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Closure of post-EMR mucosal defects: to need or not to need, that is the question
Letters to the Editor
Matsushita et al believe that gentle performance of DBE might prevent pancreatitis. Out of our 82 oral procedures that reached the cecum (oral panenteroscopy), we did not have a single episode of acute pancreatitis or a complication in 8 patients (ie, 9.8% of our oral DBEs; mean duration of the procedure was 155 minutes, range 90-270). It is therefore evident that our procedures are gentle enough and that there must be some other factors in the pathogenesis of pancreatitis after DBE. We believe (as is consistent with Jarbandhan et al,3 Matsushita et al, and our previous study1) that mechanical contusion of the pancreas is a substantial factor in post-DBE pancreatitis (Fig. 1). Abdominal pain during oral DBE is the most important, alarming sign of possible acute pancreatitis, and when this occurs, the procedure should be terminated immediately. Because of this, we consider excessively deep conscious sedation to be inappropriate in DBE. Marcela Kopa´cˇova´, MD, PhD Stanislav Rejchrt, MD, PhD Ilja Tacheci, MD Jan Bures, MD, PhD 2nd Department of Medicine Charles University in Praha Faculty of Medicine at Hradec Kra´love´ University Teaching Hospital Hradec Kra´love´, Czech Republic Figure 1. DBE panenteroscopy via the oral route (plain radiograph). The tip of the endoscope with inflated balloon (arrowhead) is in the large bowel at the right upper quadrant. In comparison with the normal situation (yellow drawing). the duodenum is markedly shifted to the left and shortened. The position of the duodenojejunal junction is fixed (arrow).
remains uncertain whether all latent hyperamylasemia after DBE, hyperamylasemia with abdominal pain without progression into acute pancreatitis, and acute pancreatitis complicating DBE could have identical pathogenesis.1 In our setting, substantial hyperamylasemia was associated with longer procedure duration, but not acute pancreatitis itself.1 From February 2006 until January 2008, we performed 82 oral DBEs in 61 patients (mean duration was 120 minutes, range 20-270) in a prospective setting. Three of these patients (one of them was presented in our study1) developed acute pancreatitis (ie, 3.7%). Of these 3 patients, 2 had involvement of the pancreatic tail, and the third had pancreatitis localized in the head region; 2 had edematous, 1 had necrotizing pancreatitis. The duration of preceding DBE was 130, 90, and 90 minutes, respectively; a diagnostic enteroscope (EN-450P5; Fujinon Corp, Saitama, Japan) was used in 2, and a therapeutic enteroscope (EN-450T5, Fujinon Corp) was used in 1 case. Jarbandhan et al3 recently reported 6 episodes of post-DBE acute pancreatitis after 441 oral DBEs (1.4%); no pancreatitis was found in 162 DBEs performed via the anal route. This finding supports our assumption that post-DBE pancreatitis may not be as rare a condition as previously thought. 812 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 4 : 2008
REFERENCES 1. Kopa´cova´ M, Rejchrt S, Tachecı´ I, et al. Hyperamylasemia of uncertain significance associated with oral double-balloon enteroscopy. Gastrointest Endosc 2007;66:1133-8. 2. Mensink PB, Haringsma J, Kucharzik T, et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy 2007;39:613-5. 3. Jarbandhan SVA, van Weyenberg SJB, van der Veer WM, et al. Double balloon endoscopy associated pancreatitis: a description of six cases. World J Gastroenterol 2008;14:720-4. doi:10.1016/j.gie.2008.04.024
Closure of post-EMR mucosal defects: to need or not to need, that is the question To the Editor: We read with interest the article by Fujii et al1 on a novel endoscopic suturing technique to close post-EMR large mucosal defects with a figure-of-8-shaped ring (8-ring) and clips. They previously described another method to close the defects with an endoloop and clips to prevent postEMR delayed bleeding.2 Because the previous technique requires a double-channel colonoscope, they modified the technique to use a single-channel colonoscope, and they closed the defects successfully, without complications, in 10 lesions. We believe that this technique has some drawbacks, and furthermore, we doubt whether the prophylactic closure could effectively prevent delayed bleeding. www.giejournal.org
Letters to the Editor
Large sessile or flat colorectal polyps have a greater malignant potential, and are traditionally treated surgically.3,4 EMR is preferable to surgery because of its curability and less invasiveness.3 On the basis of the size and location of the polyps, EMR can be performed en bloc or piecemeal. Although piecemeal resection is related to a higher recurrence rate compared with en bloc resection, the piecemeal technique is used most frequently in large polyps.3 We believe that the technique used by Fujii et al1 would cover not only large mucosal defects but residual polyp tissue, resulting in a delay of adequate treatment for the recurrence. The risk of post-EMR bleeding and perforation is reported to increase with the size of resected polyps.1 Most perforations are small enough to close with immediate clipping,5 and the method of Fujii et al1 would be useful for perforations too large to close with a simple closure. Although prophylactic clipping to close post-EMR mucosal defects has been recommended for preventing delayed bleeding, the clipping technique has not decreased the occurrence of delayed bleeding in a prospective randomized controlled study.6 If their excellent technique cannot reduce the complication rate, we believe that the suturing technique might be only more time consuming compared to EMR without suturing.
