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Sa1573 Prospective Randomized Comparison of Cold snare Polypectomy for Small Colorectal Polyps Using an Exclusive Cold Polypectomy snare vs. a Conventional Polypectomy snare
Abstracts
Sa1571 Increased Prevalence of Advanced Colorectal Polyps in Small and Very Small Polyps Among Hispanics Undergoing Colonoscopy Juan Carlos Bird-Caceres*1, Fernando Baez1, Ekie G. Vazquez1, Hiram D. Ortega-Cruz1, Doris H. Toro1, Marcia R. Cruz-Correa1,2 1 Gastroenterology, VA Caribbean Healthcare System, San Juan; 2Cancer Center, UPR Comprehensive Cancer Center, San Juan Background & Aim: Colorectal polyps !1cm in size have been customary described as having a very low potential for advanced histology. Some researchers have proposed the “predict, resect, and discard” strategy for diminutive (% 5 mm) and small (6-9 mm) polyps to reduce screening colonoscopy costs. Some other authors argue that these can be left in place or not reported. The aim of our study was to determine the prevalence of advanced polyps according to size in a Hispanic population in which data is scarce. Advanced histological features defined as villous histology, high-grade dysplasia, and/or cancer in small polyps could deter adoption of these strategies. Methods: Retrospective review of all the computerized medical records of Hispanic adults undergoing a complete colonoscopy during a five-year period. Colonic lesions that were biopsied and not excised were excluded from the study. Retrieved polyps with advanced histology were re-examined by a blinded GI pathologist. Polyps were classified by histology, location and size. The polyps’ location was defined according to colonoscopy report description. Right and left sided polyps were defined by location proximal or distal to the splenic flexure. Rectal polyps were those within the first 15 cm from the anal verge. Advanced polyps were defined by the presence of one of the following histologic findings: tubular adenoma (TA) with high-grade dysplasia (HGD), tubulovillous adenoma (TVA), villous, serrated or adenocarcinoma arising on a polyp. Results: A total of 2,310 records were evaluated of which 1976 met the inclusion criteria. The study population consisted mostly of men (98%) with a mean age of 67. A total of 4,642 polyps were identified, and 251 (5.4%) had advanced features. The mean age of the patients with advanced polyps was 69 years (range 34-87). Indications for the procedure were varied: screening (27%), surveillance (30%) and diagnostic (43%). The distribution of these polyps was as follows: 69 (27%) right-sided; 105 (42%) left-sided and 77 (31%) rectum. When stratifying by size: 77 (31%) were !1cm while 174 (69%) were R1cm (Table 1). Adenocarcinoma was found in 8 patients with sub-centimeter polyps; all within polyps 6-9 mm in size. One-third of the advanced polyps were !1 cm; and 11% within very small polyps (! 5 mm). Conclusions: Our study demonstrates that small polyps should not be disregarded as benign in nature. A third of the advanced polyps in our study were smaller than 1 cm, including those very small polyps which represented 11% of the studied sample. The practice of ‘remove and discard” or neglecting small polyps may hamper the benefits of colonoscopy and timely surveillance of advanced polyps. Removal and histologic examination of all polyps appears to be the appropriate measure to establish correct management and surveillance strategies reducing colorectal cancer. Table 1. Advanced polyps distribution according to size.
