Serrated polyps have been recognised in the last decade as important premalignant lesions accounting for between 15% and 30% of colorectal cancers. There is therefore a clinical need for guidance on ...how to manage these lesions; however, the evidence base is limited. A working group was commission by the British Society of Gastroenterology (BSG) Endoscopy section to review the available evidence and develop a position statement to provide clinical guidance until the evidence becomes available to support a formal guideline. The scope of the position statement was wide-ranging and included: evidence that serrated lesions have premalignant potential; detection and resection of serrated lesions; surveillance strategies after detection of serrated lesions; special situations-serrated polyposis syndrome (including surgery) and serrated lesions in colitis; education, audit and benchmarks and research questions. Statements on these issues were proposed where the evidence was deemed sufficient, and re-evaluated modified via a Delphi process until >80% agreement was reached. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool was used to assess the strength of evidence and strength of recommendation for finalised statements.
: we suggest that until further evidence on the efficacy or otherwise of surveillance are published, patients with sessile serrated lesions (SSLs) that appear associated with a higher risk of future neoplasia or colorectal cancer (SSLs ≥10 mm or serrated lesions harbouring dysplasia including traditional serrated adenomas) should be offered a one-off colonoscopic surveillance examination at 3 years (
).
Objective
Sodium–glucose cotransporter 2 inhibitors (SGLT2i) have been associated with diabetic ketoacidosis at the time of colonoscopy. This study aimed to identify factors associated with ketone ...concentrations in SGLT2i‐treated type 2 diabetes compared with non‐SGLT2i‐treated diabetes, and those with impaired fasting glycaemia (IFG) and normoglycaemia.
Design
Cross‐sectional, multicentre, observational study June–December 2020 in four Australian tertiary hospitals.
Participants
Capillary glucose and ketones were measured in people undergoing colonoscopy: 37 SGLT2i‐treated and 105 non‐SGLT2i‐treated type 2 diabetes, 65 IFG and 151 normoglycaemia.
Measurements
Body mass index (BMI), age, glucose, fasting duration and where relevant, HbA1c and time since last SGLT2i dose.
Results
In SGLT2i‐treated diabetes, BMI (ρ = −0.43 95% confidence interval: −0.67, −0.11) and duration since last SGLT2i dose (ρ = −0.33 −0.60, 0.00) correlated negatively with increasing ketones, but there was no correlation with fasting duration. In non‐SGLT2i‐treated diabetes, BMI correlated negatively (ρ = −0.24 −0.42, −0.05) and fasting duration positively (ρ = 0.26 0.07, 0.43) with ketones. In IFG participants, only fasting duration correlated with ketones (ρ = 0.28 0.03, 0.49). In normoglycaemic participants, there were negative correlations with BMI (ρ = −0.20 −0.35, −0.04) and fasting glucose (ρ = −0.31 −0.45, −0.15) and positive correlations with fasting duration (ρ = 0.20 0.04, 0.35) and age (ρ = 0.19 0.03, 0.34). Multiple regression analysis of the entire cohort showed BMI, age and fasting glucose remained independently associated with ketones, but in SGLT2i‐treated participants only BMI remained independently associated.
Conclusions
In SGLT2i‐treated diabetes, lower BMI was a novel risk factor for higher ketones precolonoscopy. Pending larger confirmatory studies, extra vigilance for ketoacidosis is warranted in these people.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background and Aim
Cold snare polypectomy is safe and efficacious for removing polyps <10 mm with reduced rates of delayed postpolypectomy bleeding and postpolypectomy syndrome. This technique can ...also be used for sessile polyps ≥10 mm; however, further evidence is required to establish its safety. The aim of this study was to compare intraprocedure and postprocedure adverse events in patients who underwent cold (CSP) versus hot snare polypectomy (HSP) of 10–20 mm sessile colonic polyps.
Methods
Electronic medical records and endoscopy reports of all patients who underwent polypectomy for Paris 0‐IIa, Is, or 0‐IIa + Is 10–20 mm colonic polyps between January 2015 and June 2017 at three tertiary academic hospitals and one private hospital were retrospectively reviewed. Data on patient demographics, polyp characteristics, method of polypectomy, and intraprocedural and postpolypectomy adverse events were collected.
Results
A total of 408 patients (median age 67, 50% male) had 604 polyps, 10–20 mm in size, removed. Of these, 258 polyps were removed by HSP, with a median size of 15 mm (interquartile range IQR 12–20), compared to 346 polyps that were removed by CSP, with median size of 12 mm (IQR 10–15), P < 0.001. In the HSP group, 15 patients presented with postprocedure complications, including 11 with clinically significant bleeding, 2 with postpolypectomy syndrome, and 2 with abdominal pain. This compares with no postpolypectomy complications in the CSP group, P < 0.001.
Conclusion
In this study, CSP was not associated with any postpolypectomy adverse events. CSP appears to be safer than HSP for removing 10–20 mm‐sized sessile polyps. A prospective multicenter study has been commenced to verify these findings and to assess the efficacy of CSP for the complete resection of polyps of this size.
Cold snare polypectomy of 10–20 mm sessile polyps is safe, and no complications were seen when compared with hot snare.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
Critical peptic ulcer bleeding requiring massive transfusion is a gastroenterological emergency. Few data exist on management and outcomes. The Australian and New Zealand Massive ...Transfusion Registry collects comprehensive data on adult patients receiving massive transfusion across all bleeding contexts.
Aim
To evaluate clinical factors, management (procedural interventions, transfusions) and outcomes after massive transfusion for critical peptic ulcer bleeding.
