A d v e r s e E v e n t s R e l a t e d to C o l o n i c En d o s c o p i c Mucosal Resection and Polypectomy Amrita Sethi,
MD
a,
*, Louis M. Wong Kee Song,
MD
b
KEYWORDS Adverse events Endoscopic closure Endoscopic hemostasis Endoscopic mucosal resection Perforation Polypectomy Postpolypectomy bleeding Postpolypectomy syndrome KEY POINTS Adverse events from endoscopic mucosal resection (EMR) and polypectomy include immediate and delayed bleeding, perforation, and postpolypectomy syndrome. Intraprocedural bleeding can be managed effectively with a variety of endoscopic modalities, including clips, detachable snares, and contact thermal probes or graspers, with or without epinephrine injection; the selection of one or a combination of techniques depends on the type of lesion, completeness of resection, device availability, and operator preference. Delayed postpolypectomy bleeding is self-limited in most cases and can be managed conservatively; endoscopic hemostasis is reserved for recurrent or ongoing bleeding. Immediate recognition and closure of EMR- or polypectomy-induced perforations are key determinants for a successful outcome. Endoscopic versus surgical management of perforations depends on defect size and access, presence of extraluminal contamination, and clinical status of the patient. Mucosal clip placement constitutes the mainstay of endoscopic therapy for perforation, although newer devices, such as the over-the-scope clip and endoscopic suturing, have expanded the options for closure. Close monitoring post perforation closure is essential in the context of a multidisciplinary approach, with prompt surgical intervention in the presence of clinical deterioration. Postpolypectomy syndrome is a transmural thermal injury that can mimic perforation, but whose prognosis is excellent with conservative management.
a Division of Digestive and Liver Diseases, Columbia University, 161 Fort Washington Avenue, Herbert Irving Pavilion, Suite 862, New York, NY 10032, USA; b Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA * Corresponding author. E-mail address: [email protected]
Gastrointest Endoscopy Clin N Am 25 (2015) 55–69 http://dx.doi.org/10.1016/j.giec.2014.09.007 giendo.theclinics.com 1052-5157/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
56
Sethi & Wong Kee Song
Videos demonstrating the prevention and management of adverse events associated with polypectomy and endoscopic mucosal resection of colonic lesions accompany this article at http://www.giendo.theclinics.com/ INTRODUCTION
Colonoscopy is a commonly performed procedure. The rate of adverse events (AEs) is 2.8 per 1000 screening colonoscopies.1 These AEs include cardiovascular and pulmonary events, abdominal pain, hemorrhage, perforation, postpolypectomy syndrome (PPS), infection, and death. Serious AEs, such as hemorrhage and perforation, occur most frequently when colonoscopy is performed with polypectomy.1 This article highlights the prevention and management of AEs associated with polypectomy and endoscopic mucosal resection (EMR) of colonic lesions. POLYPECTOMY AND ENDOSCOPIC MUCOSAL RESECTION OF COLONIC LESIONS
Standard polypectomy techniques involve hot or cold snaring without submucosal fluid injection. Lesions that are less than or equal to 1 cm in size can be resected safely via cold snare, whereas hot snare is usually used for larger lesions. A blended current is commonly used during hot snare polypectomy; however, there are proponents for the use of pure coagulation current.2 The use of hot biopsy forceps is not recommended because of increased risk of complications, such as PPS and delayed perforation, and the availability of safer polypectomy techniques.2 EMR is a modified version of saline-assisted polypectomy that is used in the colon to facilitate lesion resection and mitigate the risk of perforation associated with the removal of large sessile polyps. Although technical variations exist, most EMR techniques are centered on the concept of injecting a solution to provide a cushion between the mucosal and deeper layers of the colon wall. Specialized band ligation and cap-assisted EMR devices are commonly used in the esophagus and stomach, but have limited applicability in the colon. EMR in the colon usually consists of freehand snare resection following submucosal fluid injection. En bloc snare resection is preferred so that the depth and lateral margins of the resected specimen can be accurately assessed at histopathology, and this is generally feasible if the lesion is less than 2 cm in size. For lesions that are 2 cm or larger, piecemeal resection is recommended to decrease the risk of perforation. The submucosal lift can be performed using a variety of solutions (Table 1). A commonly used injectate consists of saline stained with a few drops of a dye (indigo carmine or methylene blue), with or without dilute epinephrine. A post-EMR defect that
