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There are few data on cold snare polypectomy (CSP) in direct comparison with cold forceps polypectomy (CFP) for colonoscopic resection of diminutive colorectal polyps (DCPs; ≤5 mm). The primary aim of this study was to compare the histologic polyp eradication rate of CSP with that of CFP using double-biopsy technique. This was a randomized controlled trial at a single academic hospital. Of the 165 patients invited, 54 consecutive patients having 117 eligible polyps were enrolled in this study. To evaluate histologic eradication of polyps, two or more additional biopsies were taken from the base and edges of the polypectomy site. The mean size of polyps was 3.66 mm (±1.13). Most polyps evaluated were tubular adenomas (69.9%). The rate of histologic eradication was significantly higher in the CSP group than in the CFP group (93.2% vs. 75.9%, P=0.009). The time taken for polypectomy was significantly shorter in the CSP group (14.29 vs. 22.03 s, P<0.001). Failure of tissue retrieval was noted in 6.8% of polyps resected by CSP. Multivariate analysis revealed that the method of polypectomy (CFP) and the polyp size (≥4 mm) were independent predictors associated with incomplete histologic eradication (odds ratio (OR) 4.750 (95% confidence interval (CI): 1.459-15.466), OR 4.375 (95% CI: 1.345-14.235); all P<0.05, respectively). CSP is superior to CFP for the endoscopic removal of DCPs with regard to completeness of polypectomy. CSP technique should be considered the primary method for endoscopic treatment of polyps in the 4-5-mm size range (ClinicalTrials.gov number: NCT01646242).

INTRODUCTION:Underwater endoscopic mucosal resection (UEMR) and cold snare polypectomy (CSP) are novel endoscopic procedures for superficial nonampullary duodenal epithelial tumors (SNADET). However, consensus on how to use both procedures appropriately has not been established. In this study, we evaluated treatment outcomes of both procedures, including resectability.METHODS:In this single-center randomized controlled study conducted between January 2020 and June 2022, patients with SNADET ≤12 mm were randomly allocated to UEMR and CSP groups. The primary end point was sufficient vertical R0 resection (SVR0), which was defined as R0 resection including a sufficient submucosal layer. We compared treatment outcomes including SVR0 rate between groups.RESULTS:The SVR0 rate was significantly higher in the UEMR group than in the CSP group (65.6% vs 41.5%, P = 0.01). By contrast, the R0 resection rate was not significantly different between study groups (70.3% vs 61.5%, P = 0.29). The submucosal layer thickness was significantly greater in the UEMR group than in the CSP group (median 546 [range, 309-833] μm vs 69 [0-295] μm, P < 0.01). CSP had a shorter total procedure time (median 12 [range, 8-16] min vs 1 [1-3] min, P < 0.01) and fewer total bleeding events (9.4% vs 1.5%, P = 0.06).DISCUSSION:UEMR has superior vertical resectability compared with CSP, but CSP has a shorter procedure time and fewer bleeding events. Although CSP is preferable for most small SNADET, UEMR should be selected for lesions that cannot be definitively diagnosed as mucosal low-grade neoplasias.

Background Although endoscopic mucosal resection is an established colorectal polyp treatment, local recurrence occurs in 13 % of cases due to inadequate snaring. We evaluated whether pre-clipping to the muscularis propria resulted in resected specimens with negative surgical margins without thermal denaturation. Methods Of 245 polyps from 114 patients with colorectal polyps under 20 mm, we included 188 polyps from 81 patients. We randomly allocated polyps to the conventional injection group (CG) (97 polyps) or the pre-clipping injection group (PG) (91 polyps). The PG received three-point pre-clipping to ensure ample gripping to the muscle layer on the oral and both sides of the tumor with 4 mL local injection. Endoscopic ultrasonography was performed to measure the resulting bulge. Outcomes included the number of instances of thermal denaturation of the horizontal/vertical margin (HMX/VMX) or positive horizontal/vertical margins (HM+/VM+), the shortest distance from tumor margins to resected edges, and the maximum bulge distances from tumor surface to the muscularis propria. Results The numbers of HMX and HM+ in the CG and PG were 27 and 6, and 9 and 2 ( P  = 0.001), and VMX and VM+ were 8 and 5, and 0 and 0 ( P  = 0.057). The shortest distance from tumor margin to resected edge [median (range), mm] in polyps in the CG and PG was 0.6 (0–2.7) and 4.7 (2.1–8.9) ( P  = 0.018). The maximum bulge distances were 4.6 (3.0–8.0) and 11.0 (6.8–17.0) ( P  = 0.005). Conclusions Pre-clipping enabled surgical margin-negative resection without thermal denaturation.

