesion, hematoma, cold snare defect protrusion, polyp size, wound size, the grade of wound bleeding, and morphology of Ip. These factors were incorporated into the prediction model for DB after CSP. For 1, 3, and 5 days of bleeding, the AUC of the ROC curve was 0.912, 0.939, and 0.923, respectively. The Kaplan-Meier analysis indicated that the high-risk group had a significantly higher risk of DB than the low-risk group. CONCLUSIONS: This study screened the risk factors and established a prediction model of DB after CSP. The results may help preventing and reducing the DB rate after CSP of colorectal polyps.

Colo-colonic intussusception as a rare complication of colonoscopy with polypectomy: Two case reports.

BACKGROUND: Colonoscopy is the most frequently used diagnostic and therapeutic tool for the treatment of colorectal diseases. Although the complication rate is low, it can be potentially serious. Intussusception is a rare and severe complication often associated with polypectomy. Only a handful of post-colonoscopy intussusception cases have been reported, making this study a valuable addition to the medical literature. CASE SUMMARY: Case 1: A 61-year-old man underwent colonoscopy with polypectomy for chronic abdominal pain. The patient experienced abdominal pain 11 hours later but was still discharged after pain management. He was readmitted due to recurring pain. Computed tomography (CT) showed colo-colonic intussusception. Initial conservative management and attempts at endoscopic reduction failed; therefore, laparoscopic right hemicolectomy was performed. Histopathological examination revealed tubular adenomas in the polyps and inflammation in the resected specimens. Case 2: A 59-year-old woman underwent colonoscopy with polypectomy for a polyp in the transverse colon. She experienced upper abdominal pain, fever, nausea, and vomiting 9 hours after the procedure. Emergency CT and blood tests revealed a colo-colonic intussusception near the hepatic flexure and an elevated white blood cell count. Initial attempts at endoscopic reduction failed and conservative treatment showed no improvement. She underwent successful laparoscopic reduction and recovered uneventfully. Histopathological examination of the resected polyp revealed hyperplasia. CONCLUSION: Post-colonoscopy intussusception in adults is rare, and polypectomy may contribute to its occurrence. Early diagnosis is crucial, with prompt CT examination serving as key. After excluding malignancies, conservative management and reduction of intussusception should be considered before surgical bowel resection.

Pleomorphic leiomyosarcoma of the maxilla with metastasis to the colon: A case report.

BACKGROUND: Pleomorphic leiomyosarcomas make up around 8.6% of all leiomyosarcomas. They behave aggressively and often have poor prognoses. They can affect the gastrointestinal tract and retroperitoneum. To date, pleomorphic leiomyosarcoma involving the mesocolon have been reported in nine patients. CASE SUMMARY: The patient was a 44-year-old man with a history of pleomorphic leiomyosarcoma of the left maxilla with metastasis to the lung and liver. His most recent positron emission tomography-computed tomography (PET-CT) scan showed uptake in the ascending and transverse colons. A colonoscopy revealed a 5.0 cm × 3.5 cm × 3.0 cm pedunculated polyp in the ascending colon. The polyp was removed using hot snare polypectomy technique and retrieved with Rothnet. Histopathologic examination of the polyp showed a metastatic pleomorphic leiomyosarcoma. CONCLUSION: Uptake(s) on PET-CT in a patient with pleomorphic leiomyosarcoma should raise suspicion for metastasis.

Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial.

BACKGROUND AND AIMS: Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR. METHODS: Flat, 15-50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success. RESULTS: 177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034). CONCLUSION: Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique. TRIAL REGISTRATION NUMBER: NCT04138030.

Results of the COLDWATER randomized controlled trial: enhanced performance of underwater cold snare polypectomy for colorectal polyps 5-10 mm, independent of endoscopist experience.

