Browsing by Author "Guardiola, John J."

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    A new through-the-scope clip with anchor prongs is safe and successful for a variety of endoscopic uses
    (Thieme, 2024-06-21) Guardiola, John J.; Rex, Douglas K.; Thompson, Christopher C.; Mosko, Jeffrey; Ryou, Marvin; Peetermans, Joyce; Rousseau, Matthew J.; von Renteln, Daniel; Medicine, School of Medicine
    Background and study aims Endoscopic through-the-scope clips (TTSC) are used for hemostasis and closure. We documented the performance of a new TTSC with anchor prongs. Patients and methods We conducted a prospective case series of the new TTSC in 50 patients with an indication for endoscopic clipping at three hospitals in the United States and Canada. Patients were followed for 30 days after the index procedure. Outcomes included defect closure and rate of serious adverse events (SAEs) related to the device or procedure. Results Fifty patients had 56 clipping procedures. Thirty-four procedures were clipping after endoscopic mucosal resection (EMR) in the colon (33) or stomach (1), 16 after polypectomy, two for hemostasis of active bleeding, and one each for fistula closure, per-oral endoscopic myotomy mucosal closure, or anchoring a feeding tube. Complete defect closure was achieved in 32 of 33 colon EMR defects and 21 of 22 other defects. All clips were placed per labeled directions for use. In 41 patients (82.0%), prophylaxis of delayed bleeding was reported as an indication for endoscopic clipping. There were three instances of delayed bleeding. There were no device-related SAEs. The only technical difficulty was one instance of premature clip deployment. Conclusions A novel TTSC with anchor prongs showed success in a range of defect closures, an acceptable safety profile, and low incidence of technical difficulties.
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    Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit
    (Thieme, 2024-04-23) Stark, Easton M.; Lahr, Rachel E.; Shultz, Jeremiah; Vemulapalli, Krishna C.; Guardiola, John J.; Rex, Douglas K.; Medicine, School of Medicine
    Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.
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    Characterization of endoscopic features and histology of a distinct mucosal transition zone on the ileocecal valve (with video)
    (Elsevier, 2023-09) Rex, Douglas K.; Lahr, Rachel E.; Guardiola, John J.; Dewitt, John M.; Zhang, Dongwei; Medicine, School of Medicine
    Background and Aims We have endoscopically encountered a zone of transitional mucosa between the colonic and ileal mucosa located in a 3- to 10-mm-wide ring around the ileocecal valve (ICV) orifice. We aimed to describe the features of the ICV transitional zone mucosa. Methods We used videos and photographs from normal ICVs and biopsy samples from normal colonic mucosa, transitional zone mucosa, and normal ileal mucosa to characterize the endoscopic and histologic features of the ICV transitional zone mucosa. Results The ICV transitional zone is identifiable on every ICV without a circumferential adenoma or inflammation that obliterates the zone. The zone is characterized endoscopically by an absence of villi, which distinguishes it from the ileal mucosa, but the pits are more tubular and with more prominent blood vessels compared with normal colonic mucosa. Histologically, the villi of the transitional zone are blunted, and the amount of lymphoid tissue is intermediate between the colonic mucosa and ileal mucosa. Conclusions This is the first description of the normal transitional zone of mucosa on the ICV. This zone has unique endoscopic features that should be recognized by colonoscopists and that can potentially create difficulty in identifying the margins of adenomas located on the ICV.
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    Safety of first surveillance colonoscopy at 12 months after piecemeal EMR of large nonpedunculated colorectal lesions
    (Elsevier, 2024-05) Bobay, Michael C.; Lahr, Rachel E.; Schultz, Jeremiah; Vemulapalli, Krishna C.; Guardiola, John J.; Rex, Douglas K.; Medicine, School of Medicine
    Background and Aims After piecemeal EMR (pEMR) of nonpedunculated colorectal lesions ≥20 mm, guidelines recommend first endoscopic surveillance at 6 months. However, initial surveillance at 12 months may be adequate for selected low-risk lesions and could save the cost, risk, and inconvenience of 1 surveillance examination. Methods This study retrospectively examined a prospectively collected database of all colorectal lesions referred to our center for endoscopic resection between August 2019 and April 2023. We report recurrence rates of patients with colorectal lesions ≥20 mm removed by pEMR who were assigned to 6-month first surveillance or to 12-month first surveillance (or assigned to a 6-month surveillance visit but did not return until after 10 months). Results There were 561 nonpedunculated lesions ≥20 mm that underwent first follow-up, including 490 lesions in 443 patients assigned to 6-month surveillance and 71 lesions in 65 patients assigned to 12-month surveillance. Lesions assigned to 12-month surveillance were smaller (mean size, 25.9 ± 6.1 mm vs 37.0 ± 17.4 mm), more likely serrated (63.4% vs 9.6%), and more often removed by cold pEMR (74.6% vs 20.4%). Twenty-nine lesions in 24 patients assigned to 6-month surveillance presented after 10 months, and their recurrence data were included in the group assigned to 12-month surveillance. Overall recurrence rates at 6 months and 12 months were 10.0% (46 of 461) and 10.0% (10 of 100), respectively. Mean recurrence sizes at 6 and 12 months were 10.9 ± 6.2 mm and 5.0 ± 3.1 mm, respectively. One patient in the 6-month surveillance group had cancer at the pEMR site, but no other recurrences at 6 or 12 months had either cancer or high-grade dysplasia. Conclusions Twelve-month surveillance seems acceptable for selected colorectal lesions ≥20 mm removed by pEMR. A randomized trial comparing initial 6-month versus 12-month surveillance is warranted for selected lesions.