Table 1 Selected solutions used for submucosal injection Solution
Cushion Duration
Cost
Tissue Damage
Saline
1
Cheap
No
Hypertonic saline
11
Cheap
Yes
50% Dextrose
11
Cheap
Yes
Glycerol
11
—
No
Hyaluronic acid
111
Expensive
No
Hydroxypropyl methylcellulose
111
Cheap
No
Endoscopic Mucosal Resection and Polypectomy
uniformly stains blue confirms that the resection plane is limited to the submucosal layer (Fig. 1). A wide range of dilute epinephrine (1:10,000–1:100,000) in the mixture has been reported. Although epinephrine minimizes the risk of immediate bleeding and facilitates endoscopic visualization by maintaining a dry resection field, it does not prevent delayed bleeding.3,4 A longer-lasting fluid cushion can be obtained with the use of viscous solutions, such as hetastarch, succinylated gelatin, and hydroxypropyl methylcellulose. These solutions may reduce procedural time and the number of resections needed for completing piecemeal EMR.5 ADVERSE EVENTS OF ENDOSCOPIC MUCOSAL RESECTION AND POLYPECTOMY
The major AEs related to EMR and polypectomy include hemorrhage, perforation, and PPS. Clinically relevant stricture formation can result from wide or circumferential EMR, but this is more of an issue in the esophagus than in the colon. Hemorrhage
Hemorrhage is the most common AE of colonoscopy with polypectomy,6–8 with reported incidences ranging from 0.1% to 0.5% for clinically significant bleeding.9 Hemorrhage can occur at the time of the procedure (immediate bleeding) or hours to weeks (delayed bleeding) after the procedure.10 However, most delayed bleeding events occur within 2 weeks. Intraprocedural and delayed bleeding caused by EMR of large
Fig. 1. (A) Large serrated polyp. (B) Submucosal fluid injection with methylene blue solution and dilute epinephrine. (C) Piecemeal EMR. (D) Uniform blue stain of the submucosal defect.
57
58
Sethi & Wong Kee Song
colorectal lesions occur in 1% to 11% of cases, although a wide range of EMR-related bleeding estimates have been reported (0%–45%).11,12 Predictors of hemorrhage
Several factors related to the patient, lesion, and resection technique can predict the risk of hemorrhage following polypectomy and EMR. In a large prospective study involving 9336 polypectomies in 5152 patients, immediate postpolypectomy bleeding occurred in 4% of cases. Significant risk factors for immediate bleeding included age 65 and older, use of anticoagulants, comorbid cardiovascular or chronic renal disease, polyp size greater than 1 cm, lesions featuring pedunculated polyps or laterally spreading tumors, suboptimal bowel preparation, and use of cutting current.13 In another study involving 6617 polypectomies in 3138 patients, delayed postpolypectomy bleeding occurred in 38 (0.57%) lesions and 37 (1.2%) patients. Hypertension and polyp size (10.0 6.9 vs 5.6 3.8 mm; P
MD
a,
*, Louis M. Wong Kee Song,
MD
b
KEYWORDS Adverse events Endoscopic closure Endoscopic hemostasis Endoscopic mucosal resection Perforation Polypectomy Postpolypectomy bleeding Postpolypectomy syndrome KEY POINTS Adverse events from endoscopic mucosal resection (EMR) and polypectomy include immediate and delayed bleeding, perforation, and postpolypectomy syndrome. Intraprocedural bleeding can be managed effectively with a variety of endoscopic modalities, including clips, detachable snares, and contact thermal probes or graspers, with or without epinephrine injection; the selection of one or a combination of techniques depends on the type of lesion, completeness of resection, device availability, and operator preference. Delayed postpolypectomy bleeding is self-limited in most cases and can be managed conservatively; endoscopic hemostasis is reserved for recurrent or ongoing bleeding. Immediate recognition and closure of EMR- or polypectomy-induced perforations are key determinants for a successful outcome. Endoscopic versus surgical management of perforations depends on defect size and access, presence of extraluminal contamination, and clinical status of the patient. Mucosal clip placement constitutes the mainstay of endoscopic therapy for perforation, although newer devices, such as the over-the-scope clip and endoscopic suturing, have expanded the options for closure. Close monitoring post perforation closure is essential in the context of a multidisciplinary approach, with prompt surgical intervention in the presence of clinical deterioration. Postpolypectomy syndrome is a transmural thermal injury that can mimic perforation, but whose prognosis is excellent with conservative management.