TA with HGD TVA Villous Serrated Adenocarcinoma Total
%5mm n(%)
6-9mm n(%)
R10mm n(%)
7 5 1 16 0 29 (11.5)
12 13 6 9 8 48 (19.1)
14 73 40 9 38 174 (69.3)
Sa1572 Interruption of Clopidogrel Does Not Appear to Decrease the Risk of Post Polypectomy Bleeding Muhammad O. Arif*1,2, Uma K. Murthy1, Christopher Ashley3, Jad Z. Bou-Abdallah4, Rubin Bahuva4, Katie Agnello4 1 VA Medical Center Syracuse NY, Syracuse, NY; 2Upstate Medical University, Syracuse, NY; 3VA Medical Center Albany NY, Albany, NY; 4VA Medical Center Buffalo NY, Buffalo, NY Background: Current GI society guidelines recommend consideration of holding clopidogrel for 7 to 10 days before colonoscopy/polypectomy. We have previously shown (GIE May 2010) that without any interruption of clopidogrel, risk of post polypectomy bleeding(PPB) is 3.2% but there is no data showing that holding clopidogrel for 7-10 days actually decreases the risk of PPB. Aim: To assess PPB risk after interruption of clopidogrel before colonoscopy. Patient and Methods: A retrospective, 3-VA medical centers study of patients in whom clopidogrel was held before colonoscopy/polypectomy between 2005 and 2010. Charts were reviewed for demographics and comorbidities along with details of the procedures and the post procedure course. PPB was defined as any bleeding that occured for up to one month after the procedure. Particular attention was paid to confirming interruption
AB266 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
of clopidogrel before colonoscopy and restarting it after the procedure. Results: 201 patients had clopidogrel interrupted before colonoscopy for 7-10 days (68%), less than 5 days (21%) and uncertain duration (11%). Clopidogrel was restarted within 5 days of the procedure in 29% of patients, in 5-10 days in (31%) patients and restart was not determined in the remaining. 118 of 201 patients had 296 polypectomies (2.5 polyps/patient). 117 (99%) were males. Comorbidities included Hypertension (86%), Diabetes (43%), coronary artery disease (67%), peripheral vascular disease (5%) and stroke (21%). Average polyp size was 6.3 mm (Range 2 mm to 40 mm). The modalities used for polypectomy are detailed in table 1. Cautery was used in 65 (55%) of colonoscopies. A follow up visit either in person or by telephone was found to be documented in 103 (87%) of patients. 4 cases of post procedure bleeding (3%) were found among these patients. Bleeding was reported after a mean of 12 days (range 7 to 16). Only one of these patients was confirmed to have received blood transfusions. Cautery had been used in all of the patients who had bleeding. Among these, the largest polyp removed was 8 mm while the rest were less than 5 mm. In one of these cases, bleeding had been noted to occur immediately after the polypectomy and was treated with cautery. Conclusion: Holding Clopidogrel was unnecessary in 40% of patients undergoing colonoscopy. Holding clopidogrel 7-10 days before polypectomy did not decrease the risk of PPB compared to our previous study with uninterrupted clopidogrel use. Table 1. Modalities of polypectomy used Method of polypectomy Cold snare alone Hot snare alone Cold forceps alone Hot forceps alone Multiple modalities Method of polypectomy not found in report
Number of times used in colonoscopies 3 (2.5%) 41 (35%) 42 (35%) 8 (7%) 19 (16%) 5 (4%)
Sa1573 Prospective Randomized Comparison of Cold snare Polypectomy for Small Colorectal Polyps Using an Exclusive Cold Polypectomy snare vs. a Conventional Polypectomy snare Akira Horiuchi*, Yoshiko Nakayama, Toshiyuki Makino Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan Background: The aim of this study was to compare cold snaring of small colorectal polyps using either a snare specifically designed as a cold snare or cold snaring using a conventional snare. The study was based on the hypothesis that cold polypectomy snares being thinner are likely to resect colorectal polyps more cleanly than possible with conventional polypectomy snares used without electrocautery and this difference would result in an increased complete resection rate and less damage to the submucosal layer (i.e., a lower delayed bleeding rate). Objective: To compare the outcome of polypectomy of small colorectal polyps with a snare exclusively designed as a cold snare vs. a conventional snare. Methods: Patients with colorectal polyps %10 mm in diameter were randomized to cold snare (ExactoTM cold snare) or conventional snare (Snare MasterTM snare) polypectomy. The snare wire diameter of the ExactoTM cold snare was 0.30 mm vs. 0.47 mm for the Snare MasterTM snare. The primary outcome measure was complete resection based on pathological examination. Secondary outcomes included bleeding within two weeks after polypectomy and identification of submucosal arteries and injured arteries in the resected specimens. Results: 76 patients were randomized (210 polyps): Cold snare, NZ37 (98 polyps) and Conventional snare, NZ39 (112 polyps). The patients’ demographic characteristics including the number, size, and shape of polyps removed were similar between the two groups. The complete resection rate was significantly greater with cold than conventional snare [91% (89/98) vs. 79% (88/112), PZ 0.015] and included a marked difference with polyps of 8-10 mm in size, flat or pedunculated type in morphology. Immediate bleeding and hematochezia rates were similar [19% vs. 21%, PZ0.86; 5.4% vs. 7.7%, PZ0.69]. No delayed bleeding occurred. Histology demonstrated a similar prevalence of arteries and injured arteries in the submucosa in both groups [33% (32/ 96) vs. 30% (31/104), PZ0.59; 3.1% (3/96) vs. 6.7% (7/104), PZ0.24]. Conclusions: Polypectomy using a designed cold snare resulted in complete polyp removal more often than did cold snaring with a conventional snare especially with polyps of 8-10 mm in diameter whether flat or pedunculated.
