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Cold Snare Polypectomy for Diminutive Polyps: An Assessment of the Risk of Incomplete Removal of Small Adenomas
Abstracts
lymphoma, 1 subject had a gastric carcinoid, and 1 had a malignant gastrointestinal stromal tumor identified. The proportion of subjects who had a clinically important upper GI lesion identified by EGD did not differ between subjects with and those without a clinically important lesion identified by colonoscopy (37.2% vs. 32.9%, p Z 0.06) nor in those with and without upper GI symptoms (36.6% vs. 34.1%, p Z 0.32). Synchronous lesions in the upper and lower GI tract were identified in 15.9% of patients. Conclusions: Patients with IDA have a high prevalence of clinically important lesions in the upper GI tract. These findings suggest that EGD should be strongly considered in all subjects with IDA irregardless of the presence of a clinically important lesion identified by colonoscopy or if upper GI symptoms are absent.
M1298 Cold Snare Polypectomy for Diminutive Polyps: An Assessment of the Risk of Incomplete Removal of Small Adenomas Jeremy L. Humphris, Jill Tippett, Avelyn Kwok, Peter H. Katelaris Concern about complications related to ‘hot biopsy’ electrocautery has led to the widespread adoption of cold snare polypectomy techniques for the removal of diminutive colonic polyps. While a favourable safety profile has been demonstrated with these techniques, the adequacy of polyp removal has not been subject to the same scrutiny. As hot biopsy polypectomy has been associated with residual viable polyp tissue in up to 17% of cases1, the aim of this study was to assess the completeness of polypectomy with cold snare techniques. Methods: Data was recorded prospectively from consecutive patients found to have diminutive polyps (% 5mm) at colonoscopy and who underwent cold snare polypectomy. Prior to removal, the likely histological diagnosis was predicted by the endoscopist. Standard techniques employed at the discretion of the endoscopist included use of suction to form a pseudostalk and the choice of a 10mm or 13mm snare. The presence of residual polyp was assessed by histological assessment of quadrantic forceps biopsies taken from the edges of the polypectomy site. Patients were followed up with a phone interview two weeks after the procedure. Results: In 52 patients (M73%, mean age 65yrs) 64 consecutive cold snare polypectomies were available for analysis, comprising 43 tubular adenomas, 1 sessile serrated adenoma and 20 hyperplastic polyps. Median polyp size was 3mm. Endoscopist prediction of adenomatous histology had a sensitivity of 91% and a specificity of 45%. Adenomatous histology was found in 14%, 75% and 95% of polyps in the rectum (2/14), left colon (21/28) and right colon (21/22) respectively. Residual adenomatous tissue was found in 11.4% (5/44) of the adenomas removed, including 2 of 19 (10.5%) that had been suctioned to form a pseudostalk. There were no complications. Conclusions: This study demonstrates a significant residual polyp rate with cold snare techniques (and similar to electrocautery). It confirms that endoscopic prediction of polyp histology lacks specificity. These findings mean that completeness of removal of diminutive polyps cannot be assumed after cold polypectomy, that retrieval of the polyp is necessary to confirm histology and that refinements of the techniques are required to minimise the risk of incomplete polypectomy. Reference: Peluso F. Goldner F. Gastrointestinal Endoscopy 1991; 37: 604-6.