Response:
doi:10.1016/j.gie.2008.02.081
We appreciate the comments of Matsushita et al on our study entitled ‘‘A novel endoscopic suturing technique using a specially designed so-called ‘8-ring’ in combination with resolution clips.’’1 Generally, colorectal polyps larger than 20 mm are difficult to remove en bloc endoscopically, even if conventional EMR (inject-and-cut method), instead of snare polypectomy, has been attempted; thus, EMR often occurs in a piecemeal fashion (EPMR). EPMR is more likely to result in incomplete resection and a higher rate of recurrence compared with en bloc EMR. The presence of residual neoplastic tissue around the endoscopic resection site can be difficult to detect by conventional colonoscopy; however, magnifying chromoendoscopy, as we have used in this study, has been reported to be a useful in vivo modality for distinction of neoplastic or non-neoplastic lesions, and for prediction of depth invasion of early colorectal cancers and remnant tissue after EMR.2-4 So far as the prevention of delayed bleeding after endoscopic resection is concerned, the randomized controlled trial referred to by Matsushita et al has concluded that prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy.5 The conclusion is, however, inappropriate, because the sample size is substantially underestimated, because the mean size of the lesions they studied was 7.8 mm.6 Therefore, we believe that the question regarding efficacy of endoscopic closure could not be answered by the study, and it should be confirmed through further controlled, multicenter, large-scale trials, especially for polyps larger than 20 mm. In Japan, patients with polyps larger than 10 mm are often treated as inpatients; however, all of the patients we studied, including one with a suspicious mini-perforation, were treated as outpatients without complication, and therefore, our suture technique saved time and resources. In addition to postpolypectomy bleeding, colonoscopic perforation is a common and serious complication associated with therapeutic colonoscopies. We have reported that immediate colonic perforations associated with therapeutic colonoscopies could be treated conservatively, if the endoscopic closure is successful.7 Unfortunately, successful endoscopic closure with clips was only possible in about 70% of the patients, and more than 70% of patients with unsuccessful closures finally underwent surgery due to the worsening of peritoneal symptoms. Based on our retrospective analysis, we conclude that it is difficult to close a perforation larger than 10 mm with clips. For gastric perforation associated with EMR and endoscopic submucosal dissection, Minami et al8 also suggested that gastric perforation during endoscopic resection could be conservatively treated by complete endoscopic closure with clips. They also reported that an omental-patch method for defects larger than 1 cm in size, using either the greater
www.giejournal.org
Volume 68, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 813
Mitsunobu Matsushita, MD Takayuki Matsumoto, MD Mika Omiya, MD Kazushige Uchida, MD Kazuichi Okazaki, MD Third Department of Internal Medicine Kansai Medical University Osaka, Japan
REFERENCES 1. Fujii T, Ono A, Fu KI. A novel endoscopic suturing technique using a specially designed so-called ‘‘8-ring’’ in combination with resolution clips (with videos). Gastrointest Endosc 2007;66:1215-20. 2. Matsuda T, Fujii T, Emura F, et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a twochannel colonoscope. Gastrointest Endosc 2004;60:836-8. 3. Brooker JC, Saunders BP, Shah SG, et al. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest Endosc 2002;55:371-5. 4. Matsushita M, Hajiro K, Takakuwa H, et al. Which parameter, marginal irregularity or tumor size, is more closely related to a malignant potential in flat elevated type of colorectal tumor? Gastrointest Endosc 1999; 50:306-7. 5. Taku K, Sano Y, Fu KI, et al. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol 2007;22:1409-14. 6. Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003;57:691-4.