Background: The wide range of R0 resection rates (R0RR) and incomplete resection rates (IRR) observed with conventional cold snare polypectomy (CCSP) emphasizes the necessity for technique enhancement. The COLDWATER study aimed to compare underwater cold snare polypectomy (UCSP) to CCSP for 5-10-mm colorectal polyps, focusing on comprehensive histopathological evaluation, efficacy, and safety. Methods: This was a randomized, single-blind, controlled trial comparing UCSP to CCSP for non-pedunculated colorectal polyps of size 5-10 mm. The primary outcome was to report differences in the muscularis mucosa resection ratio. The secondary outcomes focused on differences in depth of excision, R0-RR, IRR, en bloc resection rate, adverse events, and recurrence rate. Results: The COLDWATER study found higher muscularis mucosa resection in UCSP (81.72±62.81% vs. CCSP: 72.33±22.33%, P=0.003) with comparable submucosa presence (UCSP: 16.6%, CCSP: 12.5%, P=0.25). UCSP showed better outcomes regarding IRR (3.5% vs. 8.5%, P=0.05) and en bloc resection (98% vs. 93.5%, P=0.04). In CCSP, expert endoscopists achieved higher R0RR than non-experts, while UCSP showed no significant difference in R0RR across endoscopist's experience levels. Conclusions: UCSP achieves a more extensive excision of the muscularis mucosa compared to CCSP, even though it does not attain a deeper excision. Additionally, UCSP shows a higher en bloc resection rate, with lower rates of IRR, and emerges as a promising technique for training inexperienced endoscopists in polypectomy, given its experience-independent success in achieving R0 resection.

A new through-the-scope clip with anchor prongs is safe and successful for a variety of endoscopic uses.

Background and study aims Endoscopic through-the-scope clips (TTSC) are used for hemostasis and closure. We documented the performance of a new TTSC with anchor prongs. Patients and methods We conducted a prospective case series of the new TTSC in 50 patients with an indication for endoscopic clipping at three hospitals in the United States and Canada. Patients were followed for 30 days after the index procedure. Outcomes included defect closure and rate of serious adverse events (SAEs) related to the device or procedure. Results Fifty patients had 56 clipping procedures. Thirty-four procedures were clipping after endoscopic mucosal resection (EMR) in the colon (33) or stomach (1), 16 after polypectomy, two for hemostasis of active bleeding, and one each for fistula closure, per-oral endoscopic myotomy mucosal closure, or anchoring a feeding tube. Complete defect closure was achieved in 32 of 33 colon EMR defects and 21 of 22 other defects. All clips were placed per labeled directions for use. In 41 patients (82.0%), prophylaxis of delayed bleeding was reported as an indication for endoscopic clipping. There were three instances of delayed bleeding. There were no device-related SAEs. The only technical difficulty was one instance of premature clip deployment. Conclusions A novel TTSC with anchor prongs showed success in a range of defect closures, an acceptable safety profile, and low incidence of technical difficulties.

Removal of GIT lesions and the role of impedance of the injection solution-an innovative approach to known methods.

In this work, for the first time, the specific impedances of various injection solutions as well as the surface and tissue impedance after injection of these solutions were analyzed and compared regarding the radio-frequency surgical cutting process. The impedances of 0.9% NaCl, 4% gelatine, 6% hydroxyethyl starch, 10% glycerol/5% fructose, 10% glucose, 5% and 20% albumin, blood, and blood plasma as well as aqua destillata have been tested in vitro. Even if EMR and ESD are routinely used in clinical practice, there is so far no easy, fast, and safe method to remove larger lesions en bloc. We show that the impedance of the injected solution shows to be a crucial factor for safe removal, especially of larger lesions (Ø > 20 mm) and more importantly in accordance with the requirements of oncology and pathology. KEY MESSAGES: Impedance is playing a crucial factor in the radio-frequency (RF)-surgery. With a higher Impedance there will be less current necessary to reach the aimed voltage. Injection solution Aqua destillata and 10% Glucose, show significantly higher Impedances. Higher impedances lead to less surgical related complications. Minor changes in existing method to improve patent safety.

