Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm

BACKGROUND: Endoscopic removal of duodenal and colorectal adenomas is currently considered to be the standard of care for prevention of adenocarcinoma. The use of cautery carries a risk of delayed bleeding, post-polypectomy syndrome, and perforation. We examined the safety and feasibility of removing colonic and duodenal polyps ≥ 1 cm using a piecemeal cold snare polypectomy technique. PATIENTS: The study included 15 patients with duodenal polyps ≥ 1 cm and 15 patients with colonic polyps ≥ 1 cm. MAIN OUTCOME MEASUREMENTS: Bleeding, perforation, abdominal pain, or hospitalization occurring within 2 weeks of polypectomy. RESULTS: Between 24 August 2011 and 29 April 2013, 15 patients had removal of duodenal polyps ≥ 1 cm. Mean patient age was 64 years and 9/15 patients were male. The mean polyp size was 24 mm (10 - 60 mm). All polyps were removed with a cold snare and some required cold biopsy forceps. One patient required hospitalization for gastrointestinal blood loss 7 days post-polypectomy; this patient was using Coumadin. Between 27 February 2012 and 30 May 2013, 15 patients underwent resection of a ≥ 1 cm colonic polyp. Mean patient age was 68 years and 9/15 were male. The mean polyp size was 20 mm (10 - 45 mm). All polyps were primarily removed with a cold snare. None of the patients required hemostatic clips for control of immediate bleeding. One patient presented to the emergency department with abdominal pain 1 day after initial endoscopy. CT scan showed no abnormalities and the patient was discharged. CONCLUSIONS: Cold snare polypectomy for large duodenal and colonic polyps is technically feasible and may have a favorable safety profile compared to standard electrocautery-based endoscopic resection. Comparative trials are required to determine the relative safety and efficacy of cold snare techniques for complete and durable resection of large polyps compared to standard hot snare methods

Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm

Background and study aims Colonic polyps > 1 cm in size are commonly managed using hot polypectomy techniques. The most frequent adverse events (delayed bleeding, post-polypectomy syndrome, and perforation) are related to electrocautery-induced injury. We hypothesized that cold resection of large polyps may have similar efficacy and improved safety compared to hot polypectomy. Our aims were to evaluate efficacy and safety of piecemeal cold snare resection of colonic polyps > 1 cm. Patients and methods Patients undergoing lift and piecemeal cold snare polypectomy of non-pedunculated colon polyps > 1 cm from October 2013 to September 2015 were identified retrospectively. Efficacy was defined by the absence of residual adenomatous tissue at endoscopic follow-up. Adverse events (AEs), including post-procedural bleeding, bowel perforation, or post-procedural pain requiring hospitalization were assessed by chart review and telephone follow-up.  Results Seventy-three patients underwent piecemeal cold snare polypectomy for 94 colon polyps > 1 cm with 56 of 73 patients completing follow-up on 72 polyps. Residual or recurrent adenoma was found in 7 cases (9.7 %). Median polyp size was significantly greater in those with residual/recurrent adenoma (37.1 vs. 19.1 mm, P < .0001). There were no AEs among all 73 patients enrolled. Conclusions Piecemeal cold snare resection of colon polyps > 1 cm is feasible, safe and efficacious when compared to published hot polypectomy data. Additional observational and randomized comparative effectiveness studies are necessary to demonstrate comparable adenoma eradication and improved safety advantage over existing hot snare polypectomy techniques

Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients With suspected biliary complications

Diagnostic endoscopic retrograde cholangiopancreatography (D‐ERCP) is commonly performed for the evaluation of biliary complications after orthotopic liver transplantation (OLT). This practice is contrary to the national trend of reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes. Our aim was to evaluate the clinical yield and complications of D‐ERCP in OLT recipients. In this retrospective study, 165 OLT recipients who underwent ERCP between January 2006 and December 2010 at the University of Michigan were divided into 2 groups: (1) a therapeutic endoscopic retrograde cholangiopancreatography (T‐ERCP) group (if they met prespecified criteria that suggested a high likelihood of endoscopic intervention) and (2) a D‐ERCP group (if there was clinical suspicion of biliary disease but they did not meet any criteria). The 2 groups were compared with respect to the proportion of subjects undergoing high‐yield ERCP, which was defined as a procedure resulting in a clinically important intervention that modified the disease course. 66.3% of the D‐ERCP procedures were classified as high‐yield, whereas 90.1% of the T‐ERCP procedures were ( P < 0.001). Serious complications were infrequent in both groups. A survey of practitioners caring for OLT recipients suggested that the rate of high‐yield D‐ERCP seen in this study is congruent with what is considered acceptable in clinical practice. In conclusion, although T‐ERCP is more likely to reveal a pathological process requiring an intervention, D‐ERCP appears to be an acceptable clinical strategy for OLT recipients because of the high likelihood of a high‐yield study and the low rate of serious complications. Liver Transpl, 2012. © 2012 AASLD.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/95170/1/23535_ftp.pd