Matsushita et al believe that gentle performance of DBE might prevent pancreatitis. Out of our 82 oral procedures that reached the cecum (oral panenteroscopy), we did not have a single episode of acute pancreatitis or a complication in 8 patients (ie, 9.8% of our oral DBEs; mean duration of the procedure was 155 minutes, range 90-270). It is therefore evident that our procedures are gentle enough and that there must be some other factors in the pathogenesis of pancreatitis after DBE. We believe (as is consistent with Jarbandhan et al,3 Matsushita et al, and our previous study1) that mechanical contusion of the pancreas is a substantial factor in post-DBE pancreatitis (Fig. 1). Abdominal pain during oral DBE is the most important, alarming sign of possible acute pancreatitis, and when this occurs, the procedure should be terminated immediately. Because of this, we consider excessively deep conscious sedation to be inappropriate in DBE. Marcela Kopa´cˇova´, MD, PhD Stanislav Rejchrt, MD, PhD Ilja Tacheci, MD Jan Bures, MD, PhD 2nd Department of Medicine Charles University in Praha Faculty of Medicine at Hradec Kra´love´ University Teaching Hospital Hradec Kra´love´, Czech Republic Figure 1. DBE panenteroscopy via the oral route (plain radiograph). The tip of the endoscope with inflated balloon (arrowhead) is in the large bowel at the right upper quadrant. In comparison with the normal situation (yellow drawing). the duodenum is markedly shifted to the left and shortened. The position of the duodenojejunal junction is fixed (arrow).
remains uncertain whether all latent hyperamylasemia after DBE, hyperamylasemia with abdominal pain without progression into acute pancreatitis, and acute pancreatitis complicating DBE could have identical pathogenesis.1 In our setting, substantial hyperamylasemia was associated with longer procedure duration, but not acute pancreatitis itself.1 From February 2006 until January 2008, we performed 82 oral DBEs in 61 patients (mean duration was 120 minutes, range 20-270) in a prospective setting. Three of these patients (one of them was presented in our study1) developed acute pancreatitis (ie, 3.7%). Of these 3 patients, 2 had involvement of the pancreatic tail, and the third had pancreatitis localized in the head region; 2 had edematous, 1 had necrotizing pancreatitis. The duration of preceding DBE was 130, 90, and 90 minutes, respectively; a diagnostic enteroscope (EN-450P5; Fujinon Corp, Saitama, Japan) was used in 2, and a therapeutic enteroscope (EN-450T5, Fujinon Corp) was used in 1 case. Jarbandhan et al3 recently reported 6 episodes of post-DBE acute pancreatitis after 441 oral DBEs (1.4%); no pancreatitis was found in 162 DBEs performed via the anal route. This finding supports our assumption that post-DBE pancreatitis may not be as rare a condition as previously thought. 812 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 4 : 2008
REFERENCES 1. Kopa´cova´ M, Rejchrt S, Tachecı´ I, et al. Hyperamylasemia of uncertain significance associated with oral double-balloon enteroscopy. Gastrointest Endosc 2007;66:1133-8. 2. Mensink PB, Haringsma J, Kucharzik T, et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy 2007;39:613-5. 3. Jarbandhan SVA, van Weyenberg SJB, van der Veer WM, et al. Double balloon endoscopy associated pancreatitis: a description of six cases. World J Gastroenterol 2008;14:720-4. doi:10.1016/j.gie.2008.04.024
Closure of post-EMR mucosal defects: to need or not to need, that is the question To the Editor: We read with interest the article by Fujii et al1 on a novel endoscopic suturing technique to close post-EMR large mucosal defects with a figure-of-8-shaped ring (8-ring) and clips. They previously described another method to close the defects with an endoloop and clips to prevent postEMR delayed bleeding.2 Because the previous technique requires a double-channel colonoscope, they modified the technique to use a single-channel colonoscope, and they closed the defects successfully, without complications, in 10 lesions. We believe that this technique has some drawbacks, and furthermore, we doubt whether the prophylactic closure could effectively prevent delayed bleeding. www.giejournal.org
Letters to the Editor
Large sessile or flat colorectal polyps have a greater malignant potential, and are traditionally treated surgically.3,4 EMR is preferable to surgery because of its curability and less invasiveness.3 On the basis of the size and location of the polyps, EMR can be performed en bloc or piecemeal. Although piecemeal resection is related to a higher recurrence rate compared with en bloc resection, the piecemeal technique is used most frequently in large polyps.3 We believe that the technique used by Fujii et al1 would cover not only large mucosal defects but residual polyp tissue, resulting in a delay of adequate treatment for the recurrence. The risk of post-EMR bleeding and perforation is reported to increase with the size of resected polyps.1 Most perforations are small enough to close with immediate clipping,5 and the method of Fujii et al1 would be useful for perforations too large to close with a simple closure. Although prophylactic clipping to close post-EMR mucosal defects has been recommended for preventing delayed bleeding, the clipping technique has not decreased the occurrence of delayed bleeding in a prospective randomized controlled study.6 If their excellent technique cannot reduce the complication rate, we believe that the suturing technique might be only more time consuming compared to EMR without suturing.