M1299 Risk of Bleeding Following Percutaneous Endoscopic Gastrostomy (PEG): A Five Year Retrospective Study Alexandra S. Laya, Dushyant Singh, Wendell K. Clarkston Percutaneous Endoscopic Gastrostomy (PEG), the primary procedure for the long term nutrition of patients with swallowing disorders, is considered a high risk endoscopic procedure for bleeding complications. This retrospective review aims to determine predictive factors of bleeding complications associated with PEG, including the risk of anticoagulation and anti-platelet therapy. Methods: During a 5 year period (Jan 1, 2002 to Dec 31, 2006), 956 PEG were performed using a standard pull-through technique. Complete electronic medical records were available in 883 cases, and were reviewed for predictive factors of bleeding, bleeding complications, and interventions for hemostasis. Bleeding was defined as blood per PEG (bright blood, coffee ground material, heme-positive aspirate), hematemesis, melena, hematochezia, peri-stomal bleeding, drop in hemoglobin or occult blood in stool. Results: Of the 883 cases, 54.9% (nZ495) were male, 45.1% (nZ398) were female, with a mean age of 67.8 16.6 years. Gastrointestinal bleeding following PEG occurred in 28 cases (3.2%), of which only 5 cases (0.57%) were found at endoscopy to be a result of PEG placement; 3 developed immediate peri-stomal bleeding, one of which required intra-dermal injection of epinephrine. Endoscopy on the other 2 patients revealed PEG related bleeding gastric ulcers treated with injection therapy. Blood transfusion was required in 1 patient. Cases were reviewed for the use of anti-platelet (aspirin, clopidogrel) or anticoagulants (heparin, enoxaparin, warfarin). Among cases where PEG related bleeding was identified, 100% (nZ5) were on at least 1 anti-platelet or anticoagulant drug, with none having received clopidogrel. In the non-bleeding group, 62.53% (nZ549) were on at least one anti-platelet or anticoagulant drug administered in proximity to PEG insertion, and 9.7% (nZ85) were treated with clopidogrel. The mean cessation period for clopidogrel prior to PEG was 2.3 2.14 days. A multiple logistic regression analysis of variables including gender, indication, or the use of
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anti-platelet or anticoagulant medications showed that none of these variables were statistically significant predictors of bleeding (pR 0.127). Conclusions: Bleeding complications associated with PEG placement are rare, even in the face of recent use of anticoagulants and anti-platelet medications. Specifically, clopidogrel did not contribute to an increase in bleeding outcomes, despite cessation of the drug a mean of 2.3 days prior to PEG. Prospective studies are needed to establish evidence-based guidelines for optimal cessation of anti-platelet or anticoagulant medications prior to PEG.
M1300 Treatment of Achalasia By Two Sclerosing Agents: A Long-Term Experience and Analysis ´, Angel Barturen, Aintzane Arechavala, Patricia Salvador, Manuel Moreto Enrique Ojembarrena Background and Methods: After having experienced the hypothesis of ethanolamine oleate (ETO) as a treatment for achalasia, by injecting just below the cardias, we reported on the initial experience after having treated 33 patients testing two different schedules (19 and 31 patients, series 1 and 2 respectively) (Endoscopy 1996, 28,539). Later on, we have treated 23 additional patients (series 3) by polidocanol (PD) and a fourth series of 16 patients by a modified ETO schedule with the adjunction of endoscopic ultrasosography (EUS). We have analyzed: A) Absolute primary success (only occasional or no dysphagia); B) Secondary success (the same but after requiring a 20 mm balloon dilation or additional injections because of recurrence) C) Failure rate (need to dilate with a 30 mm balloon, refusal of the patient to complete the treatment once it was started, or the presence of daily dysphagia). D) The comparative stricture rates and the response to dilation with a 20 mm balloon. E) The sustained response of those patients who had to receive dilation by a 30-mm. balloon. F) The pattern of USE changes and their contribution to assess the timing of injections. Results: 88 patients could be correctly evaluated, with a mean follow up to 72 months. A) 53 and 19 patients, respectively, resulted in primary and secondary success, while 16 failed. B) 18/89 had to receive 20 mm dilation, and 8 had to be dilated with a 30 mm balloon. C) No significant differences were appreciated between the three schedules by ETO, but results were significantly poorer by PD: 6 out of 65 treated by ETO finally failed, against 10/23 in the PD group (p!0,0005). D) More patients received dilation because of stricture en the PD group (7/22) than en in ETO group (10/64) but without reaching statistical significance. E) None of the patients who received dilation required surgery, resulting in a good or fair clinical situation afterwards. F) USE could delineate three patterns: 1) No changes (they could receive more injections). 2) Areas of destroyed muscle (no more injections were applied on these areas. 3) Fibrotic changes (they pointed out to the need of dilation if dysphagia was present). Additionally, as a complication, 6 patients experienced mild or moderate gastro-esophageal reflux. Conclusions. Injections of ETO are highly effective to treat achalasia on long-term basis. PD would represent at best only an adjuvant to dilation. USE contributed to better delineate the timing of injections. When sclerotherapy by ETO fails, dilation uses to be a sufficient treatment, on a long-term basis.