Peutz-Jeghers syndrome: management for recurrent intussusceptions.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by hamartomatous gastrointestinal polyps along with the characteristic mucocutaneous freckling. Multiple surgeries for recurrent intussusception in these children may lead to short bowel syndrome. Here we present our experience of management in such patients. METHODS: From January 2015 to December 2023, we reviewed children of PJS, presented with recurrent intussusceptions. Data were collected regarding presentation, management, and follow-up with attention on management dilemma. Diagnosis of PJS was based on criteria laid by World Health Organization (WHO). RESULTS: A total of nine patients were presented with age ranging from 4 to 17 years (median 9 years). A total of eighteen laparotomies were performed (7 outside, 11 at our centre). Among 11 laparotomies done at our centre, resection and anastomosis of bowel was done 3 times while 8 times enterotomy and polypectomy was done after reduction of intussusception. Upper and lower gastrointestinal endoscopy (UGIE & LGIE) was done in all cases while intraoperative enteroscopy (IOE) performed when required. Follow-up ranged from 2 months to 7 years. CONCLUSION: Children with PJS have a high risk of multiple laparotomies due to polyps' complications. Considering the diffuse involvement of the gut, early decision of surgery and extensive bowel resection should not be done. Conservative treatment must be tried under close observation whenever there is surgical dilemma. The treatment should be directed in the form of limited resection or polypectomy after reduction of intussusception.

Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy.

Introduction/Objective Colonoscopy with polypectomy is an integral component of colorectal cancer screening. There are limited data and consensus on periprocedural anticoagulation management, especially regarding bleeding risk with uninterrupted anticoagulation and thromboembolic risk with interruption. Our aim was to determine the incidence of bleeding and thromboembolic complications among colon screening participants undergoing colonoscopy following implementation of a novel patient care pathway for standardized periprocedural anticoagulation management. Methods We conducted a retrospective study including all participants (age 50-74) on an oral anticoagulant (e.g., vitamin K antagonists, direct oral anticoagulants) referred to the British Columbia Colon Screening Program for colonoscopy following abnormal fecal immunochemical test in a 6-month period (March-August 2022). Data relating to their specific periprocedural anticoagulant management and colonoscopy results including method of polypectomy were obtained. Primary outcomes were major bleeding and arterial or venous thromboembolic events from time of oral anticoagulant interruption until 14 days of postcolonoscopy. Secondary outcomes included nonmajor and minor bleeding, acute coronary syndrome, emergency room visit, hospital admission, and death due to any cause. Results Over the 6-month period, 162 participants completed standardized periprocedural anticoagulation management, colonoscopy ± polypectomy, and 14-day follow-up. One (0.6%) had a major bleeding event and one (0.6%) had an arterial thromboembolic event. Conclusions A novel patient care pathway for standardized periprocedural anticoagulation management with a multidisciplinary team is associated with low rates of major bleeding and thrombotic complications after colonoscopy with polypectomy.

Endoscopic management of giant colonic polyps: a retrospective Italian study.

Background/Aims: Polyps greater than 30 mm are classified as "giants". Their endoscopic removal represents a technical challenge. The choice of the endoscopic removal technique is important because it provides a resection sample for precise histopathological staging. This is pivotal for diagnostic, prognostic, and management purposes. Methods: From a retrospective analysis, we obtained a sample of 38 giant polyps. Eighteen polypectomies were performed using the epinephrine volume reduction (EVR) method, nine polypectomies utilized endo-looping or clipping methods, and 11 patients underwent surgery. Results: We obtained en bloc resection with the EVR method in all cases; histology confirmed the correct indication for endoscopic resection in all cases. Moreover, no early or delayed complications were observed, and no patient required hospitalization. Using endo-looping or clipping methods, we observed advanced histology in 1/9 (11.1%) cases, while another patient (1/9, 11.1%) had delayed bleeding. Among patients who underwent surgery, 5/11 (45.5%) were deemed overtreated and three had post-surgical complications. Conclusions: We propose EVR as an alternative technique for giant polyp resection due to its safety, effectiveness, cost-efficiency, and the advantage of avoiding the need to postpone polypectomy to a later time. Further prospective studies might help improve this experience and enhance the technique.

Cost-Utility Analysis of Berberine Chemoprevention for Colorectal Cancer After Polypectomy.

