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EFFICACY, SAFETY AND OUTCOMES OF “INJECT AND CUT” ENDOSCOPIC MUCOSAL RESECTION (EMR) FOR LARGE SESSILE AND FLAT COLORECTAL POLYPS
S160
Abstracts / Digestive and Liver Disease 41S (2009), S1–S167
NTP (p=0.0002); ERCP-related mortality rate was 0% in LTP vs 0.1% in NTP (p=0.65). Conclusions: ERCP is safe and effective in the management of postOLT biliary complications. Its therapeutic effect is durable with a surprisingly low rate of post-procedure pancreatitis. # R. Therapeutic endoscopy 5. ERCP
P.229 EFFICACY, SAFETY AND OUTCOMES OF “INJECT AND CUT” ENDOSCOPIC MUCOSAL RESECTION (EMR) FOR LARGE SESSILE AND FLAT COLORECTAL POLYPS F. Ferrara ∗ ,1 , C. Luigiano 1 , P. Billi 1 , S. Ghersi 1 , V. Cennamo 2 , C. Fabbri 1 , A.M. Polifemo 1 , P. Landi 1 , M. Bassi 1 , N. D’Imperio 1 1 Presidio
Ospedaliero Bellaria-Maggiore, Bologna; 2 Policlinico S. Orsola-Malpighi, Bologna
Background and aim: EMR is widely accepted as an effective treatment for early colon cancer. The adverse events associated with EMR increase with the dimension of the lesion treated; the most frequent complications are bleeding (1-45%), perforation (0.7-4%) and post-polypectomy syndrome (0-7.6%). Another risk following EMR is recurrence, in up to 46% of cases. The aim of this study was to evaluate the outcomes of inject and cut EMR for large sessile and flat colorectal polyps. Material and methods: Between January 2006 and August 2008 a total of 157 patients (95M and 62W; mean age 66±7.7 years, range 25-83) with 182 polyps = 15 mm were included in the study. The size, shape, location, histology, technique of resection (en-bloc or piecemeal) with or without APC, complications, recurrence and accuracy of non-lifting sign were analyzed. For statistical analysis the polyps were splitted in two groups, the first group including polyps <30 mm of diameter and the second polyps ≥30 mm of diameter, and Mann-Whitney and Spearman test were used. A p-value <0.05 was considered statistically significant. Results: Because of non-lifting sign, 5 of 182 polyps were referred to surgical resection: histopathological examination revealed adenocarcinoma, T2 in 3 and T3 in 2 patients. The remaing 177 polyps (43 flat and 134 sessile; 57 with a size ≥30 mm and 120 <30 mm) were excised. Mean size of lesions removed was 24.5±10.2 mm (range 15-70) and the most common location was the sigmoid colon in 30.5% (54/177). En-bloc resection was performed in 44.6% (79/177) and piece-meal in 55.4%. APC was used in 23.7% (42/177), mostly in polyps with flat shape (P=0.001). There were 20 procedural (11.3%) and 2 late (1.1%) bleeding, 4 post-polypectomy syndrome (2.2%) and 2 perforations (1.1%). The bleeding was related to malignancy (P=0.01). Intramucosal cancer was observed in 5 cases (2.8%) while invasive cancer was observed in 8 cases (4.5%). Malignancy was mostly present in polyps with size ≥ 30 mm (P=0.003). The sensitivity, specificity, PPV and NPV of non-lifting sign was respectively 100, 95.5, 38.5 and 100%. Median follow up at 14.9±7.9 months (range 3-24) revealed a 6.8% (12/177) recurrence and was related to size ≥ 30 mm of polyps (P=0.003). Conclusions: Inject and cut EMR is practical and effective for treatment of large colorectal polyps with low risks of complications and local recurrence. # S. Endoscopy complications
P.230 ENDOSCOPIC HEMOSTASIS USING FIBRIN SEALANT TO TREAT HEMORRHAGE IN POST-SPHINCTEROTOMY BLEEDING P. Beretta ∗ , C. Cucino Istituto Clinico Santa Rita, Milano Background and aim: Endoscopic sphincterotomy (ES) has bleeding as the most common complication.Post-ES bleeding may occur
immediately or several days later. When post-ES bleeding does not stop spontaneously, endoscopic treatment is necessary, and epinephryne injection or sclerosant is the treatment of choice. Material and methods: We describe a case of an 86 years old woman taking oral anticoagulants who was admitted to our hospital for jaundice. A CT scan revealed stones in the common bile duct (CBD) and in the gallbladder. Oral anticoagulant was stopped and subcutaneous low molecular weight heparin was given. ERCP with ES was performed and a stone of 8 mm was removed from the CBD. After 5 days hemoglobin decreased from 11.5 to 6.9 mg/dL and the patient had been transfused. Endoscopy revealed a clot from the site of ES with oozing bleeding underneath, which was treated with injection of epinephrine. After 7 days hemoglobin falled again to 8 mg/dL and endoscopy confirmed the persistence of bleeding from the papilla. We than placed a pancreatic stent and performed epinephrine injection and heater probe cautery, with the apparent control of the hemorrage. Nevertheless, hemoglobin did not rise and we performed a third urgent endoscopy, which revealed that the papilla was still bleeding. We removed the standard pancreatic stent and placed a modified stent without the internal wings inside the Wirsung duct (Fig. 1). We than injected fibrin sealant and hemorrage was stopped. After few minutes from the hemostasis, the modified stent fell down (Fig. 2). Hemoglobin levels remained stable and the patient was discharged after 10 days.