Systematic review with network meta‐analysis: the efficacy of anti‐ TNF agents for the treatment of Crohn's disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107372/1/apt12749.pd

Letter: biological drugs for inducing remission in ulcerative colitis – authors' reply

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106897/1/apt12724.pd

Letter: comparative efficacy of biological therapy in patients with ulcerative colitis – authors’ reply

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107370/1/apt12773.pd

Regional and racial variations in the utilization of endoscopic retrograde cholangiopancreatography among pancreatic cancer patients in the United States

BackgroundPancreatic cancer is projected to become the second leading cause of cancerâ related deaths by 2030. Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as firstâ line therapy for biliary decompression in pancreatic cancer. The aim of our study was to characterize geographic and racial/ethnic disparities in ERCP utilization among patients with pancreatic cancer.MethodsRetrospective cohort study using the US Surveillance, Epidemiology, and End Results (SEER)â Medicare database to identify patients diagnosed with pancreatic cancer from 2003â 2013. The primary outcome was receipt of ERCP, with or without stent placement, vs any nonâ ERCP biliary intervention.ResultsOf the 36 619 patients with pancreatic cancer, 37.5% (n = 13 719) underwent an ERCP, percutaneous drainage, or surgical biliary bypass. The most common biliary intervention (82.6%) was ERCP. After adjusting for tumor location and stage, Blacks were significantly less likely to receive ERCP than Whites (aOR 0.84, 95% CI 0.72, 0.97) and more likely to receive percutaneous transhepatic biliary drainage (PTBD) (aOR 1.38, 95% CI 1.14, 1.66). Patients in the Southeast and the West were more likely to receive ERCP than those in the Northeast (Southeast aOR 1.21, 95% CI 1.04, 1.40; West aOR 1.16, 95% CI 1.01, 1.32).ConclusionRacial/ethnic and geographic disparities in access to biliary interventions including ERCP exist for patients with pancreatic cancer in the United States. Our results highlight the need for further research and policies to improve access to appropriate biliary intervention for all patients.To date, disparities in the receipt of endoscopic therapies among patients with pancreatic cancer have not been reported. The results from our study suggest that blacks with pancreatic cancer and patients in the Northeast region of the US are less likely to receive the gold standard therapy for obstructive jaundice.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149758/1/cam42225_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149758/2/cam42225.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149758/3/cam42225-sup-0001-Supinfo.pd

Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial

Abstract Background The combination of prophylactic pancreatic stent placement (PSP) – a temporary plastic stent placed in the pancreatic duct – and rectal non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Preliminary data, however, suggest that PSP may be unnecessary if rectal NSAIDs are administered. Given the costs and potential risks of PSP, we aim to determine whether rectal indomethacin obviates the need for pancreatic stent placement in patients undergoing high-risk ERCP. Methods/Design The SVI (Stent vs. Indomethacin) trial is a comparative effectiveness, multicenter, randomized, double-blind, non-inferiority study of rectal indomethacin alone versus the combination of rectal indomethacin and PSP for preventing PEP in high-risk cases. One thousand four hundred and thirty subjects undergoing high-risk ERCP, in whom PSP is planned solely for PEP prevention, will be randomized to indomethacin alone or combination therapy. Those who are aware of study group assignment, including the endoscopist, will not be involved in the post-procedure care of the patient for at least 48 hours. Subjects will be assessed for PEP and its severity by a panel of independent and blinded adjudicators. Indomethacin alone will be declared non-inferior to combination therapy if the two-sided 95 % upper confidence bound of the treatment difference is less than 5 % between the two groups. Biological specimens will be obtained from trial participants and centrally banked. Discussion The SVI trial is designed to determine whether PSP remains necessary in the era of NSAIDs pharmacoprevention. The associated bio-repository will establish the groundwork for important scientific breakthrough. Trial registration NCT02476279, registered June 2015