IU Indianapolis ScholarWorks :: Browsing by Author "Vemulapalli, Krishna C."

Browsing by Author "Vemulapalli, Krishna C."

Now showing 1 - 10 of 25

Adverse events and residual lesion rate after cold endoscopic mucosal resection of serrated lesions ≥10 mm
(Elsevier, 2020) McWhinney, Connor D.; Vemulapalli, Krishna C.; El-Rahyel, Ahmed; Abdullah, Noor; Rex, Douglas K.; Medicine, School of Medicine
Background and Aims Cold endoscopic mucosal resection (EMR) is being increasingly used for large serrated lesions. We sought to measure residual lesion rates and adverse events after cold EMR of large serrated lesions. Methods In a single academic center, we retrospectively examined a database of serrated class lesions ≥ 10 mm removed with cold EMR for safety and efficacy. Results Five hundred and sixty-six serrated lesions ≥10 mm in size were removed from 312 patients. We successfully contacted 223 patients (71.5%) with no reported serious adverse events that required hospitalization, repeat endoscopy, or transfusion. The residual lesion rate per lesion at first follow-up colonoscopy was 18 out of 225 (8%; 95% CI, 5-12.1). Lesions with residual were larger at polypectomy compared with lesions without recurrence (median, 23 mm vs 16 mm, p=0.017). Conclusion Cold EMR appears to be safe and effective for the removal of large serrated lesions.
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.
Clip Artifact after Closure of Large Colorectal Endoscopic Mucosal Resection Sites: Incidence and Recognition
(Elsevier, 2015-08) Sreepati, Gouri; Vemulapalli, Krishna C.; Rex, Douglas K.; Department of Medicine, IU School of Medicine
Background Clip closure of large colorectal EMR defects sometimes results in bumpy scars that are normal on biopsy. We refer to these as “clip artifact.” If unrecognized, clip artifact can be mistaken for residual polyp, leading to thermal treatment and potential adverse events. Objective To describe the incidence of and define predictors of clip artifact. Design Review of photographs of scars from consecutive clipped EMR defects. Setting University outpatient endoscopy center. Patients A total of 284 consecutive patients with clip closure of defects after EMR of lesions 20 mm or larger and follow-up colonoscopy. Interventions EMR, clip closure. Main Outcome Measurements Incidence of clip artifact. Results A total of 303 large polyps met the inclusion criteria. On review of photographs, 96 scars (31.7%) had clip artifact. Clip artifact was associated with increased numbers of clips placed (odds ratio for each additional clip, 1.2; 95% confidence interval, 1.02-1.38) but not polyp histology, size, or location. The rate of residual polyp by histology was 8.9% (27/303), with 21 of 27 scars with residual polyp evident endoscopically. The rate of residual polyp evident only by histology in scars with clip artifact (3/93; 3.2%) was not different from the rate in scars without clip artifact (3/189; 1.6%). Limitations Retrospective design. Sites closed primarily with 1 type of clip. Single-operator assessment of endoscopic photographs. Conclusion Clip artifact occurred in the scars of approximately one-third of large clipped EMR sites and increased with number of clips placed. Clip artifact could be consistently distinguished from residual polyp by its endoscopic appearance.
Cold versus hot snare resection with or without submucosal injection of 6-15 mm colorectal polyps: a randomized controlled trial
(ScienceDirect, 2022) Rex, Douglas K.; Anderson, Joseph C.; Pohl, Heiko; Lahr, Rachel E.; Judd, Stephanie; Antaki, Fadi; Lilley, Kirthi; Castelluccio., Peter F.; Vemulapalli, Krishna C.; Medicine, School of Medicine
Background and aims Cold snare resection of colorectal lesions has been found safe and effective for an expanding set of colorectal lesions. In this study, we sought to understand the efficacy of simple cold snare resection and cold endoscopic mucosal resection (EMR), versus hot snare resection and hot EMR for colorectal lesions 6-15 mm in size. Methods At three U.S. centers, 235 patients with 286 colorectal lesions 6-15 mm in size were randomized to cold snaring, cold EMR, hot snaring, or hot EMR for non-pedunculated colorectal lesions 6-15 mm in size. The primary outcome was complete resection determined by 4 biopsies from the defect margin and 1 biopsy from the center of the resection defect. Results The overall incomplete resection rate was 2.4% (95% CI 0.8-7.5%). All 7 incompletely removed polyps were 10-15 mm in size and removed by hot EMR (n = 4, 6.2%), hot snare (n = 2, 2.2%), or cold EMR (n = 1, 1.8%). Cold snaring had no incomplete resections, required less procedural time than the other methods, and was not associated with serious adverse events. Conclusion Cold snaring is a dominant resection technique for non-pedunculated colorectal lesions 6-15 mm in size.
Colorectal EMR outcomes in octogenarians versus younger patients referred for removal of large (≥20 mm) nonpedunculated polyps