Background Chemoprevention, such as berberine, has been developed as an alternative or complementary strategy to colonoscopy surveillance and has shown promise in reducing the morbidity and mortality of colorectal cancer. This study aims to evaluate the cost-effectiveness of berberine for postpolypectomy patients from the US third-party payer. Methods A Markov microsimulation model was developed to compare the cost and efficacy of berberine to no intervention, colonoscopy, and the combination of berberine and colonoscopy in postpolypectomy patients. Results After simulating 1 million patients, the study found that colonoscopy alone had a mean cost of $16,391 and mean quality-adjusted life-years (QALYs) of 16.03 per patient, whereas adding berberine slightly reduced the mean cost to $15,609 with a mean QALY of 16.05, making it a dominant strategy. Berberine therapy alone was less effective than colonoscopy alone, with a higher mean cost of $37,480 and a mean QALY of 15.32 per patient. However, berberine therapy was found to be a dominant strategy over no intervention. Conclusions Adding berberine to colonoscopy is the most cost-saving and effective approach for postpolypectomy patients. For patients who refuse or have limited access to colonoscopy, berberine alone is likely to be a dominant strategy compared to no intervention.

Outcomes in colorectal endoscopic submucosal dissection for large protruded lesions: A retrospective multicenter study.

Background and study aims Colorectal endoscopic submucosal dissection (ESD) is increasingly used for treating early-stage colorectal cancer, including large, protruded lesions (LPL). However, the challenges posed by LPLs, especially those accompanied by severe fibrosis or muscle-retracting sign (MRS), remain unclear. This study aims to investigate ESD outcomes for LPL, focusing on factors such as tumor size and, submucosal fibrosis. Patients and methods In a multicenter retrospective study (June 2012 to May 2023), data from 526 patients with 542 LPL lesions (≥ 2 cm) were analyzed. Parameters included lesion size, procedure time, dissection speed, physician experience, submucosal fibrosis, and adverse events. The tunnel method, including the double tunnel method, was used for cases with severe fibrosis or MRS. Multivariate analysis assessed factors affecting procedure difficulty, particularly LPLs ≥ 4 cm. Results The study revealed an impressive en bloc resection rate of 97.8% and a curative resection rate of 78.6% for LPLs. Notably, fibrosis and MRS were present in 25% and 18% of 4-cm LPLs, respectively, and their frequency tended to increase as the tumor diameter increased. One treatment strategy for LPLs was the tunneling method, which was used most frequently (41 cases, 7.6%). Factors affecting dissection speed included larger tumor size, submucosal fibrosis, MRS, and physician experience. Conclusions Treating LPLs through colorectal ESD presents significant challenges, especially in patients with fibrosis and MRS. This study highlights the importance of recognizing these complexities, and that more reliable resection strategy must be established for accurate pathological evaluation.

Low-power pure-cut hot snare polypectomy for colorectal polyps 10-14 mm in size: a multicenter retrospective study.

BACKGROUND AND AIM: Hot snare excision using electrocautery is widely used for large colorectal polyps (>10 mm); however, adverse events occur due to deep thermal injury. Colorectal polyps measuring 10-14 mm rarely include invasive cancer. Therefore, less invasive therapeutic options for this size category are demanding. We have developed hot snare polypectomy with low-power pure-cut current (LPPC HSP), which is expected to contribute to less deep thermal damage and lower risk of adverse events. This study aimed to evaluate the efficacy and safety of LPPC HSP for 10-14 mm colorectal polyps, compared with conventional endoscopic mucosal resection (EMR). METHODS: In this multicenter, retrospective, observational study, clinical outcomes of EMR and LPPC HSP for 10-14 mm nonpedunculated colorectal polyps between January 2021 and March 2022 were compared using propensity score matching. RESULTS: We identified 203 EMR and 208 LPPC HSP cases. After propensity score matching, the baseline characteristics between the groups were comparable, with 120 pairs. The en bloc and R0 resection rates were not significantly different between EMR and LPPC HSP groups (95.8% vs 97.5%, P = 0.72; 90.0% vs 91.7%, P = 0.82). The rates of delayed bleeding and perforation did not differ between the groups. CONCLUSIONS: Compared with conventional EMR, LPPC HSP showed a similar resection ability without an increase in adverse events. These results suggest that LPPC HSP is a safe and effective treatment for 10-14 mm nonpedunculated colorectal polyps.

Outcomes of endoscopic submucosal dissection in cirrhotic patients: First American cohort.

