Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide-field Endoscopic Mucosal Resection of Large Colonic Lesions

doi:10.1016/j.cgh.2013.09.049

Clinical Gastroenterology and Hepatology

Volume 12, Issue 4, April 2014, Pages 651-661.e3

Presented at Digestive Disease Week, Orlando, Florida, 2013 (oral) and at Australian Gastroenterology Week, Adelaide, Australia, 2012 (poster).

https://doi.org/10.1016/j.cgh.2013.09.049 Get rights and content

Background & Aims

Wide-field endoscopic mucosal resection (WF-EMR) of large sessile colonic polyps is a safe and cost-effective outpatient treatment. Bleeding is the main complication. Few studies have examined risk factors for bleeding during the procedure (intraprocedural bleeding [IPB]) or after it (clinically significant post-endoscopic bleeding [CSPEB]). We investigated factors associated with IPB and CSPEB in a large prospective study.

Methods

We analyzed data from WF-EMRs of sessile colorectal polyps ≥20 mm in size (mean size, 35.5 mm), which were performed on 1172 patients (mean age, 67.8 years) from June 2008–March 2013 at 7 tertiary hospitals as part of the Australian Colonic Endoscopic Resection Study. Data were collected on characteristics of patients and lesions, along with outcomes of procedures and clinical and histologic analyses. Independent predictors of IPB and CSPEB were identified by multiple logistic regression analysis.

Results

Of the patients studied, 133 (11.3%) had IPB. Independent predictors included increasing lesion size (odds ratio, 1.24/10 mm; P < .001), Paris endoscopic classification of 0–IIa + Is (odds ratio, 2.12; P = .004), tubulovillous or villous histology (odds ratio, 1.84; P = .007), and study institutions that performed the procedure on fewer than 75 patients (odds ratio, 3.78; P < .001). All IPB was successfully controlled endoscopically. IPB prolonged procedures and was associated with early recurrence (relative risk, 1.68; P = .011). Seventy-three patients (6.2%) had CSPEB. On multivariable analysis, CSPEB was associated with proximal colon location (odds ratio, 3.72; P < .001), use of an electrosurgical current not controlled by a microprocessor (odds ratio, 2.03; P = .038), and IPB (odds ratio, 2.16; P = .016). Lesion size and comorbidities did not predict CSPEB.

Conclusions

In a prospective study of patients undergoing WF-EMR of large sessile colonic polyps, IPB is associated with larger lesions, lesion histology, and Paris endoscopic classification of type 0–IIa + Is. IPB prolongs the duration of the procedure, is a marker for recurrence, and is associated with CSPEB. CSPEB occurs most frequently in the proximal colon and less when current is controlled by a microprocessor.

Section snippets

Methods

Consecutive patients referred to 1 of 7 Australian academic tertiary hospitals for the management of sessile colorectal polyps 20 mm or larger were enrolled in this prospective observational study. All lesions had been initially identified and referred by a nationally accredited consultant endoscopist. Data were recorded in a comprehensive centralized database from June 2008–March 2013. Institutional review board approval was obtained at each center. Written informed consent was obtained from

Results

Between June 2008 and March 2013, 1516 lesions in 1387 patients were enrolled in the study and assessed for resection. One hundred thirty-six patients enrolled in the active arm of a randomized prophylactic endoscopic coagulation trial were excluded. WF-EMR was not attempted in 51 patients either because of features suggesting a high risk of invasive neoplasia (n = 32) or because the lesion was unable to be safely resected for technical reasons (n = 19). Two-week follow-up data were incomplete

Discussion

EMR has matured as a technique during the last 10 years because of increasing evidence of its efficacy, safety, and cost-effectiveness in comparison to surgery.1, 2 The advent of widespread colorectal cancer screening has greatly increased the detection of AMN, and the majority of these can now be managed endoscopically by WF-EMR with great clinical and financial benefit. IPB and CSPEB remain significant limitations, and identification of the risk factors for these complications allows

Acknowledgments

The authors acknowledge the assistance of Karen Byth, PhD (NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia) with the statistical analyses.

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: Conflicts of interest The authors disclose no conflicts.

: Funding Dr Nicholas Burgess was supported by a funding grant from the Westmead Medical Research Foundation (WMRF). The Cancer Institute New South Wales provided funding for a research nurse and data manager to assist with the administration of the study. There was no influence from the WMRF or the Cancer Institute on study design or conduct, data collection and management, analysis, interpretation, preparation and review, or approval of the manuscript.

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Original articleAlimentary tractRisk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide-field Endoscopic Mucosal Resection of Large Colonic Lesions

Background & Aims

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Acknowledgments

Gastroenterology

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Tech Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

J Thromb Haemost

Gastrointest Endosc

Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions

Endoscopy

Original article
Alimentary tract
Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide-field Endoscopic Mucosal Resection of Large Colonic Lesions