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Sa1571 Increased Prevalence of Advanced Colorectal Polyps in Small and Very Small Polyps Among Hispanics Undergoing Colonoscopy Juan Carlos Bird-Caceres*1, Fernando Baez1, Ekie G. Vazquez1, Hiram D. Ortega-Cruz1, Doris H. Toro1, Marcia R. Cruz-Correa1,2 1 Gastroenterology, VA Caribbean Healthcare System, San Juan; 2Cancer Center, UPR Comprehensive Cancer Center, San Juan Background & Aim: Colorectal polyps !1cm in size have been customary described as having a very low potential for advanced histology. Some researchers have proposed the “predict, resect, and discard” strategy for diminutive (% 5 mm) and small (6-9 mm) polyps to reduce screening colonoscopy costs. Some other authors argue that these can be left in place or not reported. The aim of our study was to determine the prevalence of advanced polyps according to size in a Hispanic population in which data is scarce. Advanced histological features defined as villous histology, high-grade dysplasia, and/or cancer in small polyps could deter adoption of these strategies. Methods: Retrospective review of all the computerized medical records of Hispanic adults undergoing a complete colonoscopy during a five-year period. Colonic lesions that were biopsied and not excised were excluded from the study. Retrieved polyps with advanced histology were re-examined by a blinded GI pathologist. Polyps were classified by histology, location and size. The polyps’ location was defined according to colonoscopy report description. Right and left sided polyps were defined by location proximal or distal to the splenic flexure. Rectal polyps were those within the first 15 cm from the anal verge. Advanced polyps were defined by the presence of one of the following histologic findings: tubular adenoma (TA) with high-grade dysplasia (HGD), tubulovillous adenoma (TVA), villous, serrated or adenocarcinoma arising on a polyp. Results: A total of 2,310 records were evaluated of which 1976 met the inclusion criteria. The study population consisted mostly of men (98%) with a mean age of 67. A total of 4,642 polyps were identified, and 251 (5.4%) had advanced features. The mean age of the patients with advanced polyps was 69 years (range 34-87). Indications for the procedure were varied: screening (27%), surveillance (30%) and diagnostic (43%). The distribution of these polyps was as follows: 69 (27%) right-sided; 105 (42%) left-sided and 77 (31%) rectum. When stratifying by size: 77 (31%) were !1cm while 174 (69%) were R1cm (Table 1). Adenocarcinoma was found in 8 patients with sub-centimeter polyps; all within polyps 6-9 mm in size. One-third of the advanced polyps were !1 cm; and 11% within very small polyps (! 5 mm). Conclusions: Our study demonstrates that small polyps should not be disregarded as benign in nature. A third of the advanced polyps in our study were smaller than 1 cm, including those very small polyps which represented 11% of the studied sample. The practice of ‘remove and discard” or neglecting small polyps may hamper the benefits of colonoscopy and timely surveillance of advanced polyps. Removal and histologic examination of all polyps appears to be the appropriate measure to establish correct management and surveillance strategies reducing colorectal cancer. Table 1. Advanced polyps distribution according to size.