M1301 False-Positive Findings of a Clostridium Difficile Enzyme Immunoassay On Aspirates Obtained During Colonoscopy Eugene F. Yen, Richard B. Thomson, Katherine Appert, Karen M. Ilag, Lance R. Peterson, Ari Robicsek Background and Aims: Clostridium difficile-associated diarrhea is a major medical problem throughout the world. A widely-practiced technique in the evaluation of chronic diarrhea is perform colonoscopy/sigmoidoscopy and to aspirate stool for enzyme immunoassay (EIA) to test for C. difficile. At our institution, we observed an unexpectedly high proportion of positive C. difficile assays on stool obtained during colonoscopy, often following a negative stool test. Our goals were to evaluate for false positive C. difficile EIA tests in colonoscopy aspirates and to determine possible etiologies of false-positivity. Methods: We obtained colonoscopy aspirates from 40 consecutive patients who presented for routine colorectal cancer screening. These patients had no complaints of diarrhea prior to bowel preparation. Residual stool and liquid were aspirated into a stool trap during colonoscopy from a single physician and nurse. Stool samples were then sent to a blinded microbiologist for routine C. difficile EIA testing (CDIFF TOX A/B II, TechLab/Wampole, Blacksburg, VA). Positive EIA tests were followed-up with tissue culture cytotoxin assay for confirmation. Finally, commonly used items in colonoscopy, including simethicone, lubricant, and bowel preparation (Polyethylene Glycol 3350 - TriLyteÔ with flavor packs, Schwarz Pharma, Inc. Milwaukee, WI) mixed in sterile water, were also sent individually for routine C. difficile EIA testing. Results: Stool aspirates were processed successfully in 38 cases. EIA assay for toxins A or B was positive in 27 of 38 cases (67%). None were positive by either confirmatory tissue culture cytotoxin assays or culture for C. difficile. Further, sampling of Polyethylene Glycol 3350 bowel prep mixed with sterile water in normal dilution (but no stool), as well as simethicone alone, tested positive for C. difficile by EIA. Conclusions: We found a substantial proportion of false positive C. difficile assays on aspirates obtained during colonoscopy. A potential explanation
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB207
lymphoma, 1 subject had a gastric carcinoid, and 1 had a malignant gastrointestinal stromal tumor identified. The proportion of subjects who had a clinically important upper GI lesion identified by EGD did not differ between subjects with and those without a clinically important lesion identified by colonoscopy (37.2% vs. 32.9%, p Z 0.06) nor in those with and without upper GI symptoms (36.6% vs. 34.1%, p Z 0.32). Synchronous lesions in the upper and lower GI tract were identified in 15.9% of patients. Conclusions: Patients with IDA have a high prevalence of clinically important lesions in the upper GI tract. These findings suggest that EGD should be strongly considered in all subjects with IDA irregardless of the presence of a clinically important lesion identified by colonoscopy or if upper GI symptoms are absent.
M1298 Cold Snare Polypectomy for Diminutive Polyps: An Assessment of the Risk of Incomplete Removal of Small Adenomas Jeremy L. Humphris, Jill Tippett, Avelyn Kwok, Peter H. Katelaris Concern about complications related to ‘hot biopsy’ electrocautery has led to the widespread adoption of cold snare polypectomy techniques for the removal of diminutive colonic polyps. While a favourable safety profile has been demonstrated with these techniques, the adequacy of polyp removal has not been subject to the same scrutiny. As hot biopsy polypectomy has been associated with residual viable polyp tissue in up to 17% of cases1, the aim of this study was to assess the completeness of polypectomy with cold snare techniques. Methods: Data was recorded prospectively from consecutive patients found to have diminutive polyps (% 5mm) at colonoscopy and who underwent cold snare polypectomy. Prior to removal, the likely histological diagnosis was predicted by the endoscopist. Standard techniques employed at the discretion of the endoscopist included use of suction to form a pseudostalk and the choice of a 10mm or 13mm snare. The presence of residual polyp was assessed by histological assessment of quadrantic forceps biopsies taken from the edges of the polypectomy site. Patients were followed up with a phone interview two weeks after the procedure. Results: In 52 patients (M73%, mean age 65yrs) 64 consecutive cold snare polypectomies were available for analysis, comprising 43 tubular adenomas, 1 sessile serrated adenoma and 20 hyperplastic polyps. Median polyp size was 3mm. Endoscopist prediction of adenomatous histology had a sensitivity of 91% and a specificity of 45%. Adenomatous histology was found in 14%, 75% and 95% of polyps in the rectum (2/14), left colon (21/28) and right colon (21/22) respectively. Residual adenomatous tissue was found in 11.4% (5/44) of the adenomas removed, including 2 of 19 (10.5%) that had been suctioned to form a pseudostalk. There were no complications. Conclusions: This study demonstrates a significant residual polyp rate with cold snare techniques (and similar to electrocautery). It confirms that endoscopic prediction of polyp histology lacks specificity. These findings mean that completeness of removal of diminutive polyps cannot be assumed after cold polypectomy, that retrieval of the polyp is necessary to confirm histology and that refinements of the techniques are required to minimise the risk of incomplete polypectomy. Reference: Peluso F. Goldner F. Gastrointestinal Endoscopy 1991; 37: 604-6.
