Polyp Resection - Controversial Practices and Unanswered Questions

Detection and complete removal of precancerous neoplastic polyps are central to effective colorectal cancer screening. The prevalence of neoplastic polyps in the screening population in the United States is likely 450%. However, most persons with neoplastic polyps are never destined to develop cancer, and do not benefit for finding and removing polyps, and may only be harmed by the procedure. Further 70–80% of polyps are diminutive (≤5 mm) and such polyps almost never contain cancer. Given the questionable benefit, the high-cost and the potential risk changing our approach to the management of diminutive polyps is currently debated. Deemphasizing diminutive polyps and shifting our efforts to detection and complete removal of larger and higher-risk polyps deserves discussion and study. This article explores three controversies, and emerging concepts related to endoscopic polyp resection. First, we discuss challenges of optical resect-and-discard strategy and possible alternatives. Second, we review recent studies that support the use of cold snare resection for ≥ 5 mm polyps. Thirdly, we examine current evidence for prophylactic clipping after resection of large polyps

Laparoscopic Heller Myotomy Versus Endoscopic Balloon Dilatation for the Treatment of Achalasia A Network Meta-Analysis

Objective: Comparison of short-and long-term effects after laparoscopic Heller myotomy (LHM) and endoscopic balloon dilation (EBD) considering the need for retreatment. Background: Previously published studies have indicated that LHM is the most effective treatment for Achalasia. In contrast to that a recent randomized trial found EBD equivalent to LHM 2 years after initial treatment. Methods: A search in Medline, PubMed, and Cochrane Central Register of Controlled Trials was conducted for prospective studies on interventional achalasia therapy with predefined exclusion criteria. Data on success rates after the initial and repeated treatment were extracted. An adjusted network meta-analysis and meta-regression analysis was used, combined with a headto-head comparison, for follow-up at 12, 24, and 60 months. Results: Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at 12 months (95% confidence interval: 1.18-4.09; P = 0.01); 5.06 at 24 months (2.61-9.80; P < 0.00001) and 29.83 at 60 months (3.96-224.68; P = 0.001). LHM was also significantly superior for all time points when therapy included re-treatments , and 17.90 (2.17-147.98); P ≤ 0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up to 3) improved treatment effect by 11.9% (2.8%-21.8%). Conclusions: In this network meta-analysis, LHM demonstrated superior short-and long-term efficacy and should be considered first-line treatment of esophageal achalasia. Keywords: achalasia, economic cost, endoscopy, esophagus, health, idiopathic achalasia, laparoscopic surgery, meta-analysis, motility disorders, network meta-analysis, review, surgery (Ann Surg 2013;258:943-952 A chalasia is a rare esophageal motility disorder caused by degeneration of the myenteric plexus, resulting in esophageal dysmotility and incomplete lower esophageal sphincter relaxation. The disease is likely caused by a virus-induced autoimmune response, but this is still debated. 1 The incidence in the Western world is 1/100 000. 2-4 Treatment can be pharmacological, endoscopic, or surgical. Pharmacological treatment is only marginally effective and is reserved for patients with mild symptoms or who refuse other treatments. 7-9 Several studies and a large meta-analysis have indicated that laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. 3,4,10 However, a recent large prospective randomized controlled trial (RCT) comparing EBD and LHM has challenged this view. 11 This study found similar success rates for EBD and LHM 2 years after initial treatment. However, the number of EBD interventions per patient was notably higher than other studies. 3,11 The purpose of this meta-analysis is to determine which treatment is most effective at relieving symptoms and to further clarify the impact of retreatments for patients with achalasia. METHODS This meta-analysis was registered in the international register of systematic reviews (PROSPERO) (CRD42012002071). 12 Search Strategy and Trial Selection A prospective search of Medline, PubMed, and Cochrane Central Register of Controlled Trials was performed to identify relevant publications. The search keyword was "Esophageal Achalasia." Subsequently, the search was limited by the terms "Human," "Clinical Trial," and publication language "English." Publications from 1975 through October 2011 were considered for review To obtain indirect evidence by adjusted network meta-analysis, relative evidence is needed (LHM vs X; EBD vs X). Therefore, success rates were compared with those of either EBTI or open Heller myotomy (OHM). Direct evidence was achieved from head-to-hea

