Introduction

Endoscopic mucosal resection (EMR) is the mainstay of therapy for large colorectal polyps. A previous study has shown low complication and recurrence rates after EMR when performing margin and selective base ablation using hybrid argon plasma coagulation (h-APC). We were interested in evaluating the safety and efficacy of EMR with systematic complete margin, base and vessel ablation in a multicenter study.

Aims & Methods

Adults (18–89 years) undergoing EMR of large nonpedunculated colorectal polyps ≥20mm were enrolled in a multicenter prospective study. After EMR completion and removal of all visible adenoma, patients received systematic h-APC ablation of the post-resection margin, the resection base, and of any visible vessels as the only prophylactic therapy for bleeding. Patients were contacted at 4 weeks to assess any adverse events. First surveillance colonoscopies were scheduled at 4-6 months. The primary outcome was the rate of severe delayed bleeding within 4 weeks, defined as the need for hospitalization, transfusion, repeat endoscopy, embolization, or surgery. Secondary outcomes were the rate of recurrence, defined as pathology confirmed adenoma or serrated recurrence at the EMR site at first surveillance, and other adverse events within 4 weeks, including abdominal pain, deep mural injury (using the Sydney Classification), perforation and post-polypectomy syndrome. Continuous variables were compared using t-tests, and categorical variables were compared using chi-squared tests, with a p<0.05 considered statistically significant.

Results

A total of 178 patients (mean age 67.3 y, 44.4% female) undergoing 190 EMRs were included. h-APC margin ablation was done in all cases, partial base ablation in 43/190 and complete base ablation in 127/190. 127 post-resection defects had visible base vessels, of which 122/127 underwent h-APC as prophylactic therapy to prevent delayed bleeding. The mean polyp size was 36.7 mm, with 77.1% being proximal to the splenic flexure, and 81.8% being adenomas. The primary outcome, severe delayed bleeding, occurred in 1.7% (n=3). With regards to recurrence, 46.1% of patients (n=83) underwent a first surveillance colonoscopy at the time of writing, at a median of 4.0 months post-EMR, of which 1.2% (1/83) developed a local recurrence at the EMR resection site. Severe intraprocedural bleeding occurred in 0.6% (n=1). Post-procedural non-severe abdominal pain occurred in 3.4% (n=6), while no patients developed severe post-procedural abdominal pain. Perforation occurred in 0.6% (n=1). This was identified immediately after the procedure in a patient who received partial base ablation, and the defect was clipped. There was no deep mural injury seen during the procedure. Post-polypectomy syndrome occurred in 1.6% of patients who underwent complete base ablation (2/122). Intraprocedural type 2 deep mural injury occurred in 5.1% (n=9), with six out of nine being in the context of complete base ablation. Eight out of nine were clipped, and no patient with type 2 deep mural injury developed a perforation. There were no cases of deep mural injury type 3 to 5 identified intraprocedurally.

Conclusion

EMR with systematic h-APC ablation of the post-resection margin, base and visible vessels demonstrated to be safe and highly effective to treat large nonpedunculated colorectal polyps.

References

1. Motchum L, Levenick JM, Djinbachian R, et al. EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos). Gastrointest Endosc. 2022;96(5):840-848.e2. doi:10.1016/j.gie.2022.06.018

Disclosure

Daniel von Renteln has received research funding from ERBE Elektromedizin GmbH, Ventage, Pendopharm, Fujifilm and Pentax, and has received consultant or speaker fees from Boston Scientific Inc., ERBE Elektromedizin GmbH, and Pendopharm. The remaining authors have no conflict of interest relevant to this abstract to declare.

Introduction

Methods to clear CBDS carry varying risk of adverse effects while leaving them in situ can lead to complications secondary to retained stones.^1–3 Thus, the modality of choice reasonably affects the assessment of whether an attempted removal of asymptomatic CBDS is feasible and adequate. In Sweden, available methods to clear common bile duct stones identified on intraoperative cholangiography during cholecystectomy are flushing/manipulating with cholangio catheter, trans cystic stone extraction, intra-operative endoscopic retrograde cholangiopancreatography (IOERCP), postoperative ERCP, laparoscopic choledochotomy, open choledochotomy and leaving the stone in situ.

