Abstract
Background
Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods.
Materials and methods
Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions.
Results
Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04).
Conclusion
Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.
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References
Winawer SJ, Zauber AG, Ho MN, O’Brien MJ, Gottlieb LS, Stemberg SS, Waye JD, Schapiro M, Bond JH, Panish JF (1993) Prevention of colorectal cancer by colonoscopic polypectomy: the National Polyp Study Workgroup. N Engl J Med 329:1977–1981
Citarda F, Tomaselli G, Capocaccia R, Barcherini S, Crespi M, Italien Multicenter Study Group (2001) Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut 48:812–815
Thiis-Evensen E, Hoff GS, Sauar J, Landgmark F, Majak BM, Vatn MH (1999) Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I. Scand J Gastroenterol 34:414–420
Dafnis G, Ekbom A, Pahlman L, Blomqvist P (2001) Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden. Gastrointest Endosc 54:301–309
Dominitz JA, Eisen GM, Baron TH, Goldstein JL, Hirota WK, Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Raddawi HM, Vargo JJ, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO, Standards of Practice Committee. American Society for Gastrointestinal Endoscopy (2003) Complications of colonoscopy. Gastrointest Endosc 57:441–445
Nelson DB, McQuaid KR, Bond JH, Lieberman DA, Weiss DG, Johnston TK (2002) Procedural success and complications of large–scale screening colonoscopy. Gastrointest Endosc 55:307–314
Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout GJ (2000) Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 51:690–696
Singaram C, Torbey CF, Jacoby RF (1995) Delayed postpolypectomy bleeding. Am J Gastroenterol 90:146–147
Dobrowolski S, Dobosz M, Babicki A, Glovacki J, Nalecz A (2006) Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy. Gastrointest Endosc 63:1004–1009
Watabe H, Yamaji Y, Okamoto M, Kondo S, Ohta M, Ikenoue T, Kato J, Togo G, Matsumura M, Yoshida H, Kawabe T, Omata M (2006) Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc 64:73–78
Kim H, Kim T, Kim W, Kim YH, Kim HJ, Yang SK, Myung SJ, Byeon JS, Lee MS (2006) Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 101:1333–1341
Hui A, Wong R, Ching J, Hung LC, Chung SC, Sung JJ (2004) Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc 59:44–48
Di Giorgio P, De Luca L, Calcagno G, Rivellini G, Mandato M, De Luca B (2004) Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a rendomized and controlled study. Endoscopy 36(10):860–863
Hsieh YH, Lin HJ, Tseng GY, Pemg CL, Li AF, Chang FY, Lee SD (2001) Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology 48:1379–1382
Dobrowolski S, Dobosz M, Babicki A, Dymecki D, Hac S (2004) Prophylactic submucosal saline–adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 18:990–993
Hachisu T (1991) A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc 5:70–74
Lishi H, Tatsuta M, Narahara H, Iseki K, Ishiguro S (1996) Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc 44:594–597
Matsushita M, Hajiro K, Takakuwa H, Kusumi F, Marno T, Ohan M, Tominaga M, Okano A, Yakoki V (1998) Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps. Gastrointest Endosc 47:496–499
Rey JF, Marek TA (1997) Endo-loop in the prevention of the postpolypectomy bleeding: preliminary results. Gastrointest Endosc 46:387–389
Iida Y, Miura S, Munemoto Y, Kasahara Y, Asada Y, Toya D, Fujisawa M (1994) Endoscopic resection of large colorectal polyps using a clip** method. Dis Colon Rectum 37:179–180
Hachisu T, Yamada H, Satoh S, Kouzu T (1996) Endoscopic clip** with a new rotable clip-device and a long clip. Dig Endosc 8:127–133
Shioji K, Suzuki Y, Kobayashi M, Nakamura A, Azumaya M, Takenchi M, Baba V, Honma T, Narisawa R (2003) Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 57:691–694
Paspatis G, Paraskeva K, Theodoropoulou A, Mathou N, Vardas E, Oustamanolakis P, Chouverakis G, Karagianis I (2006) A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 101:2805–2809
Morson BC (1974) The polyp–cancer sequence in the large bowel. Proc R Soc Med 67:451–457
Singh N, Harrison M, Rex DK (2004) A survey of colonoscopic polypectomy practices among clinical gastroenterologists. Gastrointest Endosc 60:414–418
Doniec JM, Lohnert MS, Schniewind B, Bokelmann F, Kremer B, Grimm H (2003) Endoscopic removal of large colorectal polyps: prevention of unnecessary surgery? Dis Colon Rectum 46:340–348
Stergiou N, Riphaus A, Lange P, Menke D, Kockerling F, Wehmann T (2003) Endoscopic snare resection of large colonic polyps: how far can we go? Int J Colorectal Dis 18:131–135
Folwaczny C, Heldwein W, Obermaier G, Schindlbeck N (1997) Influence of prophylactic local administration of epinephrine on bleeding complications after polypectomy. Endoscopy 29:31–33
Cipolletta L, Bianco MA, Rotondano G, Catalano M, Prisco A, De Simone T (1999) Endoclipassisted resection of large pedunculated colon polyps. Gastrointest Endosc 50:405–406
Chung SS, Lau JY, Sung JJ, Chan AC, Lai CW, Ng EK, Chan FK, Yang MY, Li AK (1997) Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. BMJ 314:1307–1311
Conflicts of interest
This study was presented in part at the UEGW 2007 meeting and was awarded with a travel grant.
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Kouklakis, G., Mpoumponaris, A., Gatopoulou, A. et al. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 23, 2732–2737 (2009). https://doi.org/10.1007/s00464-009-0478-3
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DOI: https://doi.org/10.1007/s00464-009-0478-3