Background Endoscopic mucosal resection (EMR) is an effective therapeutic technique well-standardized worldwide for the treatment of gastrointestinal neoplasm limited to the mucosal layer. To date, no study has compared technical and clinical differences based on the number of EMRs performed per year. This study aimed to compare EMR technical success, complications, and clinical outcome between low-volume centers (LVCs) and high-volume centers (HVCs). A total of nine endoscopic centers were included in the study. Methods This prospective study investigated consecutive patients with sessile polyps or flat colorectal lesions 1 cm or larger referred for EMR. Results A total of 427 lesions were resected in 384 patients at nine endoscopic centers. Males accounted for 60.4 % and females for 39.6 % of the patients. Most of the EMRs (84.8 %) were performed in HVCs and only 15.2 % in LVCs. All the lesions were resected in only one session. Argon plasma coagulation was performed on the margins of piecemeal resection in 15.7 % of the patients in HVCs only. Complete excision was achieved for 98.6 % of the lesions in HVCs and 98.8 % of the lesions in LVCs. The complication rate was 4.4 % in HVCs and 4.6 % in LVCs ( p  = 0.94). Delayed bleeding occurred in 2.5 % of the HVC cases and 3.1 % of the LVC cases. Perforation occurred in 1.9 % of the HVC cases and 1.5 % of the LVC cases ( p  = 1.00). Recurrences were experienced with 15 % of the lesions: 15.5 % in HVCs and 14 % in LVCs ( p  = 0.79). Conclusions The study showed that EMR can be performed also in LVC.

ObjectiveTo assess the efficacy and safety of endoscopic resection of large colorectal polyps.DesignRelevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966–2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed.Results50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%).ConclusionsEndoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.

Although capsule endoscopy (CE) is becoming an increasingly popular procedure, only recently data on its clinical application in pediatric gastroenterology are just emerging. Our aim is to investigate the diagnostic value of CE in small intestine diseases and to determine its safety, tolerance, and applicability in a large number of pediatric patients referred to our Tertiary Center of Pediatric Gastroenterology Unit, University of Parma. A total of 87 Italian patients, 49 of which were male with an age range from 18 months to 18 yr with a suspected small-bowel disease (inflammatory bowel disease 37%, polyps 38%, obscure gastrointestinal bleeding 24%, malabsorption 1%), were investigated with the M2A capsule (GIVEN((R)) Imaging Ltd., Yoqneam, Israel). A total of 77 patients swallowed the capsule, while in 10 it was endoscopically positioned (age range 1.5-11 yr, median age 5.3 yr). Eighty patients naturally evacuated the capsule, one patient needed surgery. The capsule evidenced pathological findings in 62 patients (71%), ileal lymphoid nodular hyperplasia in four subjects (5%), it was negative in 18 subjects (21%), and technically failed in three subjects (3%). In 21 out of 28 patients with known polyposis and in all the five patients with suspected polyposis, small-bowel polyps were found. In 16 out of 22 patients suffering from known inflammatory bowel disease (Crohn's disease colitis or indeterminate colitis), small intestine lesions were found. CE examination identified a possible small intestine bleeding source in 13 out of 21 patients with suspected obscure gastrointestinal bleeding. In 5 out of 10 patients with suspected small-bowel inflammatory disease, CE evidenced ileum lesions suggesting Crohn's disease, which was subsequently confirmed through diagnostic procedures and the clinical history. A patient with malabsorption presented a negative capsule study. Our experience, which includes the largest number of pediatric patients and the youngest child reported in literature, confirms that CE is a very useful system for the clinical work in suspected small-bowel diseases in infancy. The high rate of positive examination is due to the very careful selection of the patients, obligatory to conduct a safe examination since CE is not highly tested in children.

BACKGROUND, AIMS, AND PATIENTS: In a prospective follow up and intervention study of colorectal polyps, leaving all polyps less than 10 mm in situ for three years, analysis of redetection rate, growth, and new polyp formation was carried out in 116 patients undergoing annual colonoscopy. The findings in relation to growth and new polyp formation were applied to 58 subjects who received placebo. RESULTS: Redetection rate varied from 75-90% for each year, and was highest in the rectum and sigmoid colon. There was no net change in size of all polyps in the placebo group, however, polyps less than 5 mm showed a tendency to net growth, and polyps 5-9 mm a tendency to net regression in size, both for adenomas and hyperplastic polyps. This pattern was verified by computerised image analysis. Patients between 50 and 60 years showed evidence of adenoma size increase compared with the older patients, and the same was true for those with multiple adenomas (four to five) compared with those with a single adenoma. The new adenomas were significantly smaller and 71% were located in the right side of the colon. Patients with multiple adenomas had more new polyps at all the follow up examinations than patients with a single adenoma. One patient developed an invasive colorectal carcinoma, which may be evolved from a previously overlooked polyp. Two polyps, showing intramucosal carcinoma after follow up for three years, were completely removed, as judged by endoscopy and histological examination. CONCLUSIONS: The results show that follow up of unresected colorectal polyps up to 9 mm is safe. The consistency of growth retardation of medium sized polyps suggests extended intervals between the endoscopic follow up examinations, but the increased number of new polyps in the proximal colon indicates total colonoscopy as the examination of choice. The growth retardation of the medium sized polyps may partly explain the discrepancy between the prevalence of polyps and the incidence of colorectal cancer.