Method
Demographics, diagnosis, procedures and mortality data were available for 5482 massive transfusion cases from 23 hospitals. International Classification of Diseases 10th Edition, Australian Modification codes were used to determine peptic ulcer bleeding and the Australian Classification of Health Intervention for interventions (i.e. endoscopic, radiological, surgical).
Results
Peptic ulcer bleeding accounted for 270 (4.9%) of all in‐hospital massive transfusion cases; 70% were male. Median number of red blood cell (RBC) units transfused was 7 (interquartile range, 6–10). Thirty‐day mortality was 19.6%. Age (75 vs 67 years; P = 0.009) and Charlson Comorbidity Index (3 vs 1; P < 0.001) were higher in those who died. Highest 24‐h international normalised ratio (1.5 vs 1.4; P < 0.001) and creatinine (118 μmol/L vs 96 μmol/L; P = 0.03) and nadir platelet count (86 × 109/L vs 118 × 109/L; P = 0.01) were also associated with 30‐day mortality. There were no differences in mortality according to number of RBC, platelets or plasma units transfused, gastroscopy (with or without intervention), interventional radiology or surgery.
Conclusion
One in five patients with critical peptic ulcer bleeding requiring massive transfusion died by 30 days. Mortality was associated with patient characteristics rather than clinical interventions (e.g. procedures, blood product transfusion).
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
Management of major gastrointestinal bleeding (GIB) may require massive transfusion (MT), but limited data are available. Upper and lower GIB have different aetiologies, prognosis, ...bleeding patterns and outcomes. Better understanding of current transfusion management and outcomes in these patients is important. We sought to define and validate an algorithm based on clinical coding data to distinguish critical upper and lower GIB using data from the Australian and New Zealand Massive Transfusion Registry (ANZ‐MTR).
Study Design and Methods
Australian and New Zealand Massive Transfusion Registry hospital‐source data on adult patients receiving a MT (defined as ≥5 red cell units within 4 h) for any bleeding context were used. An algorithm allocating ICD‐10‐AM codes into ‘probable’ or ‘possible’ causes of GIB was developed and applied to the ANZ‐MTR. Source medical records of 69 randomly selected cases were independently reviewed to validate the algorithm.
Results
Of 5482 MT cases available from 25 hospitals, 716 (13%) were identified as GIB with 538/716 (75%) categorized ‘probable’ and 178/716 ‘possible’ GIB. Upper and lower GIB causes of MT were identified for 455/538 (85%) and 76/538 (14%) ‘probable’ cases, respectively; 7/538 (1·3%) cases had both upper and lower GIB. Allocation by the algorithm into a ‘probable’ GIB category had a 95·7% (CI: 90–100%) positive predictive value when validated against source medical records.
Conclusion
An algorithm based on ICD‐10‐AM codes can be used to accurately categorize patients with luminal GIB as the primary reason for MT, enabling further study of this critically unwell and resource‐intensive cohort of patients.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Delayed postpolypectomy bleeding (DPPB) is the most common complication of colonoscopic polypectomy. Prophylactic clipping after an uncomplicated polypectomy is increasingly used, but it is unclear ...if this results in the prevention of DPPB. This study aimed to review prophylactic clip use and its effect on the rates of DPPB. MEDLINE, Embase, and the Cochran Library were systematically searched for studies (1995–March 2017) that used prophylactic hemoclips and assessed DPPB as an outcome. Of 1402 articles identified, nine papers were eligible for inclusion, evaluating 4311 patients and 7783 polyps; 118 patients experienced a DPPB, and 49 of these patients received prophylactic clips. There was no significant difference in DPPB rates in patients who received prophylactic clipping compared to those who did not (odd ratio: 0.8; 95% confidence interval: 0.36–1.77; P = 0.56). There was also no significant difference in the DPPB of polyps <20 mm compared with polyps ≥20 mm. Clip application for prophylactic management of an uncomplicated polypectomy has not been demonstrated to reduce the risk of DPPB, casting doubt on the use of this costly practice.
Clip application for prophylactic management of an uncomplicated polypectomy for nonpedunculated polyps has not been demonstrated to reduce the risk of delayed postpolypectomy bleeding, casting doubt on the use of this costly practice.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
During surveillance colonoscopy of patients with long-standing ulcerative colitis UC, a variety of dysplastic and non-dysplastic lesions are detected. The aim of this study was to address the ...diagnostic accuracy of endoscopic characterization of endoscopic trimodal imaging ETMI and chromoendoscopy CE. ETMI includes the combination of autofluorescence imaging AFI, narrow band imaging NBI and white light endoscopy WLE.
This is a pre-specified additional analysis of a multi-centre, randomized controlled trial that compared AFI with CE for dysplasia detection in 210 patients with long-standing UC FIND-UC trial. In the AFI arm, endoscopists used the ETMI system to record AFI colour, Kudo pit pattern using NBI and WLE for lesion characterization. For AFI, purple colour and ambiguous colour combined with pit pattern type III-V on NBI was considered dysplastic. Kudo pit pattern was described in the CE arm. For pit pattern description using NBI and CE, type III-V was considered dysplastic. Histology was the reference standard.
In total, 52 dysplastic and 255 non-dysplastic lesions were detected. Overall sensitivity for real-time prediction of dysplasia was 76.9% (95% confidence interval CI 46.2-95.0) for ETMI, and 81.6% 95% CI 65.7-92.3 for CE. Overall negative predictive value NPV for ETMI was 96.9% 95% CI 92.0-98.8 and 94.7% 90.2-97.2 for CE.
Sensitivity for endoscopic differentiation of dysplastic lesions detected during surveillance of patients with long-standing UC seems limited using ETMI and CE. Future research is warranted as the high NPV indicates that these techniques are valuable for the exclusion of dysplastic lesions NTR4062.
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