Quality of endoscopy reporting at index colonoscopy significantly impacts outcome of subsequent EMR in patients with > 20 mm colon polyps

Abstract

Background and study aims Endoscopic mucosal resection (EMR) is safe and cost-effective in management of patients with colon polyps. However, very little is known about the actions of the referring endoscopist following identification of these lesions at index colonoscopy, and the impact of those actions on the outcome of subsequent referral for EMR. The aim of this study was to identify practices at index colonoscopy that lead to failure of subsequent EMR. Patients and methods Two hundred and eighty-nine consecutive patients with biopsy-proven non-malignant colon polyps (> 20 mm) referred for EMR were analyzed to identify practices that could be improved from the time of identifying the lesion at index colonoscopy until completion of therapy. Results EMR was abandoned at colonoscopy at the EMR center in 71 of 289 patients (24.6 %). Reasons for abandoning EMR included diagnosis of invasive carcinoma (n = 9; 12.7 %), tethered lesions (n = 21; 29.6 %) from prior endoscopic interventions, and overly large (n = 22; 31 %) and inaccessible lesions (n = 17; 24 %) for complete and safe resection whose details were not recorded in the referring endoscopy report, or polyposis syndromes (n = 2; 2.8 %) that were not recognized. Conclusions In our practice, one in four EMR attempts were abandoned as a result of inadequate diagnosis or management by the referring endoscopist, which could be improved by education on optical diagnosis of polyps, comprehensive documentation of the procedure and avoidance of interventions that preclude resection.

The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis

“…This IPDMA involving 8229 colorectal polyps from 13 studies shows that prophylactic clipping in general did Our findings are in accordance with recent studies on prophylactic clipping that concluded that prophylactic clipping should not be routinely performed after polyp resection in the whole colon, but should be considered for bleeding prevention after large proximal polyp resection. 8,9,12,26,30,31 Based on this, it can well be concluded that in a setting where cost issues do not play an important role, all proximal polyps 20 mm may be routinely clipped. Nonetheless, costs considerations often are an important factor in general care settings.…”

“…The risk of delayed bleeding varies from 0.4% to 12.7% 2,3 and increases with polyp size and type, location in the colon proximal to the splenic flexure, polyp type, antithrombotic, use and in patients on antithrombotics. [3][4][5][6][7][8][9][10] Prophylactic clipping has been suggested to prevent delayed bleeding, but contradicting results have been reported. 2,[9][10][11][12] Clip closure is defined as the placement of 1 or more clips to close the mucosal defect after radical polyp resection.…”

“…[3][4][5][6][7][8][9][10] Prophylactic clipping has been suggested to prevent delayed bleeding, but contradicting results have been reported. 2,[9][10][11][12] Clip closure is defined as the placement of 1 or more clips to close the mucosal defect after radical polyp resection. Because current evidence is not irrefutable, current guidelines advise against the routine use of prophylactic clipping of the resection defect, except for right-side lesions >20 mm and certain high-risk patient groups.…”

“…Some resection defects are difficult to close, especially when the defect is wide and extends over a colonic fold, and complete closure rates have been reported to vary from 28.9% to 67.3%. 9,10 Additionally, it is still unclear whether the use of antithrombotics justifies prophylactic clipping after polyp resection irrespective of the size or location of the polyp. 9,10,13 Nonetheless, it has been reported that the use of antithrombotics is the most important decision factor for endoscopists to use prophylactic clips in daily clinical practice.…”

“…9,10 Additionally, it is still unclear whether the use of antithrombotics justifies prophylactic clipping after polyp resection irrespective of the size or location of the polyp. 9,10,13 Nonetheless, it has been reported that the use of antithrombotics is the most important decision factor for endoscopists to use prophylactic clips in daily clinical practice. 18,19 To reach consensus about the patient groups that may benefit from prophylactic clipping, a detailed and robust analysis of the available data is important.…”