Aims & Methods

This observational cohort study was based on the national Swedish Register for Gallstone Surgery and ERCP (GallRiks) with validated prospectively assembled data for 90% of all cholecystectomies and ERCP procedures in Sweden from 2009 to 2023.⁴ The aim was to assess efficacy and safety of the respective methods of clearing CBDS by estimating their odds ratio (OR) of failing to reach textbook outcome. Leaving CBDS in situ was considered reference method.
Textbook outcome was defined as cholecystectomy and CBDS clearance laparoscopically completed in one session without immediate or 30-day surgical complications (bleeding from wound or GI tract, wound dehiscence, wound infection, sepsis, bile duct injury with or without leakage or bleeding), readmissions, reinterventions, stent placement or prolonged postoperative hospitalization beyond three days.
The size of CBDS was categorized as small (<4mm) intermediate (4-8 mm) and large (>8mm). Patients were considered asymptomatic if no previous or current sign of bilirubinemia, cholangitis or pancreatits was recorded.

Results

Among the 192 203 patients in the register between 2009 and 2023, 25 295 patients presented with a CBDS during cholecystectomy. Failure to achieve textbook outcome was seen for 12 147 (48%) across all stone sizes and management options. Odds ratio of failing textbook outcome when adjusting only for CBDS size was 0.7 (95%CI 0.63-0.77) for intraoperative ERCP and 0.63 (95% CI 0.55-0.71) for transcystic extraction while flushing and manipulating the stone had OR 0.5 (95% CI 0.44-0.57). Laparoscopic choledochotomy had OR 14.36 (95% CI 8.83- 25.09) to fail textbook outcome. All compared to leaving the stone in situ.
For a subgroup of asymptomatic stones smaller than 4mm the flushing manipulating option was the only one beneficial compared to leaving them in situ with unadjusted OR 0.73(95% CI 0.59-0.90) of failing textbook outcome.

Conclusion

This study introduces a novel composite outcome measure—textbook outcome—to define successful, complication-free clearance of common bile duct stones (CBDS) encountered during cholecystectomy. Using this measure, the greatest benefit was seen in the flush/manipulate group, which was also the only approach that provided a clear advantage for small asymptomatic stones compared to leaving them in situ.
Balancing safety and efficacy of CBDS clearance methods remains essential, given the potential for complications associated with interventions in the common bile duct.
Importantly, small asymptomatic stones did not seem to benefit from more invasive removal techniques beyond flushing and manipulation with the cholangiocatheter,
when evaluated using this composite outcome measure. However, these results need to be interpreted with caution due to the risk of selection bias.

References

1 Lammert F, Gurusamy K, Ko CW, Miquel J-F, Méndez-Sánchez N, Portincasa P, et al. Gallstones. Nat Rev Dis Primers [Internet]. Nature Publishing Group; 2016 Apr 28 [cited 2023 Nov 6]; 2: 1–17. Available from: https://www.nature.com/articles/nrdp201624
2 Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, et al. Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones. World J Gastroenterol [Internet]. 2021 May 14 [cited 2023 Oct 24]; 27: 2131–2140. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117734/
3 Berg LS, Friis-Andersen H, Zinther NB, Öztoprak M, Gotschalck KA. Feasibility and outcome of transcystic laparoscopic common bile duct exploration as first-line treatment for common bile duct stones: a retrospective cross-sectional study. Surg Endosc [Internet]. 2025 Feb 11 [cited 2025 Feb 17]; 1–11. Available from: https://link.springer.com/article/10.1007/s00464-025-11587-7
4 Enochsson, L. S G. GallRiks Annual Reports 2018 [Internet]. 2019 [cited 2019 Oct 3]. Available from: https://www.ucr.uu.se/gallriks/fou/arsrapporter/arsrapport-2018-2/viewdocument/837

Introduction

Although randomized controlled trials have shown that artificial intelligence (AI) for polyp detection improve adenoma detection rate (ADR) in colonoscopy, it is unknown how implementation of AI changes endoscopists’ behavior on standard colonoscopy (colonoscopy without AI assistance). We aimed at answering this important clinical question.