Benefits and challenges in implementation of artificial intelligence in colonoscopy: World Endoscopy Organization position statement

The number of artificial intelligence (AI) tools for colonoscopy on the market is increasing with supporting clinical evidence. Nevertheless, their implementation is not going smoothly for a variety of reasons, including lack of data on clinical benefits and cost-effectiveness, lack of trustworthy guidelines, uncertain indications, and cost for implementation. To address this issue and better guide practitioners, the World Endoscopy Organization (WEO) has provided its perspective about the status of AI in colonoscopy as the position statement. WEO Position Statement: Statement 1.1: Computer-aided detection (CADe) for colorectal polyps is likely to improve colonoscopy effectiveness by reducing adenoma miss rates and thus increase adenoma detection; Statement 1.2: In the short term, use of CADe is likely to increase health-care costs by detecting more adenomas; Statement 1.3: In the long term, the increased cost by CADe could be balanced by savings in costs related to cancer treatment (surgery, chemotherapy, palliative care) due to CADe-related cancer prevention; Statement 1.4: Health-care delivery systems and authorities should evaluate the cost-effectiveness of CADe to support its use in clinical practice; Statement 2.1: Computer-aided diagnosis (CADx) for diminutive polyps (≤5 mm), when it has sufficient accuracy, is expected to reduce health-care costs by reducing polypectomies, pathological examinations, or both; Statement 2.2: Health-care delivery systems and authorities should evaluate the cost-effectiveness of CADx to support its use in clinical practice; Statement 3: We recommend that a broad range of high-quality cost-effectiveness research should be undertaken to understand whether AI implementation benefits populations and societies in different health-care systems

Effects of Blended (Yellow) vs Forced Coagulation (Blue) Currents on Adverse Events, Complete Resection, or Polyp Recurrence After Polypectomy in a Large Randomized Trial

Background & aims: There is debate over the type of electrosurgical setting that should be used for polyp resection. Some endoscopists use a type of blended current (yellow), whereas others prefer coagulation (blue). We performed a single-blinded, randomized trial to determine whether type of electrosurgical setting affects risk of adverse events or recurrence. Methods: Patients undergoing endoscopic mucosal resection of nonpedunculated colorectal polyps 20 mm or larger (n = 928) were randomly assigned, in a 2 × 2 design, to groups that received clip closure or no clip closure of the resection defect (primary intervention) and then to either a blended current (Endocut Q) or coagulation current (forced coagulation) (Erbe Inc) (secondary intervention and focus of the study). The study was performed at multiple centers, from April 2013 through October 2017. Patients were evaluated 30 days after the procedure (n = 919), and 675 patients underwent a surveillance colonoscopy at a median of 6 months after the procedure. The primary outcome was any severe adverse event in a per patient analysis. Secondary outcomes were complete resection and recurrence at first surveillance colonoscopy in a per polyp analysis. Results: Serious adverse events occurred in 7.2% of patients in the Endocut group and 7.9% of patients in the forced coagulation group, with no significant differences in the occurrence of types of events. There were no significant differences between groups in proportions of polyps that were completely removed (96% in the Endocut group vs 95% in the forced coagulation group) or the proportion of polyps found to have recurred at surveillance colonoscopy (17% and 17%, respectively). Procedural characteristics were comparable, except that 17% of patients in the Endocut group had immediate bleeding that required an intervention, compared with 11% in the forced coagulation group (P = .006). Conclusions: In a randomized trial to compare 2 commonly used electrosurgical settings for the resection of large colorectal polyps (Endocut vs forced coagulation), we found no difference in risk of serious adverse events, complete resection rate, or polyp recurrence. Electrosurgical settings can therefore be selected based on endoscopist expertise and preference

