Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial

Sidhu, Mayenaaz; Shahidi, Neal; Vosko, Sergei; McKay, Owen; Bahin, Farzan F.; Zahid, Simmi; Whitfield, Anthony; Lee, Eric Yong Tat; Burgess, Nicholas G.; Bourke, Michael J.

doi:10.1016/s2468-1253(21)00384-8

Cited by 36 publications

(19 citation statements)

References 31 publications

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“…A subsequent study from Spain that enrolled 235 patients with LNPCLs at high bleeding risk found a risk reduction from 12.1% to 5.0% in an intention-to-treat analysis and a reduction to 1.5% if the defect could be completely closed (20). Recently, another RCT reinforced these conclusions (21). Similar results were seen in some but not all studies.…”

Section: Prophylactic Measuresmentioning

confidence: 88%

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Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

et al. 2022

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The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.

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Section: Prophylactic Measuresmentioning

confidence: 88%

“…In recent years, the results of randomized controlled trials (RCTs) support the use of hemoclips for mucosal defect closure after hot snare EMR to prevent CSPEB (18)(19)(20)(21) as the only preventive measure with clinical evidence.…”

Section: Introductionmentioning

confidence: 99%

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

et al. 2022

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“…For ESD, following formation of a submucosal cushion, dissection is performed with a Dual-J Knife (Olympus, Tokyo Japan). Technical innovations were adopted as the evidence to support them emerged [24,25,29].…”

Section: Accepted Manuscriptmentioning

confidence: 99%

Endoscopic resection-related colorectal strictures: risk factors, management, and long-term outcomes

et al. 2023

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Introduction: Colorectal strictures related to endoscopic resection (ER) of large non-pedunculated colorectal polyps (LNPCPs) may be problematic. Data pertaining to prevalence, risk factors and management is limited. We report a prospectively collected experience of colorectal strictures following ER and describe our standard approach to management. Methods: We analysed prospectively collected data over 150 months, until June 2021, for all patients who underwent ER for LNPCPs ≥40mm. The extent of the ER-defect was graded as <60%, 60-89% or ≥90% of luminal circumference. Strictures were considered ‘severe’ if patients experienced obstructive symptoms, ‘moderate’ if an adult colonoscope was unable to be passed through the stenosis or ‘mild’ if there was resistance on successful passage. Primary outcomes included stricture prevalence, risk factors and management. Results: The final analysis included 916 LNPCPs ≥ 40mm (median age 69 years [IQR 61-76], male gender 484 [52.8%]. The primary modality of resection was EMR in 859 [93.8%]. Risk of stricture formation with an ER-defect ≥90%, 60-89% and <60% was respectively 74.2% (n=23/31), 25% (n=22/88) and 0.8% (n=6/797). Severe strictures only occurred with an ER-defect ≥90% (22.6%, 7/31). A defect <60% conferred low risk of only mild strictures (0.8%, n=6/797). Severe strictures required earlier (median 0.9months vs. 4.9months; P=0.006) and more frequent balloon dilations (median 3 vs. 2; P=0.024) than moderate strictures. Conclusion: Most patients with an ER-defect ≥90% of luminal circumference develop a stricture. A high proportion of these are severe and require early balloon dilation. Conversely, there is minimal risk with an ER-defect <60.

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“…The potential risk of malignancy increases with size, type of growth, and location of the lesion. It has also to be balanced against the risk profile of the patient and location including the likelihood of post-interventional bleeding and a more challenging procedure in the thin-walled proximal colon with a higher incidence of perforation during the endoscopic intervention [20][21][22][23]. In the case of larger flat adenomas, called laterally spreading tumors [24], the malignant potential of the nongranular type is about 15% compared to 1-3% in LSTs with a granular growth pattern [25][26][27][28].…”

Section: Endoscopic Resectionmentioning

confidence: 99%

Diagnostic and Therapeutic Management of Early Colorectal Cancer

et al. 2022

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Background: Early colorectal cancer (eCRC) is defined as cancer that does not cross the submucosal layer of the colon or rectum, including carcinoma in situ (pTis), pT1a, and pT1b. Early carcinomas differ in their prognosis depending on the risk profile. The differentiation between low and high risk is essential. The low-risk group includes R0-resected, well (G1) or moderately (G2) differentiated tumors without lymphatic vessel invasion (L0), without blood vessel invasion (V0) and a tumor size ≤3 cm. In this constellation, the estimated risk of lymph node metastasis is around 1% or below. The high-risk group includes tumors with incomplete resection (Rx), poor (G3) or undifferentiated (G4) carcinomas, and/or lymphatic and blood vessel invasion (L1) and size ≥3 cm. In a “high-risk” situation, there is a risk for lymph node metastasis of up to 23%. Summary: The incidence of eCRC is rising with a rate of 10% in all endoscopically removed lesions during colonoscopy. For a correct histological evaluation, all suspected lesions should be completely resected. In case of a pT1 lesion in the rectum, pelvic magnetic resonance imaging should be performed to evaluate for suspicious lymph nodes. The therapeutic approach for eCRC is based on histological assessment and ranges from endoscopic resection to radical oncological surgery. The advantages, disadvantages, and associated risks of the individual treatment strategy need to be carefully discussed on a tumor board and with the patient. Key Messages: Treatment options for early colorectal cancer depend on the histological assessment. Poorly differentiated carcinomas, a Kudo ≥ SM2 classified lesion, and a Haggitt level 4 always represent a “high-risk” situation. It should also be mentioned that in rectal cancer, local surgical tumor excision (full-wall excision) is also sufficient for pT1 carcinomas with a “low-risk” constellation (G1/G2; L0, size <3 cm) and an R0 resection.

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Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial

Cited by 36 publications

References 31 publications

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

Endoscopic resection-related colorectal strictures: risk factors, management, and long-term outcomes

Diagnostic and Therapeutic Management of Early Colorectal Cancer

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