M1299 Risk of Bleeding Following Percutaneous Endoscopic Gastrostomy (PEG): A Five Year Retrospective Study Alexandra S. Laya, Dushyant Singh, Wendell K. Clarkston Percutaneous Endoscopic Gastrostomy (PEG), the primary procedure for the long term nutrition of patients with swallowing disorders, is considered a high risk endoscopic procedure for bleeding complications. This retrospective review aims to determine predictive factors of bleeding complications associated with PEG, including the risk of anticoagulation and anti-platelet therapy. Methods: During a 5 year period (Jan 1, 2002 to Dec 31, 2006), 956 PEG were performed using a standard pull-through technique. Complete electronic medical records were available in 883 cases, and were reviewed for predictive factors of bleeding, bleeding complications, and interventions for hemostasis. Bleeding was defined as blood per PEG (bright blood, coffee ground material, heme-positive aspirate), hematemesis, melena, hematochezia, peri-stomal bleeding, drop in hemoglobin or occult blood in stool. Results: Of the 883 cases, 54.9% (nZ495) were male, 45.1% (nZ398) were female, with a mean age of 67.8 16.6 years. Gastrointestinal bleeding following PEG occurred in 28 cases (3.2%), of which only 5 cases (0.57%) were found at endoscopy to be a result of PEG placement; 3 developed immediate peri-stomal bleeding, one of which required intra-dermal injection of epinephrine. Endoscopy on the other 2 patients revealed PEG related bleeding gastric ulcers treated with injection therapy. Blood transfusion was required in 1 patient. Cases were reviewed for the use of anti-platelet (aspirin, clopidogrel) or anticoagulants (heparin, enoxaparin, warfarin). Among cases where PEG related bleeding was identified, 100% (nZ5) were on at least 1 anti-platelet or anticoagulant drug, with none having received clopidogrel. In the non-bleeding group, 62.53% (nZ549) were on at least one anti-platelet or anticoagulant drug administered in proximity to PEG insertion, and 9.7% (nZ85) were treated with clopidogrel. The mean cessation period for clopidogrel prior to PEG was 2.3 2.14 days. A multiple logistic regression analysis of variables including gender, indication, or the use of
www.giejournal.org
anti-platelet or anticoagulant medications showed that none of these variables were statistically significant predictors of bleeding (pR 0.127). Conclusions: Bleeding complications associated with PEG placement are rare, even in the face of recent use of anticoagulants and anti-platelet medications. Specifically, clopidogrel did not contribute to an increase in bleeding outcomes, despite cessation of the drug a mean of 2.3 days prior to PEG. Prospective studies are needed to establish evidence-based guidelines for optimal cessation of anti-platelet or anticoagulant medications prior to PEG.
