Halim Awadie

Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe

BACKGROUND AND STUDY AIMS : Large series suggest endoscopic mucosal resection is safe and effective for the removal of large (≥ 10 mm) sessile serrated polyps (SSPs), but it exposes the patient to the risks of electrocautery, including delayed bleeding. We examined the feasibility and safety of piecemeal cold snare polypectomy (pCSP) for the resection of large SSPs. METHODS Sequential large SSPs (10 - 35 mm) without endoscopic evidence of dysplasia referred over 12 months to a tertiary endoscopy center were considered for pCSP. A thin-wire snare was used in all cases. Submucosal injection was not performed. High definition imaging of the defect margin was used to ensure the absence of residual serrated tissue. Adverse events were assessed at 2 weeks and surveillance was planned for between 6 and 12 months. RESULTS 41 SSPs were completely removed by pCSP in 34 patients. The median SSP size was 15 mm (interquartile range [IQR] 14.5 - 20 mm; range 10 - 35 mm). The median procedure duration was 4.5 minutes (IQR 1.4 - 6.3 minutes). There was no evidence of perforation or significant intraprocedural bleeding. At 2-week follow-up, there were no significant adverse events, including delayed bleeding and post polypectomy syndrome. First follow-up has been undertaken for 15 /41 lesions at a median of 6 months with no evidence of recurrence. CONCLUSIONS There is potential for pCSP to become the standard of care for non-dysplastic large SSPs. This could reduce the burden of removing SSPs on patients and healthcare systems, particularly by avoidance of delayed bleeding.

EMR of large laterally spreading lesion of the duodenum involving the ampulla

re 1. A, Endoscopic assessment of duodenal laterally spreading lesion (LSL). B, Involvement of ampulla of Vater. C, D, Sequential endoscopic resecof laterally spreading component. E, F, Complete endoscopic mucosal resection of LSL and ampullectomy. G, First surveillance endoscopic view ing small diminutive polyp recurrence of LSL component. H, Surveillance endoscopic view showing no recurrence at the ampullectomy site. en transcript of the video audio is available online at www.VideoGIE.org.

When Colonoscopy Fails… Refer, Repeat, and Succeed

In this issue of the journal, Ponte et al. [1] report important outcome data on repeat colonoscopy by an advanced endoscopist after a prior incomplete colonoscopy. All experienced endoscopists are aware that colonoscopy may be very challenging, often for reasons that may not be immediately apparent, including normal anatomical variations between patients [2]. Incomplete colonoscopy should not be seen as a failure, as curtailing a procedure when progress stalls limits the risks of complications in a scenario where the prospects of clinical benefit to the patient are rapidly diminishing. In this retrospective cohort study on the yield of colonoscopy completion by an advanced endoscopist after failed elective colonoscopy performed in the same department over 70 months until October 2016, 93 (1.5%) of 6,196 patients had an incomplete colonoscopy. Indications were divided into surveillance (inflammatory bowel disease, previous cancer or polyp, family history screening) and investigation for symptoms (iron deficiency anaemia, abdominal mass, abdominal pain, change in bowel habits, inflammatory bowel disease assessment, diarrhoea, rectal bleeding, and abnormal colonic imaging). Reasons for incomplete colonoscopy were mainly looping and redundant colon (82.2%) and suspected adhesions (15.1%); hence, 78.5% of the procedures were aborted in the left colon. Patients who had incomplete colonoscopy were referred to either computed tomography colonography (CTC), colonoscopy by an advanced endoscopist, or retrograde single balloon enteroscopy (SBE). Only 82.8% (n = 77) of patients had a second examination. The outcome for the additional 16 patients is not described, but is certainly important based on the literature and the findings of this study. CTC, colonoscopy by an advanced endoscopist, and SBE were performed in 45.5% (n = 35),

The clinical significance and synchronous polyp burden of large (≥ 20 mm) sessile serrated polyps in patients without serrated polyposis syndrome

BACKGROUND Sessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval cancer. Large SSPs (≥ 20 mm) outside the definition of serrated polyposis syndrome (SPS) have not been studied in comparison with SPS. We aimed to describe the characteristics of patients with large SSPs in this context. METHODS Patients with at least one SSP (≥ 20 mm) were eligible. Data from three consecutive colonoscopies were used to compare clinical and endoscopic characteristics in three patient groups: SPS, a solitary large SSP, and patients with at least two SSPs without fulfilling the criteria for SPS (oligo-SSP). Data on the diagnostic colonoscopy were collected retrospectively, whereas the remaining data was collected prospectively. RESULTS 67/146 patients (45.9 %) had SPS, 53/146 (36.3 %) had a solitary SSP, and 26/146 (17.8 %) were categorized as oligo-SSP. Personal (16.4 %, 9.4 %, and 11.5 %, respectively) and family (17.9 %, 17.0 %, and 23.1 %, respectively) history of colorectal carcinoma did not differ significantly between groups. Polyp burden was greater in SPS compared with solitary SSP but was not different from oligo-SSP (advanced adenomas: SPS 32.8 % vs. solitary SSP 9.4 % [P = 0.002] vs. oligo-SSP 34.6 % [P = 0.87]; ≥ 10 conventional adenomas: 11.9 % vs. 0 % [P = 0.01] vs. 3.8 % [P = 0.44], respectively). Dysplasia in large SSPs was frequent in all groups (41.1 % overall). SPS was recognized by referring endoscopists in only 9.0 % of cases. CONCLUSION Patients with oligo-SSPs have similar synchronous polyp burden and clinical characteristics as patients with SPS and may require similar surveillance. Modification of the criteria for the diagnosis of SPS to include this group seems warranted. Patients with a solitary SSP have a lower risk of synchronous polyps, including advanced adenomas. Larger studies are warranted to determine whether these patients may return to standard surveillance following complete examination and clearance of the colon.