Aims & Methods

We conducted a multicenter, observational study at four Polish endoscopy centers. These centers implemented AI tools for polyp detection in the end of 2021, after which colonoscopies were done either with or without AI assistance at endoscopists’ discretion. We evaluated the change in the quality of all the diagnostic colonoscopies between September of 2021 and February of 2022, by comparing two different phases: 3 months before and after the AI implementation in clinical practice. The primary outcome measure was ADR of standard colonoscopy. To investigate the independent factors that affected ADR, multivariable logistic regression analysis was also done.

Results

A total of 1,460 patients underwent standard colonoscopy before and after the AI implementation (795 and 665, respectively; mean age 57.1± 15.5 with female accounting for 58.6%). ADR of standard colonoscopy significantly decreased from 28.4% (226/795; 95% confidence interval [CI] 25.29- 31.56) to 22.1% (147/665; 95% CI 18.95 - 25.26; P=.006) after the AI implementation, corresponding to a 6.3% absolute reduction (95%CI 6.2 - 6.5) and a 22.2% relative reduction (95% CI 21.8 - 22.7). In multivariable regression analysis showed that AI implementation in clinical practice (risk ratio 0.774; 95% CI 0.64-0.93), sex (risk ratio 1.33; 95% CI 1.14-1.54) and age (risk ratio 1.535; 95% CI 1.29-1.79) were the only independent factors that affected ADR.

Conclusion

Implementation of AI in clinical practice negatively affected the ADR during standard colonoscopy, raising a question of deskilling effect brought about by an advanced AI technology.

Disclosure

Prateek Sharma: Consultant: Boston Scientific, Olympus Inc; Grant support: US Endoscopy,
Medtronic, Fujifilm, Ironwood, Cosmo pharmaceuticals, Erbe
Michał Filip Kamiński: Consultant: Olympus, Erbe speaker: Boston Scientific, Ipsen,
Recordati; Grant support: Olympus
Yuichi Mori - Olympus: consultation, speaking fees, device loan
Cessare Hassan is a consultant for Alpha-Sigma, Fujifilm, Medtronic, Norgine, Olympus and Pentax.
Rest of authors: nothing to declare.

Introduction

A 37-year-old woman was referred to our unit because of typical biliary colics with transient cholestasis. Her relevant medical history included a cholecystectomy and a sleeve gastrectomy, later on converted to a gastric bypass. After multidisciplinary discussion, we opted for an endoscopic ultrasound-directed transgastric ERCP (EDGE) using a 20/10 lumen-apposing metal stent (LAMS). Due to the previous sleeve gastrectomy, the LAMS had to be placed between the jejunum and the excluded antrum. According to international expert recommendations, the ERCP was scheduled two weeks post-LAMS placement to allow for tract maturation [1] . Nevertheless, the proximal flange of the LAMS dislocated during duodenoscope introduction and ended up in the peritoneal cavity. A decompressing needle was placed and the proximal flange was retrieved in the peritoneal cavity under fluoroscopic guidance, using a therapeutic gastroscope. After a non-successful attempt to reposition the proximal flange through the fistula tract in the jejunum, a guidewire was placed through the LAMS lumen in het excluded antrum. A bridging attempt with a 22mm x 10 cm fully covered enteral stent through the LAMS lumen failed. Subsequently, intraperitoneal endoscopic closure of the fistula towards the excluded antrum was performed with the X-tack system.
Next, we removed the LAMS and the enteral stent from the peritoneal cavity and completely sealed the fistula tract from the jejunal side with x-tack endosutures and clips. The patient was put on antibiotics and could start oral feeding the day after the procedure. Besides moderate abdominal pain the first 2 days after the procedure and a transient elevation of the CRP, the further clinical course was uneventful.

Aims & Methods

The rescue intervention was conducted with a gastroscope with 3,8 mm working channel. A 22 x 10 cm fully covered enteral SEMS was used in the attempt of bridging the excluded antrum. X-tack endosuture system was chosen to achieve the closure of the fistula.

Results

The X-tack system proved to be an effective tool in addressing not only the intraluminal perforation but also in the intraperitoneal endoscopic closure of the fistula extending towards the excluded antrum.

Conclusion

This case illustrates the potential of endoscopic suturing devices as minimally invasive alternatives to surgery for management of large iatrogenic perforations.

References

[1] S. Stefanovic et al., “International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process,” Am. J. Gastroenterol., Dec. 2023, doi: 10.14309/ajg.0000000000002571.

Disclosure

Nothing to disclosure