a Division of Digestive and Liver Diseases, Columbia University, 161 Fort Washington Avenue, Herbert Irving Pavilion, Suite 862, New York, NY 10032, USA; b Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA * Corresponding author. E-mail address: [email protected]
Gastrointest Endoscopy Clin N Am 25 (2015) 55–69 http://dx.doi.org/10.1016/j.giec.2014.09.007 giendo.theclinics.com 1052-5157/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
56
Sethi & Wong Kee Song
Videos demonstrating the prevention and management of adverse events associated with polypectomy and endoscopic mucosal resection of colonic lesions accompany this article at http://www.giendo.theclinics.com/ INTRODUCTION
Colonoscopy is a commonly performed procedure. The rate of adverse events (AEs) is 2.8 per 1000 screening colonoscopies.1 These AEs include cardiovascular and pulmonary events, abdominal pain, hemorrhage, perforation, postpolypectomy syndrome (PPS), infection, and death. Serious AEs, such as hemorrhage and perforation, occur most frequently when colonoscopy is performed with polypectomy.1 This article highlights the prevention and management of AEs associated with polypectomy and endoscopic mucosal resection (EMR) of colonic lesions. POLYPECTOMY AND ENDOSCOPIC MUCOSAL RESECTION OF COLONIC LESIONS
Standard polypectomy techniques involve hot or cold snaring without submucosal fluid injection. Lesions that are less than or equal to 1 cm in size can be resected safely via cold snare, whereas hot snare is usually used for larger lesions. A blended current is commonly used during hot snare polypectomy; however, there are proponents for the use of pure coagulation current.2 The use of hot biopsy forceps is not recommended because of increased risk of complications, such as PPS and delayed perforation, and the availability of safer polypectomy techniques.2 EMR is a modified version of saline-assisted polypectomy that is used in the colon to facilitate lesion resection and mitigate the risk of perforation associated with the removal of large sessile polyps. Although technical variations exist, most EMR techniques are centered on the concept of injecting a solution to provide a cushion between the mucosal and deeper layers of the colon wall. Specialized band ligation and cap-assisted EMR devices are commonly used in the esophagus and stomach, but have limited applicability in the colon. EMR in the colon usually consists of freehand snare resection following submucosal fluid injection. En bloc snare resection is preferred so that the depth and lateral margins of the resected specimen can be accurately assessed at histopathology, and this is generally feasible if the lesion is less than 2 cm in size. For lesions that are 2 cm or larger, piecemeal resection is recommended to decrease the risk of perforation. The submucosal lift can be performed using a variety of solutions (Table 1). A commonly used injectate consists of saline stained with a few drops of a dye (indigo carmine or methylene blue), with or without dilute epinephrine. A post-EMR defect that
Table 1 Selected solutions used for submucosal injection Solution
Cushion Duration
Cost
Tissue Damage
Saline
1
Cheap
No
Hypertonic saline
11
Cheap
Yes
50% Dextrose
11
Cheap
Yes
Glycerol
11
—
No
Hyaluronic acid
111
Expensive
No
Hydroxypropyl methylcellulose
111
Cheap
No
Endoscopic Mucosal Resection and Polypectomy
uniformly stains blue confirms that the resection plane is limited to the submucosal layer (Fig. 1). A wide range of dilute epinephrine (1:10,000–1:100,000) in the mixture has been reported. Although epinephrine minimizes the risk of immediate bleeding and facilitates endoscopic visualization by maintaining a dry resection field, it does not prevent delayed bleeding.3,4 A longer-lasting fluid cushion can be obtained with the use of viscous solutions, such as hetastarch, succinylated gelatin, and hydroxypropyl methylcellulose. These solutions may reduce procedural time and the number of resections needed for completing piecemeal EMR.5 ADVERSE EVENTS OF ENDOSCOPIC MUCOSAL RESECTION AND POLYPECTOMY
The major AEs related to EMR and polypectomy include hemorrhage, perforation, and PPS. Clinically relevant stricture formation can result from wide or circumferential EMR, but this is more of an issue in the esophagus than in the colon. Hemorrhage
Hemorrhage is the most common AE of colonoscopy with polypectomy,6–8 with reported incidences ranging from 0.1% to 0.5% for clinically significant bleeding.9 Hemorrhage can occur at the time of the procedure (immediate bleeding) or hours to weeks (delayed bleeding) after the procedure.10 However, most delayed bleeding events occur within 2 weeks. Intraprocedural and delayed bleeding caused by EMR of large
Fig. 1. (A) Large serrated polyp. (B) Submucosal fluid injection with methylene blue solution and dilute epinephrine. (C) Piecemeal EMR. (D) Uniform blue stain of the submucosal defect.
57
58
Sethi & Wong Kee Song
colorectal lesions occur in 1% to 11% of cases, although a wide range of EMR-related bleeding estimates have been reported (0%–45%).11,12 Predictors of hemorrhage
Several factors related to the patient, lesion, and resection technique can predict the risk of hemorrhage following polypectomy and EMR. In a large prospective study involving 9336 polypectomies in 5152 patients, immediate postpolypectomy bleeding occurred in 4% of cases. Significant risk factors for immediate bleeding included age 65 and older, use of anticoagulants, comorbid cardiovascular or chronic renal disease, polyp size greater than 1 cm, lesions featuring pedunculated polyps or laterally spreading tumors, suboptimal bowel preparation, and use of cutting current.13 In another study involving 6617 polypectomies in 3138 patients, delayed postpolypectomy bleeding occurred in 38 (0.57%) lesions and 37 (1.2%) patients. Hypertension and polyp size (10.0 6.9 vs 5.6 3.8 mm; P