M1300 Treatment of Achalasia By Two Sclerosing Agents: A Long-Term Experience and Analysis ´, Angel Barturen, Aintzane Arechavala, Patricia Salvador, Manuel Moreto Enrique Ojembarrena Background and Methods: After having experienced the hypothesis of ethanolamine oleate (ETO) as a treatment for achalasia, by injecting just below the cardias, we reported on the initial experience after having treated 33 patients testing two different schedules (19 and 31 patients, series 1 and 2 respectively) (Endoscopy 1996, 28,539). Later on, we have treated 23 additional patients (series 3) by polidocanol (PD) and a fourth series of 16 patients by a modified ETO schedule with the adjunction of endoscopic ultrasosography (EUS). We have analyzed: A) Absolute primary success (only occasional or no dysphagia); B) Secondary success (the same but after requiring a 20 mm balloon dilation or additional injections because of recurrence) C) Failure rate (need to dilate with a 30 mm balloon, refusal of the patient to complete the treatment once it was started, or the presence of daily dysphagia). D) The comparative stricture rates and the response to dilation with a 20 mm balloon. E) The sustained response of those patients who had to receive dilation by a 30-mm. balloon. F) The pattern of USE changes and their contribution to assess the timing of injections. Results: 88 patients could be correctly evaluated, with a mean follow up to 72 months. A) 53 and 19 patients, respectively, resulted in primary and secondary success, while 16 failed. B) 18/89 had to receive 20 mm dilation, and 8 had to be dilated with a 30 mm balloon. C) No significant differences were appreciated between the three schedules by ETO, but results were significantly poorer by PD: 6 out of 65 treated by ETO finally failed, against 10/23 in the PD group (p!0,0005). D) More patients received dilation because of stricture en the PD group (7/22) than en in ETO group (10/64) but without reaching statistical significance. E) None of the patients who received dilation required surgery, resulting in a good or fair clinical situation afterwards. F) USE could delineate three patterns: 1) No changes (they could receive more injections). 2) Areas of destroyed muscle (no more injections were applied on these areas. 3) Fibrotic changes (they pointed out to the need of dilation if dysphagia was present). Additionally, as a complication, 6 patients experienced mild or moderate gastro-esophageal reflux. Conclusions. Injections of ETO are highly effective to treat achalasia on long-term basis. PD would represent at best only an adjuvant to dilation. USE contributed to better delineate the timing of injections. When sclerotherapy by ETO fails, dilation uses to be a sufficient treatment, on a long-term basis.
M1301 False-Positive Findings of a Clostridium Difficile Enzyme Immunoassay On Aspirates Obtained During Colonoscopy Eugene F. Yen, Richard B. Thomson, Katherine Appert, Karen M. Ilag, Lance R. Peterson, Ari Robicsek Background and Aims: Clostridium difficile-associated diarrhea is a major medical problem throughout the world. A widely-practiced technique in the evaluation of chronic diarrhea is perform colonoscopy/sigmoidoscopy and to aspirate stool for enzyme immunoassay (EIA) to test for C. difficile. At our institution, we observed an unexpectedly high proportion of positive C. difficile assays on stool obtained during colonoscopy, often following a negative stool test. Our goals were to evaluate for false positive C. difficile EIA tests in colonoscopy aspirates and to determine possible etiologies of false-positivity. Methods: We obtained colonoscopy aspirates from 40 consecutive patients who presented for routine colorectal cancer screening. These patients had no complaints of diarrhea prior to bowel preparation. Residual stool and liquid were aspirated into a stool trap during colonoscopy from a single physician and nurse. Stool samples were then sent to a blinded microbiologist for routine C. difficile EIA testing (CDIFF TOX A/B II, TechLab/Wampole, Blacksburg, VA). Positive EIA tests were followed-up with tissue culture cytotoxin assay for confirmation. Finally, commonly used items in colonoscopy, including simethicone, lubricant, and bowel preparation (Polyethylene Glycol 3350 - TriLyteÔ with flavor packs, Schwarz Pharma, Inc. Milwaukee, WI) mixed in sterile water, were also sent individually for routine C. difficile EIA testing. Results: Stool aspirates were processed successfully in 38 cases. EIA assay for toxins A or B was positive in 27 of 38 cases (67%). None were positive by either confirmatory tissue culture cytotoxin assays or culture for C. difficile. Further, sampling of Polyethylene Glycol 3350 bowel prep mixed with sterile water in normal dilution (but no stool), as well as simethicone alone, tested positive for C. difficile by EIA. Conclusions: We found a substantial proportion of false positive C. difficile assays on aspirates obtained during colonoscopy. A potential explanation
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB207