polyp resection - controversial practices and unanswered questions daniel von renteln资料.pdf

该【polyp resection - controversial practices and unanswered questions daniel von renteln资料 】是由【彩屏】上传分享，文档一共【7】页，该文档可以免费在线阅读，需要了解更多关于【polyp resection - controversial practices and unanswered questions daniel von renteln资料 】的内容，可以使用淘豆网的站内搜索功能，选择自己适合的文档，以下文字是截取该文章内的部分文字，如需要获得完整电子版，请下载此文档到您的设备，方便您编辑和打印。Citation:ClinicalandTranslationalGastroenterology(2017)8,e76;doi:.6&2017theAmericanCollegeofGastroenterology2155-384X/17CLINICALANDSYSTEMATICREVIEWSPolypResection-ControversialPracticesandUnansweredQuestionsDanielvonRenteln,MD1andHeikoPohl,%.However,mostpersonswithneoplasticpolypsareneverdestinedtodevelopcancer,anddonotbenefitforfindingandremovingpolyps,–80%ofpolypsarediminutive(≤5mm),thehigh--,,wediscusschallengesofopticalresect-and-,wereviewrecentstudiesthatsupporttheuseofcoldsnareresectionfor≥,(2017)8,e76;doi:.6;publishedonline9March2017SubjectCategory:ReviewINTRODUCTIONpolyps,coldsnareresectionofmid-sizepolyps,(CRC)preventionreducesCRC–observationscallforrefocusingourcancerpreventioneffortsinmortalityby~50%.13Thebenefitofcolonoscopyoncancerpracticeandresearchfromremovingdiminutivepolypstothepreventionisdependentoneffectivepolypdetectionanddetectionandsaferesectionofhigher-:Shouldweadoptaresect-and-discardstrategyforThefirstaspectisrelatedtothemanagementofdiminutivediminutivepolyps?.Currentcolonoscopypracticeguide-polyps(polypsupto5mminsize).Becausediminutivepolypsmendtoremove,wheneverpossible,allpolypoidmonandalmostnevercontaincancer,newlesionsforhistopathologyassessmentirrespectiveofthesizemanagementstrategiestoimprovecost-,70–80%arediminu-4,5“”-and-discardstrategythatusestive,and~50%ofdiminutivepolypsarenon--timepolypdiagnosisofdiminutivepolypshasbeenCancerisexceedinglyrare,,%-%–17Arecentandlargest“”Whilehotelectrocauterysnareresectionhasbeenthecross-sectionalstudytodateincluded442,000polypec-standard-of-careforseveraldecades,recentstudiessuggesttomiesofupto9mmpolypsdidnotfindanycancerinanyofthat“cold”,,yetthebenefitonFinally,severalstudieshavefocusedonthemanagementofcancerpreventionbyremovingdiminutivepolypsislarge≥20mmpolyps,,19,20However,,lipclosureofthediminutivepolypsremainsimportantbecausepresenceofmonpractice;however,adenomamaydeterminelow-orhigh-,wediscussrecentresearchdevelopmentsandOneavenuetoreducecolonoscopyrelatedcostwouldbetocontroversieswithregardstothemanagementofdiminutivereplacehistopathologyassessmentbyusingendoscopic1DepartmentofMedicine,DivisionofGastroenterology,MontrealUniversityHospital(CHUM),andMontrealUniversityHospitalResearchCenter(CR-CHUM),Montréal,Quebec,Canadaand2DepartmentofVeteransAffairsMedicalCenter,WhiteRiverJunction,Vermont,andGeiselSchoolofMedicineandTheDartmouthInstitute,Hanover,NewHampshire,USACorrespondence:DvonRenteln,MD,DepartmentofMedicine,DivisionofGastroenterology,MontrealUniversityHospital(CHUM),andMontrealUniversityHospitalResearchCenter(CR-CHUM),900RueSaint-Denis,Montréal,QuebecH2X0A9,Montreal,-mail:******@Received26September2016;accepted5January2017PolypResection-ControversialPracticesvonRentelnandPohl2Figure1Diminutivepolypsexaminedwithwhitelightandopticalchromoendoscopy(a)adenomatouspolypinwhitelightimaging(b)adenomatouspolypinopticalchromoendoscopy(c)hyperplasticpolypinwhitelightimaging(d),enhancingmodalitiestodistinguishneoplasticfromand-discardapproachrequiresadditionaleffortsbythenon-neoplasticpolyps(Figure1).5,22Novelimagemodalitiesendoscopistduringtheexamination,addedphotoandtexturacydocumentation,,“resect-and-discard”,diminutivepolypsarediagnosedrealtimeassimplifytheresect-and-discardstrategyandminimizeoradenomasornon-adenomatouspolypsbyusingdigitaleliminatetheneedforopticalandhistopathologyassessmentchromoendoscopy,likenarrowbandimaging(NBI).,anon-thatarediagnosedwithhighconfidenceareresectedandopticalresect-and-discardstrategywasexamined,inwhichalldiscarded,-Calculatedcostsavingsofthisapproachhavebeenestimatedplasticandallpolypsproximaltotherectosigmoidastobe33,000,000$%-opticalstrategyagreedwiththeagreementbetweentheopticalandthepathology-basedpathology-mendationsin89%ofmendationshasbeensetastherequiredpatients,justshyofthe90%benchmark,butnotsignificantlyqualitybenchmarkinordertoadopttheresect-and--,multiplestudieshaveshownthatalsoreducedthenumberofrequiredpathologyexaminationsplished,menda-,26Onthebasisofopticalresect-and--and-discardtheseresults,theresect-and-discardstrategyhasbeenisapromisingideatoreducecolonoscopyassociatedcost,endorsedbytheEuropeanandAmericanSocietiesforfurtherresearchonhowtomaketheconceptfeasiblefor–GastrointestinalEndoscopy(ESGEandASGE).-and-,supportanevenmoreradicalapproachtopolypmanagement,,,theresect-removethosethathavegrowntohigher-riskpolypsduringtheClinicalandTranslationalGastroenterologyPolypResection-%–37withcoldsnareresection;however,allresolvedsponta-AccordingtoCTcolonographyguidelines,polyps≤5mmareneously,,37Availablearesmallandbleedingisnotwelldefined,however,theresultsstudiesonnaturalhistoryofpolyps,,Asidefromrandomizedtrials,anincreasingnumberofandcost-effectivenessstudieshaveonlyconsideredthatuncontrolledcohortstudiessuggestthatcoldsnarepoly-,50,52follow-upCTcolonographystudies,themajorityof6-monlyusedsnareshavebeendesignedtobepolyps(65–78%)didnotgrowwithin2–,40Interest-usedwithelectrocauteryandmaynoteasilycutthroughtheingly,,≤paredtheuseofadedicatedcoldsnarepolyps,itisplausiblethattheirresectiondoesnotsufficientlywithastandardsnareforcoldresectionofupto10mmpolypscontributetoCRCpreventiontojustifytheirremoval,,42Instead,overdiagnosisanddedicatedcoldsnare(%).,aparadigmshift,inarecentsurvey72%,44Also,,49,54Amongthosethreeindailypractice,gastroenterologistsmaynotresectdiminutivestudies,immediatebleedingrequiringinterventiononlypolypswhentheirappearancesuggestsnon-,itshouldbenoted,thatcoldsnarepolypectomyhasdiminutivepolypswouldresultina64%-studieswillhavetoshowthesafetyandefficacyofthiscations(perforation,post-polypectomysyndrome)andallowapproachandwhetherittrulydoesnotaffectoverallforbetterhistopathologyevaluationofthepolypandexamina-,patients’,?.stillemerging,≤3mmpolyps,-efficacyandsafetyofcoldsnareresection;,46Incurrentpractice,heupperlimitforen-blocandpiecemealresection,commonapproachtoremovingmediumandlargesizedtheneedforsubmucosalinjection,andassociatedbleedingpolyps≥5mmistouseelectrocauteryor“hot”,47,48Addedcauteryablatesmarginaltissueandpletenessofresection(Figure2).lippingafterlargepolypFurther,?.TheriskofadvancedhistologyoftransitiontoHowever,––adenomaresection(CARE),study10%of5–20mmneoplas-%.912,1416Therefore,-of-%pleteresectionofupto20mmdemonstratedthatresectioncaneffectivelyandsafelypolypswhenusingacoldsnaresuggestingthatresectionmayremove85–90%,55–-pedunculatedpolyps,endoscopicmucosalresec-Withrespecttobleedingriskarandomizedtrialamongtion(EMR)isthecurrentstandard-of--However,inthemajorityofthesepolypsenblocresectionimmediate(%)anddelayedbleedingrisk(%)cannotbeachievedandarethereforeremovedpiece-