Response:
doi:10.1016/j.gie.2008.02.081
We appreciate the comments of Matsushita et al on our study entitled ‘‘A novel endoscopic suturing technique using a specially designed so-called ‘8-ring’ in combination with resolution clips.’’1 Generally, colorectal polyps larger than 20 mm are difficult to remove en bloc endoscopically, even if conventional EMR (inject-and-cut method), instead of snare polypectomy, has been attempted; thus, EMR often occurs in a piecemeal fashion (EPMR). EPMR is more likely to result in incomplete resection and a higher rate of recurrence compared with en bloc EMR. The presence of residual neoplastic tissue around the endoscopic resection site can be difficult to detect by conventional colonoscopy; however, magnifying chromoendoscopy, as we have used in this study, has been reported to be a useful in vivo modality for distinction of neoplastic or non-neoplastic lesions, and for prediction of depth invasion of early colorectal cancers and remnant tissue after EMR.2-4 So far as the prevention of delayed bleeding after endoscopic resection is concerned, the randomized controlled trial referred to by Matsushita et al has concluded that prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy.5 The conclusion is, however, inappropriate, because the sample size is substantially underestimated, because the mean size of the lesions they studied was 7.8 mm.6 Therefore, we believe that the question regarding efficacy of endoscopic closure could not be answered by the study, and it should be confirmed through further controlled, multicenter, large-scale trials, especially for polyps larger than 20 mm. In Japan, patients with polyps larger than 10 mm are often treated as inpatients; however, all of the patients we studied, including one with a suspicious mini-perforation, were treated as outpatients without complication, and therefore, our suture technique saved time and resources. In addition to postpolypectomy bleeding, colonoscopic perforation is a common and serious complication associated with therapeutic colonoscopies. We have reported that immediate colonic perforations associated with therapeutic colonoscopies could be treated conservatively, if the endoscopic closure is successful.7 Unfortunately, successful endoscopic closure with clips was only possible in about 70% of the patients, and more than 70% of patients with unsuccessful closures finally underwent surgery due to the worsening of peritoneal symptoms. Based on our retrospective analysis, we conclude that it is difficult to close a perforation larger than 10 mm with clips. For gastric perforation associated with EMR and endoscopic submucosal dissection, Minami et al8 also suggested that gastric perforation during endoscopic resection could be conservatively treated by complete endoscopic closure with clips. They also reported that an omental-patch method for defects larger than 1 cm in size, using either the greater
www.giejournal.org
Volume 68, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 813
Mitsunobu Matsushita, MD Takayuki Matsumoto, MD Mika Omiya, MD Kazushige Uchida, MD Kazuichi Okazaki, MD Third Department of Internal Medicine Kansai Medical University Osaka, Japan
REFERENCES 1. Fujii T, Ono A, Fu KI. A novel endoscopic suturing technique using a specially designed so-called ‘‘8-ring’’ in combination with resolution clips (with videos). Gastrointest Endosc 2007;66:1215-20. 2. Matsuda T, Fujii T, Emura F, et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a twochannel colonoscope. Gastrointest Endosc 2004;60:836-8. 3. Brooker JC, Saunders BP, Shah SG, et al. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest Endosc 2002;55:371-5. 4. Matsushita M, Hajiro K, Takakuwa H, et al. Which parameter, marginal irregularity or tumor size, is more closely related to a malignant potential in flat elevated type of colorectal tumor? Gastrointest Endosc 1999; 50:306-7. 5. Taku K, Sano Y, Fu KI, et al. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol 2007;22:1409-14. 6. Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003;57:691-4.