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

Background & aims: Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding. Methods: We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (≥20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse event. Results: A total of 919 patients were randomly assigned to groups and completed follow-up. Postprocedure bleeding occurred in 3.5% of patients in the clip group and 7.1% in the control group (absolute risk difference [ARD] 3.6%; 95% confidence interval [CI] 0.7%-6.5%). Among 615 patients (66.9%) with a proximal large polyp, the risk of bleeding in the clip group was 3.3% and in the control group was 9.6% (ARD 6.3%; 95% CI 2.5%-10.1%); among patients with a distal large polyp, the risks were 4.0% in the clip group and 1.4% in the control group (ARD -2.6%; 95% CI -6.3% to -1.1%). The effect of clip closure was independent of antithrombotic medications or polyp size. Serious adverse events occurred in 4.8% of patients in the clip group and 9.5% of patients in the control group (ARD 4.6%; 95% CI 1.3%-8.0%). Conclusions: In a randomized trial, we found that endoscopic clip closure of the mucosal defect following resection of large colon polyps reduces risk of postprocedure bleeding. The protective effect appeared to be restricted to large polyps located in the proximal colon

Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America

Background & Aims Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. Methods We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. Results Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. Conclusions ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions

Differentiation of solitary pulmonary nodules based on morphologic criteria: Comparison between computed tomography and magnetic resonance imaging at 46 patients