(Elsevier, 2021-03) Lee, Christopher J.; Vemulapalli, Krishna C.; Rex, Douglas K.; Medicine, School of Medicine
Background and Aims Data are limited on safety and outcomes of colorectal EMR in octogenarians (≥80 years old). We sought to review outcome data for patients aged ≥80 in a prospectively collected database of patients referred for large polyp removal. Methods We retrospectively evaluated a database of patients referred for large (≥20 mm) nonpedunculated polyp removal. From 2000 to 2019, we compared the rates of follow-up, recurrence, adverse events, and synchronous neoplasia detection between younger patients and patients aged ≥80. Results There were 167 patients aged ≥80 years and 1686 <80 years. Patients in the elderly group returned for surveillance less often (67.1% vs 75.1%, P = .024), had greater first follow-up recurrence rates (27.5% vs 13.8%, P < .001), but had similar adverse event rates (1.8% vs 2.8%, P = .619) compared with younger patients. Rates of synchronous neoplasia were similar and high in both groups. Conclusions EMR is safe and well tolerated for large polyp removal in patients over 80 years old. Patients aged ≥80 years are less likely to present for follow-up after EMR. They had a higher recurrence rate and a similarly high prevalence of synchronous precancerous lesions. Follow-up after EMR should be encouraged in the elderly, and an attempt to clear the colon of synchronous disease at the time of the initial EMR may be warranted.
A comparison of 2 distal attachment mucosal exposure devices: a noninferiority randomized controlled trial
(Elsevier, 2019) Rex, Douglas K.; Sagi, Sashidhar V.; Kessler, William R.; Rogers, Nicholas A.; Fischer, Monika; Bohm, Matthew E.; Dewitt, John M.; Lahr, Rachel E.; Searight, Meghan P.; Sullivan, Andrew W.; McWhinney, Connor D.; Garcia, Jonathan R.; Broadley, Heather M.; Vemulapalli, Krishna C.; Medicine, School of Medicine
Background and Aims Endocuff and Endocuff Vision are effective mucosal exposure devices for improving polyp detection during colonoscopy. AmplifEYE is a knock-off device that appears similar to the Endocuff devices but has received minimal clinical testing. Methods We performed a randomized controlled clinical trial using a noninferiority design to compare Endocuff Vision with AmplifEYE. Results The primary endpoint of adenomas per colonoscopy was similar in AmplifEYE at 1.63 (2.83) versus 1.51 (2.29) with Endocuff Vision; p=0.535. The 95% lower confidence limit was 0.88 for ratio of means, establishing noninferiority of AmplifEYE (p=0.008). There was no difference between the arms in mean insertion time, and mean inspection time (withdrawal time minus polypectomy time and time for washing and suctioning) was shorter with AmplifEYE (6.8 minutes vs 6.9 minutes, p=0.042). Conclusions AmplifEYE is noninferior to Endocuff Vision for adenoma detection. The decision of which device to use can be based on cost. Additional comparisons of AmplifEYE to Endocuff by other investigators are warranted.
Determining the adenoma detection rate and adenomas per colonoscopy by photography alone: proof-of-concept study
(Thieme, 2015-09) Rex, Douglas K.; Hardacker, Kyle; MacPhail, Margaret; Rahmani, Farrah; Vemulapalli, Krishna C.; Kahi, Charles J.; Department of Medicine, IU School of Medicine
Background and study aims: The adenoma detection rate (ADR) and adenomas detected per colonoscopy (APC) are measures of the quality of mucosal inspection during colonoscopy. In a resect and discard policy, pathologic assessment for calculation of ADR and APC would not be available. The aim of this study was to determine whether ADR and APC calculation based on photography alone is adequate compared with the pathology-based gold standard. Patients and methods: A prospective, observational, proof-of-concept study was performed in an academic endoscopy unit. High definition photographs of consecutive polyps were taken, and pathology was estimated by the colonoscopist. Among 121 consecutive patients aged ≥ 50 years who underwent colonoscopy, 268 polyps were removed from 97 patients. Photographs of consecutive polyps were reviewed by a second endoscopist. Results: The resect and discard policy applied to lesions that were ≤ 5 mm in size. When only photographs of lesions that were ultimately proven to be adenomas were included, the reviewer assessed ADR and APC to be lower than that determined by pathology (absolute reductions of 6.6 % and 0.17, and relative reductions of 12.6 % and 13.1 % in ADR and APC, respectively). When all photographs were included for calculation of ADR and APC, the reviewer determined the ADR to be 3.3 % lower (absolute reduction) and the APC to be the same as the rates determined by pathology. Conclusions: In a simulated resect and discard strategy, a high-level detector can document adequate ADR and APC by photography alone.
