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Efficacy and Safety of the Inject and Cut Technique for Endoscopic Colonic Polypectomy

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Efficacy and Safety of the Inject and Cut Technique for Endoscopic Colonic Polypectomy Original articles Efficacy and safety of the inject and cut technique for endoscopic colonic polypectomy William Otero R., MD,1 Alejandro Concha M., MD,2 Martín Gómez Z., MD.3 1 Professor of Medicine in the Gastroenterology Abstract Unit at the Universidad Nacional de Colombia, Gastroenterologist at the Clínica Fundadores of the Colonic polypectomy is the most important tool for stopping adenoma-cancer, and the inject and cut technique Hospital Fundación San Carlos has demonstrated efficacy and safety in studies conducted in other countries. Since in our country there are no 2 Gastroenterologist at the Hospital San Ignacio reported data on performance of this technique, it is necessary to describe the experience of a gastroenterology 3 Professor of Medicine in the Gastroenterology Unit at the Universidad Nacional de Colombia, unit of a university. Objectives: The objectives of this study were to describe operational characteristics of en- Gastroenterologist at the Hospital El Tunal doscopic colonic polypectomy using the inject and cut technique and to describe demographic characteristics of patients undergoing this procedure. Materials and Methods: We included all patients who underwent endosco- ......................................... Received: 03-10-12 pic colonic polypectomies in the gastroenterology unit of the Clínica Fundadores in Bogotá from January 2003 to Accepted: 17-01-13 September 2011. Data were processed using SPSS version 18 18.8 (SPSS-IBM) statistical package. Results: 420 patients underwent polypectomies which resected a total of 548 polyps. Mean patient age was 56.3 years (range 14 to 93), 201 patients were male, and 219 were female. Polyps were most commonly located in the left colon (238/64.4%). Average size was 1.6 cm. 83.8% were pedunculated, 13.3% were sessile, and 2.85% were flat. Intraoperative bleeding occurred in 36 cases (8.6%). There was no relationship between this complication and the size of polyps (<= 20vs> 20 mm), OR: 0.44 (CI 0.19-1.01), nor with the number of resected polyps (1Vs> 1) OR: 1.44, (95%:0.65-3 .2). All cases of bleeding were controlled endoscopically without further complications. There was no need for surgery. There were no local recurrences during follow-up. Conclusions: This study showed that the inject and cut technique is a practical, effective, economical and easy to perform technique for removal of colonic polyps. To date this is the largest series published in our country on the subject. Keywords Polypectomy, inject, cut, efficacy, safety. INTRODUCTION rates of complications. Complications which can occur during resection include hemorrhaging and perforations Extensive use of colonoscopy either as a diagnostic or while postpolypectomy syndrome occurs afterwards (4). screening tool has increased detection of colonic polyps There are two techniques for endoscopic treatment of and colon cancers at early stages (1). The removal of colon colon polyps: endoscopic mucosal resection (mucosec- polyps (CP) has been shown to decrease the incidence of tomy) and endoscopic submucosal dissection (ESD) (4). colon cancer (CC) and is also a therapeutic modality for The latter has been developed to achieve en bloc resection early colon cancer (1, 2). Currently, CPs are often treated of large lesions of the upper gastrointestinal tract (7) and endoscopically (1, 3-5). Therapeutic challenges include has been used more and more frequently for resection large sessile polyps with diameters of more than 2cm and of large colonic, flat or sessile polyps in the distal colon heights of more than 2.5 mm and flat polyps less than 2.5 (8-10). It has efficiently replaced standard mucosectomy mm high (6). These types frequently exhibit high-grade for complete eradication of these lesions and complies dysplasia, malignancies, adenocarcinoma (2, 3) and high with the main goal of endoscopic treatment of breaking the 10 © 2013 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología adenoma-cancer sequence (12-15). Endoscopic resection MATERIALS AND METHODS using the submucosal injection technique to separate the muscle has become the standard technique for resecting Patients large colonic polyps (16) since, like ESD, it can achieve complete resection of most lesions if appropriate quality We included all patients who underwent endoscopic standards are followed (12, 17-19). With the inject and cut polypectomy for sessile, flat or pedunculated colonic technique, resection of most lesions is accomplished in polyps greater than or equal to 10 mm in the gastroen- toto which allows for histologic evaluation that can accu- terology and endoscopy unit of Clinica Fundadores in rately determine whether resection was complete and did Bogota, Colombia from January 2003 to September 2011. not leave any residual adenomatous tissue that could cause Patients were included only when we had the exact des- recurrence of adenomas. Malignancy remains a risk when cription of the procedure and pathology results. 