Endoscopic resection-related colorectal strictures: risk factors, management, and long-term outcomes

INTRODUCTION Colorectal strictures related to endoscopic resection (ER) of large non-pedunculated colorectal polyps (LNPCPs) may be problematic. Data pertaining to prevalence, risk factors and management is limited. We report a prospectively collected experience of colorectal strictures following ER and describe our standard approach to management. METHODS We analysed prospectively collected data over 150 months, until June 2021, for all patients who underwent ER for LNPCPs ≥40mm. The extent of the ER-defect was graded as <60%, 60-89% or ≥90% of luminal circumference. Strictures were considered 'severe' if patients experienced obstructive symptoms, 'moderate' if an adult colonoscope was unable to be passed through the stenosis or 'mild' if there was resistance on successful passage. Primary outcomes included stricture prevalence, risk factors and management. RESULTS The final analysis included 916 LNPCPs ≥ 40mm (median age 69 years [IQR 61-76], male gender 484 [52.8%]. The primary modality of resection was EMR in 859 [93.8%]. Risk of stricture formation with an ER-defect ≥90%, 60-89% and <60% was respectively 74.2% (n=23/31), 25% (n=22/88) and 0.8% (n=6/797). Severe strictures only occurred with an ER-defect ≥90% (22.6%, 7/31). A defect <60% conferred low risk of only mild strictures (0.8%, n=6/797). Severe strictures required earlier (median 0.9months vs. 4.9months; P=0.006) and more frequent balloon dilations (median 3 vs. 2; P=0.024) than moderate strictures. CONCLUSION Most patients with an ER-defect ≥90% of luminal circumference develop a stricture. A high proportion of these are severe and require early balloon dilation. Conversely, there is minimal risk with an ER-defect <60.

[1]  M. Bourke,et al.  A rectum-specific selective resection algorithm optimizes oncologic outcomes for large non-pedunculated rectal polyps. , 2022, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[2]  K. Byth,et al.  Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial , 2021, The Lancet Gastroenterology & Hepatology.

[3]  CME Exam 2: Outcomes of Thermal Ablation of the Mucosal Defect Margin After Endoscopic Mucosal Resection: A Prospective, International, Multicenter Trial of 1000 Large Nonpedunculated Colorectal Polyps , 2021, Gastroenterology.

[4]  K. Byth,et al.  Optical evaluation for predicting cancer in large non-pedunculated colorectal polyps is accurate for flat lesions. , 2021, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[5]  M. Bourke,et al.  Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: A prospective, international, multi-centre trial of 1000 large non-pedunculated colorectal polyps. , 2021, Gastroenterology.

[6]  K. Byth,et al.  Outcomes of deep mural injury after endoscopic resection: An international cohort of 3717 large non-pedunculated colorectal polyps. , 2021, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[7]  K. Byth,et al.  Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods , 2020, Gut.

[8]  D. Lieberman,et al.  Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. , 2020, The American journal of gastroenterology.

[9]  M. Bourke,et al.  How I remove polyps larger than 20 mm , 2019, Endoscopy.

[10]  D. Corley,et al.  Morbidity and Mortality After Surgery for Nonmalignant Colorectal Polyps: A 10-Year Nationwide Analysis , 2019, The American journal of gastroenterology.

[11]  M. Bourke,et al.  How to Perform Wide-Field Endoscopic Mucosal Resection and Follow-up Examinations. , 2019, Gastrointestinal endoscopy clinics of North America.

[12]  Rajvinder Singh,et al.  The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon , 2018, Endoscopy.

[13]  M. Bourke,et al.  Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions , 2017, Endoscopy.

[14]  M. Bourke,et al.  Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis , 2017, Gut.

[15]  K. Byth,et al.  Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. , 2017, Gastroenterology.

[16]  S. Kudo,et al.  Management and risk factor of stenosis after endoscopic submucosal dissection for colorectal neoplasms. , 2017, Gastrointestinal endoscopy.

[17]  K. Byth,et al.  Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. , 2017, Gastrointestinal endoscopy.

[18]  Paul Fockens,et al.  Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline , 2017, Endoscopy.

[19]  M. Bourke,et al.  How to Perform High-Quality Endoscopic Mucosal Resection During Colonoscopy. , 2017, Gastroenterology.

[20]  K. Byth,et al.  Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors , 2016, Gut.

[21]  M. Bourke,et al.  Endoscopic resection of subtotal or completely circumferential laterally spreading colonic adenomas: technique, caveats, and outcomes , 2016, Endoscopy.

[22]  Rajvinder Singh,et al.  Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions. , 2016, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[23]  T. Azuma,et al.  Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms , 2015, Endoscopy.

[24]  M. Bourke,et al.  Advanced polypectomy and resection techniques. , 2015, Gastrointestinal endoscopy clinics of North America.

[25]  G. Ahlenstiel,et al.  Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. , 2014, Gastrointestinal endoscopy.

[26]  K. Byth,et al.  Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study , 2014, Gut.

[27]  Rajvinder Singh,et al.  Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. , 2014, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[28]  M. Bourke,et al.  Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos). , 2013, Gastrointestinal endoscopy.

[29]  K. Byth,et al.  Complete Barrett’s excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture , 2011, Endoscopy.

[30]  K. Byth,et al.  Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. , 2011, Gastroenterology.

[31]  Michelle A. Anderson,et al.  Management of antithrombotic agents for endoscopic procedures. , 2009, Gastrointestinal endoscopy.

[32]  N. Yamamichi,et al.  Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms , 2009, Endoscopy.

[33]  S. Pocock,et al.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. , 2007, Preventive medicine.

[34]  M. Bourke,et al.  Carbon dioxide insufflation reduces number of postprocedure admissions after endoscopic resection of large colonic lesions: a prospective cohort study. , 2013, Gastrointestinal endoscopy.