Endoscopy staff are concerned about acquiring COVID-19 infection when resuming elective endoscopy
(Elsevier, 2020) Rex, Douglas K.; Vemulapalli, Krishna C.; Lahr, Rachel E.; McHenry, Lee; Sherman, Stuart; Al-Haddad, Mohammad; Medicine, School of Medicine
Findings in the Distal Colorectum are not associated with Proximal Advanced Serrated Lesions
(Elsevier, 2015-02) Kahi, Charles J.; Vemulapalli, Krishna C.; Snover, Dale C.; Jawad, Khaled H. Abdel; Cummings, Oscar W.; Rex, Douglas K.; Department of Medicine, IU School of Medicine
Background & Aims Serrated lesions are an important contributor to colorectal cancer (CRC), notably in the proximal colon. Findings in the distal colorectum are markers of advanced proximal adenomatous neoplasia. However, it is not known whether they affect the odds of advanced proximal serrated lesions. Methods We performed a retrospective cross-sectional study of data from 1910 patients (59.3 ± 8.0 years, 53.8% female) who underwent an average-risk screening colonoscopy from August 2005 through April 2012 at Indiana University Hospital and an associated ambulatory surgery center. Colonoscopies were performed by an endoscopist with high rates of detection of adenomas and serrated polyps. Tissue samples of all serrated polyps (hyperplastic, sessile serrated adenoma/polyp [SSA/P], or traditional serrated adenoma) proximal to the sigmoid colon and serrated polyps >5 mm in the rectum or sigmoid colon were reviewed by a gastrointestinal pathologist and reclassified on the basis of World Health Organization criteria. Advanced serrated lesion (ASL) was defined as SSA/P with cytologic dysplasia, SSA/P ≥10 mm, or traditional serrated adenoma. Advanced conventional adenomatous neoplasia (ACN) was defined as tubular adenoma ≥10 mm, villous histology, high-grade dysplasia, or cancer. The prevalence of proximal ASL and ACN was calculated on the basis of distal colorectal findings. Multivariable logistic regression analysis was performed to determine the age-adjusted and sex-adjusted odds of advanced proximal adenomatous and serrated lesions. Secondary analyses were performed to examine the effect of variable ASL definitions. Results Fifty-two patients (2.7%) had proximal ASL, and 99 (5.2%) had proximal ACN. Of the 52 patients with proximal ASL, 27 (52%) had no distal polyps. Of the 99 patients with proximal ACN, 40 (40%) had no distal polyps. Age and type of distal adenomas were significantly associated with proximal ACN. There were no significant associations between distal polyp type and proximal ASL. In secondary analyses, distal SSA/Ps (P = .008) but not distal hyperplastic polyps or conventional adenomas were associated with any proximal SSA/P. Conclusions The findings at flexible sigmoidoscopy that traditionally serve as indications for colonoscopy (conventional adenomas) are likely to be ineffective for detection of proximal ASL. This finding, plus the observation that most patients with proximal ASL have no distal polyps, favors screening colonoscopy over sigmoidoscopy, especially in the elderly. The observation that non-advanced distal SSA/Ps are associated with any proximal SSA/P warrants further study.
High-definition colonoscopy versus Endocuff versus EndoRings versus Full-Spectrum Endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial
(Elsevier, 2018) Rex, Douglas K.; Repici, Alessandro; Gross, Seth A.; Hassan, Cesare; Ponugoti, Prasanna L.; Garcia, Jonathan R.; Broadley, Heather M.; Thygesen, Jack C.; Sullivan, Andrew W.; Tippins, William W.; Main, Samuel A.; Eckert, George J.; Vemulapalli, Krishna C.; Medicine, School of Medicine
Background Devices used to improve polyp detection during colonoscopy have seldom been compared with each other. Methods We performed a 3-center prospective randomized trial comparing high-definition (HD) forward-viewing colonoscopy alone to HD with Endocuff to HD with EndoRings to the Full Spectrum Endoscopy (FUSE) system. Patients were age ≥50 years and had routine indications and intact colons. The study colonoscopists were all proven high-level detectors. The primary endpoint was adenomas per colonoscopy (APC) Results Among 1,188 patients who completed the study, APC with Endocuff (APC Mean ± SD 1.82 ± 2.58), EndoRings (1.55 ± 2.42), and standard HD colonoscopy (1.53 ± 2.33) were all higher than FUSE (1.30 ± 1.96,) (p<0.001 for APC). Endocuff was higher than standard HD colonoscopy for APC (p=0.014) . Mean cecal insertion times with FUSE (468 ± 311 seconds) and EndoRings (403 ± 263 seconds) were both longer than with Endocuff (354 ± 216 seconds) (p=0.006 and 0.018, respectively). Conclusions For high-level detectors at colonoscopy, forward-viewing HD instruments dominate the FUSE system, indicating that for these examiners image resolution trumps angle of view. Further, Endocuff is a dominant strategy over EndoRings and no mucosal exposure device on a forward-viewing HD colonoscope.

Browsing by Author "Vemulapalli, Krishna C."

Results Per Page

Sort Options