2-4 mm there is residual adenoma (18, 20). polyps were resected with biopsy forceps provided they Advanced adenomas (larger than a centimeter with could be completely “embraced.” Larger polyps which villous histologic features or high-grade dysplasia) pose the were still less than 10 mms were resected with a snare but greatest risks of becoming cancer (21-24). The most impor- without use of an electrosurgery unit (cold snare) (9, 10). tant issue related to polyps is their recognized relationship These small polyps represent 90% of the polyps found in with CC (18-20). Currently it is accepted that 95% of CCs daily practice (29, 30, 31). As part of the treatment pro- originate in adenomatous polyps (1-3). tocol in the gastroenterology unit, the patient signed an Colonic polypectomy is the most important tool for informed consent form for the therapeutic procedure. stopping the adenoma-cancer sequence as clearly demons- Sedation was always administered by an anesthesiologist trated in population studies. The management of polyps and always required that the patient sign an additional with standard polypectomy techniques has revealed defi- informed consent form for sedation. ciencies in its main objective of breaking the adenoma- At the institution where the study was performed cancer sequence. Strictly speaking, performing a colonic prothrombin time, partial thromboplastin time and CBC polypectomy using the inject and cut technique is an were measured for all patients before scheduling the pro- endoscopic mucosal resection when performed according cedure in accordance with the protocol. Patients receiving to appropriate quality standards (24) since after separa- anticoagulants or anti-platelet therapy were advised to dis- ting the muscularis submucosa, the lesion in the mucosa continue such drugs for at least a week before the proce- is resected (13, 24, 26). The ultimate benefit of this tech- dure was due to be performed. When there was any doubt nique is to allow complete resection of the lesion which is about the need for such drugs, patients were referred to essential to reduction of recurrence of adenomas as well as internal medicine or cardiology for approval of gastroen- to healing of early tumors (13, 26, 27). terology recommendations or for a change of anticoagu- Although studies in other countries (25, 26) have lation scheme or other treatment modification. Cleaning shown that this technique is effective and safe, a review of of the colon, similar to that for diagnostic colonoscopies, Colombian literature found no studies describing expe- used oral sodium phosphate solution (Travad oral ® 133 rience performing colonic polypectomies using the inject ml) or a polyethylene glycol solution with electrolytes and cut technique. Given this lack of studies on this subject (Nulytely ®, Tecnofarma or Klean Prep ®, Biotoscana). The in our Colombia, the high prevalence of colon cancer here, first was given to patients under 60 years of age without the fact that it is the fourth leading cause of cancer death in cardiovascular comorbidities, renal failure, or diabetes both sexes in this country(28), we decided to conduct this mellitus. Polyethylene glycol was given to patients over 60 study to report the experience of a university center with a or to those who had any of the medical conditions men- large series of patients. tioned. Preparations began the day before the procedure The overall objectives of this research are to describe the with normal diet until lunch followed by a liquid diet. If characteristics of cases in which colon endoscopic polypec- oral Travad was chosen, the patient drank a container of it tomy was conducted through the inject and cut technique and at 5 pm followed by five to seven cups of liquid (water or to describe the operational characteristics of this method. juice). Two hours later the patient repeated this procedure. The specific objectives of this study are to describe If polyethylene glycol was chosen, the patient drank a glass demographic characteristics in terms of gender and age of of a solution of two envelopes diluted in one liter of water the patients who underwent colonoscopic polypectomies, each every 15 minutes until all two liters had been con- to describe the pathological features of resected polyps, sumed (over two hours). Two additional envelopes were and to evaluate the efficacy, safety and clinical outcomes of ingested following the same pattern three hours before the this technique. procedure. If the procedure was performed under sedation, Efficacy and safety of the inject and cut technique for endoscopic colonic polypectomy 11 the patient consumed all four envelopes the day before the remained. Any remaining residual tissue found was removed procedure and fasted until the procedure. in a fashion similar to that which has been described. Polyps greater than or equal to two cm were removed piecemeal Polypectomy until complete resection was achieved and the muscularis mucosa or the muscularis itself could be properly viewed All polypectomies were performed by one of the authors (3, 16, 33). We always tried to completely resect the lesion (WO).
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