Studienziel: Die Studie sollte die Qualität der Dignitätsbeurteilung mittels Computer- und Magnet-Resonanz-Tomographie bei fokalen Lungenläsionen vergleichen. Es sollten die Möglichkeiten zur Dignitätsbestimmung durch die Computer- und Magnet-Resonanz-Tomographie, sowie durch Kombination dieser Methoden erfasst werden. Es sind hierfür Sequenzen im CT, in der MRT-Protonengewichtung und in MRT-Kontrastmittelstudien untersucht worden. Material und Methoden: 46 Patienten mit einem solitären Lungenrundherd ungeklärter Dignität wurden mittels CT und MRT-Protonenwichtung und MRT-Kontrastmittelstudien. Per Resektion und histologischer Analyse oder zweijähriger Verlaufskontrolle wurden 22 Rundherde als benigne und 24 als maligne erkannt. Ergebnisse: Im CT sind die für eine Dignitätsbeurteilung signifikanten Parameter: Form, Randerscheinung, Spikulierung, Vessel-sign und Pleuraanschluß bzw. Pleuraretraktion. In der MRT-Protonenwichtung sind die für eine Dignitätsbeurteilung signifikanten Parameter: Form, Randerscheinung, Inhomogenität und das Vessel-sign. Bei den MRT-Kontrastmittelaufnahmen sind die für die Dignitätseinschätzung signifikanten Parameter: keine Aufnahme von Kontrastmittel, homogene, inhomogene, ringförmige oder noduläre Kontrastmittelaufnahme. Bei Verwendung der auf dem Niveau p<0,05 signifikanten Parameter ergeben sich für die einzelnen Untersuchungsmethoden folgende Sensitivität und Spezifität: CT 96 % Sensitivität, 55 % Spezifität; MRT-Protonenwichtung 92 % Sensitivität, 64 % Spezifität; MRT-Protonenwichtung kombiniert mit Kontrastmitteldynamik: 92 % Sensitivität, 59 % Spezifität; CT kombiniert mit MRT-Protonenwichtung und Kontrastmittel-untersuchungen: 96 % Sensitivität, 73 % Spezifität. Bei einer durchgeführten statistischen Analyse nur unter Berücksichtigung der morphologischen Kriterien Form und Randerscheinung ließ sich im CT bereits eine Sensitivität von 96 % bei einer Spezifität von 55 % erreichen. Bei der MRT-Protonenwichtung lag unter ausschließlicher Berücksichtigung der morphologischen Merkmale Form und Randerscheinung die Sensitivität bei 96 % bei einer Spezifität von 50 %. Zum Vergleich dieser Ergebnisse mit dem Befundungsalltag in radiologischen Kliniken wurden Befundungssitzungen mit dem CT- und MRT-Bildmaterial durch 3 Radiologen durchgeführt. Es ergaben sich folgende Werte: Sensitivität der CT-Befundung: 95 %. Spezifität der CT-Befundungen: 41 %. Sensitivität bei der MRT-Protonenwichtung: 89 %, Spezifität bei der MRT-Protonenwichtung: 42 %. Sensitivität bei der MRT-Protonenwichtung kombiniert mit KM-Befundungen: 91 %, Spezifität bei der MRT-Protonenwichtung kombiniert mit KM-Befundungen: 41 %. Schlußfolgerung: MRT-protonengewichtete Aufnahmen lassen sich gleichwertig bei der Dignitätseinschätzung zu CT-Aufnahmen verwenden. Die Kombination aus CT, MRT-Protonenwichtung und MRT-KM-Studien lieferte das beste Ergebnis bei einer Sensitivität von 96 % und einer Spezifität von 73 %. Die Befundungen des Bildmaterials durch drei Untersucher erreichte eine vom Verfahren (CT oder MRT) unabhängige Sensitivität von im Mittel 91 %, bei einer vom Verfahren (CT oder MRT) unabhängigen Spezifität von im Mittel 41 %.Purpose: To evaluate and compare computed tomography (CT) and magnetic resonance imaging (MRI) in the morphologic analysis of solitary pulmonary nodules (SPN). To determine the possibilities of each method or the combination of methods in the differentiation between malignant and benign solitary pulmonary nodules. Therefore CT and MRI-2D-GRE as well as contrast enhanced MRI images were used. Materials and methods: 46 patients met the inclusion criteria of a solitary pulmonary nodule. CT and MRI-2D-GRE as well as MRI contrast enhanced series were made of all SPN. Through histological diagnosis or observation over 2 years 22 SPN were revealed as benign and 24 as malign. Results: For the differentiation in benign or malign SPN the significant parameters on computed tomography are: form, shape, spiculae, pleural retraction and vessel sign. For differentiation in benign or malign SPNs on MRI-2D-GRE are the significant parameters: form, shape, inhomogeneous structure and vessel sign. For differentiation in benign or malign SPN on contrast enhanced MRI are the significant parameters: no enhancement, homogenous enhancement, inhomogeneous enhancement, ring-shaped enhancement or nodular enhancement. Using these parameters significant on the level p<0.05 we reached the following sensitivity and specificity: CT 96 % sensitivity, 55 % specificity; MRI-2D-GRE 92 % sensitivity, 64 % specificity; MRI-2D-GRE combined with contrast enhanced MRI: 92 % sensitivity, 59 % specificity; CT combined with MRI-2D-GRE and contrast enhanced MRI: 96 % sensitivity, 73 % specificity. In the statistical analysis only regarding the morphologic criteria form and shape the sensitivity using CT was 96 % and the specificity was 55 %. On MRI-2D-GRE only regarding the two parameters form and shape the sensitivity was 96 % and the specificity was 50 %. To evaluate these results in a clinical setting we performed a diagnostic assessment of the images with three radiologists. The diagnostic sensitivity compared to the histological findings was: CT 95 % sensitivity, 41 % specificity. MRI-2D-GRE 89 % sensitivity, 42 % specificity. MRI-2D-GRE combined with contrast enhanced MRI combined: 91 % sensitivity, 41 % specificity Conclusion: MRI-2D-GRE series are equal to computed tomography in the morphological analysis and in the examination of the differences between malignant and benign solitary pulmonary nodules. The best result in the differentiation between benign and malign SPN was reached by the combination of MRI-2D-GRE, contrast enhanced MRI and CT. Diagnostic assessments of the images with three radiologists reached the same results in sensitivity and specificity independent of the used sequences (MRI or CT)