Figure 1
Figure 2
Results: We treated successfully a case of post-ES bleeding with human fibrin injection and the placement of a plastic stent. Conclusions: The main advantage of using fibrin sealant is the absence of tissue damage when injected at the bleeding area, so that the hemostatic procedure can be repeated multiple times. The disadvantages are represented by high costs of the human products and the potential risk of viral disease transmission, which cannot be excluded despite stringent controls to the selection of the blood donors. Nevertheless, we suggest that the application of this kind of sealant could be very useful for the selected persistent post-ES bleeding. # S. Endoscopy complications
P.231 ELABORATION DATA SOFTWARE APPLIED TO CEUS FOR QUANTITATIVE EVALUATION OF MICROVASCULAR ACTIVATION AND CORRELATION WITH BIOLOGICAL ACTIVITY IN ILEAL CROHN’S DISEASE L. Guidi ∗ ,1 , A. Di Veronica 2 , A. Armuzzi 1 , C. Felice 1 , M. Marzo 1 , G. Mocci 1 , I. Roberto 1 , B. De Pascalis 1 , I. De Vitis 1 , A. Papa 1 , A. De Franco 2 1 UO Gastroenterologia, Complesso Integrato Columbus, Università Cattolica Sacro Cuore, Roma; 2 UO Radiodiagnostica, Complesso Integrato Columbus, Università Cattolica Del Sacro Cuore, Roma
Background and aim: Microvascular activation and angiogenesis induced by inflammation in ileal loops affected by Crohn’s disease (CD) can be demonstrated by contrast-enhanced wideband harmonic imaging
Abstracts / Digestive and Liver Disease 41S (2009), S1–S167
NTP (p=0.0002); ERCP-related mortality rate was 0% in LTP vs 0.1% in NTP (p=0.65). Conclusions: ERCP is safe and effective in the management of postOLT biliary complications. Its therapeutic effect is durable with a surprisingly low rate of post-procedure pancreatitis. # R. Therapeutic endoscopy 5. ERCP
P.229 EFFICACY, SAFETY AND OUTCOMES OF “INJECT AND CUT” ENDOSCOPIC MUCOSAL RESECTION (EMR) FOR LARGE SESSILE AND FLAT COLORECTAL POLYPS F. Ferrara ∗ ,1 , C. Luigiano 1 , P. Billi 1 , S. Ghersi 1 , V. Cennamo 2 , C. Fabbri 1 , A.M. Polifemo 1 , P. Landi 1 , M. Bassi 1 , N. D’Imperio 1 1 Presidio
Ospedaliero Bellaria-Maggiore, Bologna; 2 Policlinico S. Orsola-Malpighi, Bologna
Background and aim: EMR is widely accepted as an effective treatment for early colon cancer. The adverse events associated with EMR increase with the dimension of the lesion treated; the most frequent complications are bleeding (1-45%), perforation (0.7-4%) and post-polypectomy syndrome (0-7.6%). Another risk following EMR is recurrence, in up to 46% of cases. The aim of this study was to evaluate the outcomes of inject and cut EMR for large sessile and flat colorectal polyps. Material and methods: Between January 2006 and August 2008 a total of 157 patients (95M and 62W; mean age 66±7.7 years, range 25-83) with 182 polyps = 15 mm were included in the study. The size, shape, location, histology, technique of resection (en-bloc or piecemeal) with or without APC, complications, recurrence and accuracy of non-lifting sign were analyzed. For statistical analysis the polyps were splitted in two groups, the first group including polyps <30 mm of diameter and the second polyps ≥30 mm of diameter, and Mann-Whitney and Spearman test were used. A p-value <0.05 was considered statistically significant. Results: Because of non-lifting sign, 5 of 182 polyps were referred to surgical resection: histopathological examination revealed adenocarcinoma, T2 in 3 and T3 in 2 patients. The remaing 177 polyps (43 flat and 134 sessile; 57 with a size ≥30 mm and 120 <30 mm) were excised. Mean size of lesions removed was 24.5±10.2 mm (range 15-70) and the most common location was the sigmoid colon in 30.5% (54/177). En-bloc resection was performed in 44.6% (79/177) and piece-meal in 55.4%. APC was used in 23.7% (42/177), mostly in polyps with flat shape (P=0.001). There were 20 procedural (11.3%) and 2 late (1.1%) bleeding, 4 post-polypectomy syndrome (2.2%) and 2 perforations (1.1%). The bleeding was related to malignancy (P=0.01). Intramucosal cancer was observed in 5 cases (2.8%) while invasive cancer was observed in 8 cases (4.5%). Malignancy was mostly present in polyps with size ≥ 30 mm (P=0.003). The sensitivity, specificity, PPV and NPV of non-lifting sign was respectively 100, 95.5, 38.5 and 100%. Median follow up at 14.9±7.9 months (range 3-24) revealed a 6.8% (12/177) recurrence and was related to size ≥ 30 mm of polyps (P=0.003). Conclusions: Inject and cut EMR is practical and effective for treatment of large colorectal polyps with low risks of complications and local recurrence. # S. Endoscopy complications
P.230 ENDOSCOPIC HEMOSTASIS USING FIBRIN SEALANT TO TREAT HEMORRHAGE IN POST-SPHINCTEROTOMY BLEEDING P. Beretta ∗ , C. Cucino Istituto Clinico Santa Rita, Milano Background and aim: Endoscopic sphincterotomy (ES) has bleeding as the most common complication.Post-ES bleeding may occur
immediately or several days later. When post-ES bleeding does not stop spontaneously, endoscopic treatment is necessary, and epinephryne injection or sclerosant is the treatment of choice. Material and methods: We describe a case of an 86 years old woman taking oral anticoagulants who was admitted to our hospital for jaundice. A CT scan revealed stones in the common bile duct (CBD) and in the gallbladder. Oral anticoagulant was stopped and subcutaneous low molecular weight heparin was given. ERCP with ES was performed and a stone of 8 mm was removed from the CBD. After 5 days hemoglobin decreased from 11.5 to 6.9 mg/dL and the patient had been transfused. Endoscopy revealed a clot from the site of ES with oozing bleeding underneath, which was treated with injection of epinephrine. After 7 days hemoglobin falled again to 8 mg/dL and endoscopy confirmed the persistence of bleeding from the papilla. We than placed a pancreatic stent and performed epinephrine injection and heater probe cautery, with the apparent control of the hemorrage. Nevertheless, hemoglobin did not rise and we performed a third urgent endoscopy, which revealed that the papilla was still bleeding. We removed the standard pancreatic stent and placed a modified stent without the internal wings inside the Wirsung duct (Fig. 1). We than injected fibrin sealant and hemorrage was stopped. After few minutes from the hemostasis, the modified stent fell down (Fig. 2). Hemoglobin levels remained stable and the patient was discharged after 10 days.
Figure 1
Figure 2
Results: We treated successfully a case of post-ES bleeding with human fibrin injection and the placement of a plastic stent. Conclusions: The main advantage of using fibrin sealant is the absence of tissue damage when injected at the bleeding area, so that the hemostatic procedure can be repeated multiple times. The disadvantages are represented by high costs of the human products and the potential risk of viral disease transmission, which cannot be excluded despite stringent controls to the selection of the blood donors. Nevertheless, we suggest that the application of this kind of sealant could be very useful for the selected persistent post-ES bleeding. # S. Endoscopy complications
P.231 ELABORATION DATA SOFTWARE APPLIED TO CEUS FOR QUANTITATIVE EVALUATION OF MICROVASCULAR ACTIVATION AND CORRELATION WITH BIOLOGICAL ACTIVITY IN ILEAL CROHN’S DISEASE L. Guidi ∗ ,1 , A. Di Veronica 2 , A. Armuzzi 1 , C. Felice 1 , M. Marzo 1 , G. Mocci 1 , I. Roberto 1 , B. De Pascalis 1 , I. De Vitis 1 , A. Papa 1 , A. De Franco 2 1 UO Gastroenterologia, Complesso Integrato Columbus, Università Cattolica Sacro Cuore, Roma; 2 UO Radiodiagnostica, Complesso Integrato Columbus, Università Cattolica Del Sacro Cuore, Roma
Background and aim: Microvascular activation and angiogenesis induced by inflammation in ileal loops affected by Crohn’s disease (CD) can be demonstrated by contrast-enhanced wideband harmonic imaging