TA with HGD TVA Villous Serrated Adenocarcinoma Total
%5mm n(%)
6-9mm n(%)
R10mm n(%)
7 5 1 16 0 29 (11.5)
12 13 6 9 8 48 (19.1)
14 73 40 9 38 174 (69.3)
Sa1572 Interruption of Clopidogrel Does Not Appear to Decrease the Risk of Post Polypectomy Bleeding Muhammad O. Arif*1,2, Uma K. Murthy1, Christopher Ashley3, Jad Z. Bou-Abdallah4, Rubin Bahuva4, Katie Agnello4 1 VA Medical Center Syracuse NY, Syracuse, NY; 2Upstate Medical University, Syracuse, NY; 3VA Medical Center Albany NY, Albany, NY; 4VA Medical Center Buffalo NY, Buffalo, NY Background: Current GI society guidelines recommend consideration of holding clopidogrel for 7 to 10 days before colonoscopy/polypectomy. We have previously shown (GIE May 2010) that without any interruption of clopidogrel, risk of post polypectomy bleeding(PPB) is 3.2% but there is no data showing that holding clopidogrel for 7-10 days actually decreases the risk of PPB. Aim: To assess PPB risk after interruption of clopidogrel before colonoscopy. Patient and Methods: A retrospective, 3-VA medical centers study of patients in whom clopidogrel was held before colonoscopy/polypectomy between 2005 and 2010. Charts were reviewed for demographics and comorbidities along with details of the procedures and the post procedure course. PPB was defined as any bleeding that occured for up to one month after the procedure. Particular attention was paid to confirming interruption
AB266 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
of clopidogrel before colonoscopy and restarting it after the procedure. Results: 201 patients had clopidogrel interrupted before colonoscopy for 7-10 days (68%), less than 5 days (21%) and uncertain duration (11%). Clopidogrel was restarted within 5 days of the procedure in 29% of patients, in 5-10 days in (31%) patients and restart was not determined in the remaining. 118 of 201 patients had 296 polypectomies (2.5 polyps/patient). 117 (99%) were males. Comorbidities included Hypertension (86%), Diabetes (43%), coronary artery disease (67%), peripheral vascular disease (5%) and stroke (21%). Average polyp size was 6.3 mm (Range 2 mm to 40 mm). The modalities used for polypectomy are detailed in table 1. Cautery was used in 65 (55%) of colonoscopies. A follow up visit either in person or by telephone was found to be documented in 103 (87%) of patients. 4 cases of post procedure bleeding (3%) were found among these patients. Bleeding was reported after a mean of 12 days (range 7 to 16). Only one of these patients was confirmed to have received blood transfusions. Cautery had been used in all of the patients who had bleeding. Among these, the largest polyp removed was 8 mm while the rest were less than 5 mm. In one of these cases, bleeding had been noted to occur immediately after the polypectomy and was treated with cautery. Conclusion: Holding Clopidogrel was unnecessary in 40% of patients undergoing colonoscopy. Holding clopidogrel 7-10 days before polypectomy did not decrease the risk of PPB compared to our previous study with uninterrupted clopidogrel use. Table 1. Modalities of polypectomy used Method of polypectomy Cold snare alone Hot snare alone Cold forceps alone Hot forceps alone Multiple modalities Method of polypectomy not found in report
Number of times used in colonoscopies 3 (2.5%) 41 (35%) 42 (35%) 8 (7%) 19 (16%) 5 (4%)
Sa1573 Prospective Randomized Comparison of Cold snare Polypectomy for Small Colorectal Polyps Using an Exclusive Cold Polypectomy snare vs. a Conventional Polypectomy snare Akira Horiuchi*, Yoshiko Nakayama, Toshiyuki Makino Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan Background: The aim of this study was to compare cold snaring of small colorectal polyps using either a snare specifically designed as a cold snare or cold snaring using a conventional snare. The study was based on the hypothesis that cold polypectomy snares being thinner are likely to resect colorectal polyps more cleanly than possible with conventional polypectomy snares used without electrocautery and this difference would result in an increased complete resection rate and less damage to the submucosal layer (i.e., a lower delayed bleeding rate). Objective: To compare the outcome of polypectomy of small colorectal polyps with a snare exclusively designed as a cold snare vs. a conventional snare. Methods: Patients with colorectal polyps %10 mm in diameter were randomized to cold snare (ExactoTM cold snare) or conventional snare (Snare MasterTM snare) polypectomy. The snare wire diameter of the ExactoTM cold snare was 0.30 mm vs. 0.47 mm for the Snare MasterTM snare. The primary outcome measure was complete resection based on pathological examination. Secondary outcomes included bleeding within two weeks after polypectomy and identification of submucosal arteries and injured arteries in the resected specimens. Results: 76 patients were randomized (210 polyps): Cold snare, NZ37 (98 polyps) and Conventional snare, NZ39 (112 polyps). The patients’ demographic characteristics including the number, size, and shape of polyps removed were similar between the two groups. The complete resection rate was significantly greater with cold than conventional snare [91% (89/98) vs. 79% (88/112), PZ 0.015] and included a marked difference with polyps of 8-10 mm in size, flat or pedunculated type in morphology. Immediate bleeding and hematochezia rates were similar [19% vs. 21%, PZ0.86; 5.4% vs. 7.7%, PZ0.69]. No delayed bleeding occurred. Histology demonstrated a similar prevalence of arteries and injured arteries in the submucosa in both groups [33% (32/ 96) vs. 30% (31/104), PZ0.59; 3.1% (3/96) vs. 6.7% (7/104), PZ0.24]. Conclusions: Polypectomy using a designed cold snare resulted in complete polyp removal more often than did cold snaring with a conventional snare especially with polyps of 8-10 mm in diameter whether flat or pedunculated.
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