New method
Clinical endoscopy
Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos)

https://doi.org/10.1016/j.gie.2013.02.030Get rights and content

Background

Wide-field EMR (WF-EMR) of large colonic lesions exposes submucosal vessels, which may result in intraprocedural bleeding (IPB). Ongoing bleeding may obscure the endoscopic field, prolonging the procedure and reducing safety and accuracy. A number of potential interventions to control bleeding exist; however, they have inherent limitations. Safe, readily applicable, inexpensive, and effective therapy to control EMR-IPB has not yet been described.

Objective

To evaluate the safety and efficacy of the snare tip soft coagulation (STSC) technique to control IPB after WF-EMR of large colonic lesions.

Design

Single-center, prospective cohort study.

Setting

Tertiary care referral center.

Patients

A total of 196 patients undergoing wide-field colonic EMR for flat and sessile lesions 20 mm or larger.

Interventions

A standard inject-and-resect EMR technique was applied. IPB was defined as bleeding obscuring the endoscopic field that persisted for 60 seconds or longer. STSC was performed by using the tip of the polypectomy snare to apply soft coagulation (80 W) to sites of IPB.

Main Outcome Measurements

Immediate hemostasis, postprocedural bleeding, and other adverse events.

Results

A total of 198 lesions (mean size 41.5 mm, 64% in the right colon) were removed in 196 patients (mean age 68 years, 52.5% male). STSC alone achieved effective hemostasis in 40 of 44 cases of IPB (91%). In the remaining 4 cases, additional treatment with coagulating forceps or clips was required to achieve hemostasis. There were no immediate STSC-related adverse events. There was no statistically significant difference between the IPB and non-IPB groups in relation to the use of antiplatelet (P = .2) or anticoagulation agents (P = .4), postprocedural bleeding (P = .8) and adverse event rates (P = .7).

Limitations

Nonrandomized study.

Conclusions

STSC is a simple and efficient first-line technique for achieving hemostasis of IPB during WF-EMR in the colon. It succeeds in the majority of cases and appears to be safe.

Section snippets

Methods

Between January 2011 and September 2012, a subgroup of patients referred for WF-EMR of AMN consented to participate in this observational cohort study. The study was approved by the hospital research ethics committee (SAC2010/5/4.9(3155) AU RED HREC/10/WMEAD/103). Patients were asked to withhold antiplatelet agents 7 days before the procedure. Anticoagulants were managed in accordance with current American Society for Gastrointestinal Endoscopy guidelines.4 Two senior endoscopists (MJB, SJW)

Results

A total of 198 lesions were removed in 196 patients (Table 1). The mean age was 68.0 years and 52.6% of patients were male. The mean lesion size was 41.5 mm (range 20-120 mm). Of the patients, 54.1% had lesions located in the right colon. Twenty-five (12.8%) and 6 (3.1%) patients were receiving antiplatelet and warfarin therapy, respectively. The mean time of cessation of aspirin, clopidogrel, and warfarin was 5, 6.5, and 4.3 days, respectively. Forty-seven patients (24.0%) had IPB. The

Discussion

Intraprocedural hemostasis is a highly relevant, yet underdocumented aspect of advanced endoscopic resection. In our cohort, IPB developed in 24% of patients undergoing WF-EMR for colonic AMN. Kim et al13 reported an immediate postpolypectomy bleeding (IPPB) rate of 2.8% in a cross-sectional study of an unselected cohort of 9336 polypectomies for colonic lesions larger than 4 mm. On multivariate analysis, polyp size greater than 10 mm, age 65 years and older, laterally spreading tumors, or

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DISCLOSURE: The authors disclosed no financial relationships relevant to this publication.

If you would like to chat with an author of this article, you may contact Dr Bourke at [email protected].

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