BackgroundLocal recurrence after cold snare polypectomy (CSP) of colorectal polyps has not been well analyzed. In this study, we analyzed the characteristics of local recurrence.MethodsWe retrospectively reviewed consecutive lesions resected by CSP from 2014 to 2016 and lesions that were followed up at ≥ 10 months after CSP, were analyzed. Our indication for CSP was a benign tumor of < 15 mm in size. We analyzed local recurrence and its risk factors using multivariate analyses. In addition, we compared lesions of ≥ 10 mm and < 10 mm. Moreover, therapeutic methods for recurrence were analyzed.ResultsFinally, we analyzed 554 cases out of 820 consecutive cases. The mean polyp size was 5.3 ± 2.8 mm and the en bloc resection and histopathological complete resection rates were 99.3% and 70.2%, respectively. The overall recurrence rate was 1.9% (mean follow-up period: 13.0 ± 4.0 months). Significant differences were observed between 11 recurrent lesions and 543 lesions without recurrence regarding polyp size (8.0 ± 3.7 mm vs. 5.2 ± 2.7 mm, p < 0.001), rate of sessile-serrated polyp (27.3% vs. 3.0%, p < 0.001), and histopathological positive margin (45.4% vs. 3.7%, p = 0.019). Multivariate analyses showed that a histopathological positive margin was the only significant risk factor for local recurrence (OR 16.600, 95% CI 3.707–74.331, p < 0.001). Regarding the comparison between 74 lesions of ≥ 10 mm and 480 lesions of < 10 mm, significant differences were observed in the en bloc resection rate (93.2% vs. 100%, p < 0.001), high-grade dysplasia rate (8.1% vs. 0.8%, p < 0.001), and histopathological complete resection rate (54.0% vs. 72.7%, p = 0.001). The recurrence rates of these two groups were 5.4% and 1.4%, respectively (p = 0.069). All recurrent cases could be resected with repeat CSP.ConclusionsThe local recurrence rate after CSP for lesions of < 10 mm was 1.4%. CSP was not recommended for lesions of ≥ 10 mm due to high rates of recurrence and malignancy.

Surgical site infections (SSIs) remain a common and costly morbidity after colorectal surgery. This rate remains high even in the setting of strict adherence to Surgical Care Improvement Project Protocols. The aim of our pilot study was to determine the feasibility and safety of subcutaneous gentamicin injection or pressurized irrigation as adjuncts to reduce SSI. A total of 132 patients who underwent colorectal surgery at the VA North Texas Health Care System were prospectively assigned to a pressurized irrigation group (n = 44), a preincision gentamicin injection group (n = 48), or control (n = 40). The primary objective was to assess safety and feasibility of these strategies. Patient demographics were matched among groups. Univariate and multivariate analyses were performed to identify possible predictions of SSI in this cohort. The rate of SSI in the control group was 25 per cent, 13.5 per cent in the pressurized irrigation group, and 12.5 per cent in the gentamicin group ( P = 0.26). Combined, the intervention groups had a 13 per cent SSI versus 25 per cent control ( P = 0.09). Operative time was not increased by the interventions and no intraoperative complications specifically related to the interventions were noted. Postoperative complications were not different between groups. Both albumin and body mass index were associated with SSI. Body mass index was and independent predictor of SSI ( P = 0.006). In conclusion, this pilot study demonstrates the feasibility of the interventions described. There was no detrimental effect of either intervention. There was trend toward a reduction in SSI in the intervention group, which warrants further investigation.

Background Recently in Japan, the morbidity of colorectal polyp has been increasing. As a result, a large number of cases of colorectal polyps that are diagnosed and treated using colonoscopy has now increased, and clinical guidelines are needed for endoscopic management and surveillance after treatment. Methods Three committees [the professional committee for making clinical questions (CQs) and statements by Japanese specialists, the expert panelist committee for rating statements by the modified Delphi method, and the evaluating committee by moderators] were organized. Ten specialists for colorectal polyp management extracted the specific clinical statements from articles published between 1983 and September 2011 obtained from PubMed and a secondary database, and developed the CQs and statements. Basically, statements were made according to the GRADE system. The expert panel individually rated the clinical statements using a modified Delphi approach, in which a clinical statement receiving a median score greater than seven on a nine-point scale from the panel was regarded as valid. Results The professional committee created 91CQs and statements for the current concept and diagnosis/treatment of various colorectal polyps including epidemiology, screening, pathophysiology, definition and classification, diagnosis, treatment/management, practical treatment, complications and surveillance after treatment, and other colorectal lesions (submucosal tumors, nonneoplastic polyps, polyposis, hereditary tumors, ulcerative colitis-associated tumor/carcinoma). Conclusions After evaluation by the moderators, evidence-based clinical guidelines for management of colorectal polyps have been proposed for 2014.