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

Departments of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Sydney, NSW
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association (Impact Factor: 7.9). 09/2013; 12(4). DOI: 10.1016/j.cgh.2013.09.049
Source: PubMed


& 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 following it (clinically significant post-EMR bleeding, CSPEB). We investigated factors associated with IPB and CSPEB in a large prospective study.
We analyzed data from WF-EMRs of sessile colorectal polyps ≥20 mm in size (mean size, 35.5mm), performed on 1172 patients (mean age 67.8 y) from June 2008 through 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.
Of the patients studied, 133 had IPB (11.3%). Independent predictors included increasing lesion size (odds ratio [OR], 1.24/10 mm; P <.001), Paris endoscopic classification of 0-IIa+Is (OR, 2.12; P=.004), tubulovillous or villous histology (OR, 1.84; P=.007), and study institutions that performed the procedure on fewer than 75 patients (OR, 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 had CSPEB (6.2%). On multivariable analysis, CSPEB was associated with proximal colon location (OR, 3.72; P <.001), use of an electrosurgical current not controlled by a microprocessor (OR, 2.03; P=.038) and IPB (OR, 2.16; P=.016). Lesion size and comorbidities did not predict CSPEB.
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. IBP 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.

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    ABSTRACT: Background & Aims: Clinically significant postendoscopic mucosal resection bleeding (CSPEB) is the most frequent significant complication of wide-field endoscopic mucosal resection (WF-EMR) of advanced mucosal neoplasia (sessile or laterally spreading colorectal lesions > 20 mm). CSPEB requires resource-intensive management and there is no strategy for preventing it. We investigated whether prophylactic endoscopic coagulation (PEC) reduces the incidence of CSPEB. Methods: We performed a prospective randomized controlled trial of 347 patients (mean age, 67.1 y; 55.3% with proximal colonic lesions) undergoing WF-EMR for advanced mucosal neoplasia at 3 Australian tertiary referral centers. Patients were assigned randomly (1:1) to groups receiving PEC (n= 172) or no additional therapy (n= 175, controls). PEC was performed with coagulating forceps, applying low-power coagulation to nonbleeding vessels in the resection defect. CSPEB was defined as bleeding requiring admission to the hospital. The primary end point was the proportion of CSPEB. Results: Patients in each group were similar at baseline. CSPEB occurred in 9 patients receiving PEC (5.2%) and 14 controls (8.0%; P= .30). CSPEB was associated significantly with proximal colonic location on multivariate analysis (odds ratio, 3.08; P= .03). Compared with the proximal colon, there was a significantly greater number (3.8 vs 2.1; P= .002) and mean size (0.5-1 vs 0.3-0.5 mm; P= .04) of visible vessels in the distal colon. Conclusions: PEC does not significantly decrease the incidence of CSPEB after WF-EMR. There were significantly more and larger vessels in the WF-EMR mucosal defect of distal colonic lesions, yet CSPEB was more frequent with proximal colonic lesions. NCT01368731.
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