Outcomes of Deep Mural Injury After Endoscopic Resection: An International Cohort of 3717 Large Non-Pedunculated Colorectal Polyps

AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review

“…Endoscopic suturing may not be possible because it is not compatible with colonoscopes and requires an upper endoscope. Thus, closure of right colon perforation has been limited to TTSCs only 60 (Video 1). Recently a new suture-based device for defect closure, X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery, Austin, TX) has been introduced.…”

Comparison of precutting endoscopic mucosal resection and endoscopic submucosal dissection for large (20–30 mm) flat colorectal lesions

“…No difference in perforation rate of large (20–30 mm) colorectal lesions was observed between both groups (1.9% vs 1.8%, P = 0.97). A recent study showed that most of the perforations could be resolved through defect closure with endoscopic clips 38 . In this study, all intraprocedural perforations were resolved through defect closure with endoscopic clip and using antibiotics with the patient kept NPO.…”

Through-the-Scope Clips Are Indispensable in Treating Deep Mural Injury From Colorectal EMR

“…Key factors to optimizing procedural outcomes include having the necessary devices/equipment (of particular importance are the indispensable TTSCs, colonoscopes with waterjet capability, and an adaptive electrosurgical generator); working with experienced procedural staff; using carbon dioxide gas for insufflation; and ensuring the colorectal field is clean and that the patient is positioned so that a lesion is not resected in a gravity-dependent location, in case of complete perforation. Bar-Yishay et al 6 provide a flow diagram depicting a rational "algorithm for significant deep mural injury management" in their manuscript, which is in keeping with other published guidance on this topic. 8,9 There are 2 concepts that deserve further discussion in patients who sustain EMR-related colorectal S-DMI.…”

“…It is in addressing the latter issue of deep mural injury and frank perforation that Bar-Yishay et al 6 make their contribution in this issue of Clinical Gastroenterology and Hepatology. This well-known group of international investigators, mainly based in Australia, used terminology that they previously described 7 to study, primarily, the efficacy and safety of endoscopic through-the-scope-clip (TTSC) closure of significant deep mural injury (S-DMI) in patients who underwent EMR of large (20 mm) nonpedunculated colorectal polyps (LNPCPs).…”

“…[and] TTSC closure carries the potential to mitigate perforation-related surgery and its associated morbidity." Bar-Yishay et al 6 should be congratulated for their reporting on yet another important procedural outcome pertaining to patients undergoing conventional, submucosal-lift, colorectal EMR (namely that of S-DMI), and how this adverse event can be effectively and safely managed. The 2.7% rate of S-DMI reported by these investigators using the ACE cohort is in keeping with an analysis conducted by the American Society for Gastrointestinal Endoscopy Standards of Practice Committee that reported a 1.1% pooled rate for perforation when 6529 colorectal EMRs were evaluated.…”