BACKGROUND: Among patients with cirrhosis and pre-malignant or early malignant mucosal lesions, surgical intervention carries a much higher bleeding risk. When such lesions are discovered, endoscopic submucosal dissection (ESD) may offer curative therapy with lower risks than surgery and improved outcomes compared to traditional endoscopic resection. AIM: To evaluate the outcomes of ESD in patients with cirrhosis. METHODS: Patients with cirrhosis undergoing ESD between July 2015 and August 2022 were retrospectively matched in 1:2 fashion to controls based on lesion location, size, and anticoagulation use. Procedural outcomes were compared between groups. RESULTS: A total of 64 Lesions from 59 patients were included (16 cirrhosis, 43 control). There were no differences in patient or lesion characteristics between groups. En bloc and curative resection was achieved in 84.21%, 78.94% of the cirrhosis group and 88.89%, 68.89% of controls, respectively, with no significant differences. Cirrhotic patients had significantly higher rates of intra-procedural coagulation grasper use for control of bleeding (47.37% vs 20%; P = 0.02). There were otherwise no significant differences in adverse event rates. In the 29 patients with follow up, we found higher rates of recurrence in the cirrhosis group compared to controls (40% vs 5.26%; P = 0.019), however this effect did not persist on multivariable analysis controlling for known confounders. CONCLUSION: ESD may be safe and effective in patients with cirrhosis. Most procedure related outcomes were not significantly different between groups. Intra-procedural bleeding requiring use of the coagulation grasper use was expectedly higher in the cirrhosis group given the known effects of liver disease on hemostasis.

Endoscopic management of intraprocedural bleeding during endoscopic interventions.

Endoscopic resection techniques have evolved over time, allowing effective and safe resection of the majority of pre-malignant and early cancerous lesions in the gastrointestinal tract. Bleeding is one of the most commonly encountered complications during endoscopic resection, which can interfere with the procedure and result in serious adverse events. Intraprocedural bleeding is relatively common during endoscopic resection and, in most cases, is a mild and self-limiting event. However, it can interfere with the completion of the resection and may result in negative patient-related outcomes in severe cases, including the need for hospitalization and blood transfusion as well as the requirement for radiological or surgical interventions. Appropriate management of intraprocedural bleeding can improve the safety and efficacy of endoscopic resection, and it can be readily achieved with the use of several endoscopic hemostatic tools. In this review, we discuss the recent advances in the approach to intraprocedural bleeding complicating endoscopic resection, with a focus on the various endoscopic hemostatic tools available to manage such events safely and effectively.

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.

Safety of first surveillance colonoscopy at 12 months after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal lesions.

BACKGROUND AND AIMS: After piecemeal endoscopic mucosal resection (pEMR) of nonpedunculated colorectal lesions ≥ 20 mm, guidelines recommend first endoscopic surveillance at 6 months. However, initial surveillance at 12 months may be adequate for selected low-risk lesions, and could save the cost, risk and inconvenience of one surveillance examination. METHODS: We retrospectively examined a prospectively collected database of all colorectal lesions referred to our center for endoscopic resection between August 2019 and April 2023. We report recurrence rates of colorectal lesions ≥ 20 mm removed by pEMR who were assigned to 6-month first surveillance or assigned to 12-month first surveillance (or assigned to 6-month but did not return until after 10 months). RESULTS: There were 561 nonpedunculated lesions ≥ 20 mm that underwent first follow-up, including 490 lesions in 443 patients assigned to 6-month, and 71 lesions in 65 patients assigned to 12-month surveillance. Lesions assigned to 12-month surveillance were smaller (mean size 25.9 ± 6.1mm vs. 37.0 ± 17.4mm), more likely serrated (63.4% vs. 9.6%), and more often removed by cold pEMR (74.6% vs 20.4%). Twenty-nine lesions in 24 patients assigned 6-month surveillance presented after 10 months and their recurrence data were included in the group assigned 12-month surveillance. Overall recurrence rates at 6 months and 12 months were 10.0% (46/461) and 9.0% (9/100), respectively. Mean recurrence sizes at 6 and 12 months were 10.9 ± 6.2mm and 4.2 ± 1.9mm, respectively. One patient in the 6-month surveillance group had cancer at the pEMR site, but no other recurrences at 6 or 12 months had either cancer or high-grade dysplasia. CONCLUSION: Twelve-month surveillance appears acceptable for selected colorectal lesions ≥ 20 mm removed by pEMR. A randomized trial comparing initial 6-month to 12-month surveillance is warranted for selected lesions.