Ricerc@Sapienza

Polyp size, location and morphology have a significant impact on the difficult of endoscopic polypectomy.[1] Although there is no standard definition, polyps longer than 2 cm in diameter and polyps occupying at least two haustral folds or more than one third of the colonic circumference, or located in particular anatomic regions (such as involving the ileocecal valve, close to the dentate line, in an area that is difficult to access with a colonoscope, or peridiverticular polyps) are considered difficult polyps.[2] Approximately 10-15% of colonic polyps are categorized as difficult polyps.[1]

Size, Morphology, Site, Access (SMSA) is a scoring system to grade the difficulty encountered during polypectomy. Four polyps levels (with increasing level of complexity) were identified: Level 1(4-5); Level 2 (6-9); Level 3 (10-12); Level 4 (>12). [3] .

With increasing difficult, the risk of complications, recurrence and malignancy also increase. The major risks of this procedure are perforation and bleeding. A multivariate regression analysis in The Munich Polypectomy Study (MUPS) revealed polyp size as the main risk factor for complications. Right-sided polyp location was shown to be a significant risk factor for major complications. It was shown that polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk. The study also concluded that a cut-off value of 3% as an acceptable rate for major complications.[4]

The Endocuff Vision (EV) is a new endoscopic device that is attached like a cap to the distal tip of the colonoscope. The device has eight flexible branches arranged in a single row. These branches are used to flatten the folds of the colon while withdrawing the colonoscope, allowing for improved visibility behind the folds.
Several studies showed that the use of endocuff significantly improves the Adenoma Detection Rate (ADR). [5-6-7] Has been also previously shown that the endocuff facilitates colonoscopic access for complex polypectomy and scar assessment in the sigmoid colon.[8]
To date, there are no studies that investigated the efficacy of EV in improving stability, reducing operation time and complication rate during difficult colon polypectomy. More endoscopic procedures are needed to assess the efficacy of EV. Our preliminary results are encouraging for the continuation of enrollment. Neverthless we believe it is necessary to increase the number of patients to evaluate the efficacy of EcV in order to reduce intervention time and complication rate during difficult colon polypectomies, in particular for polyps longer than 20 mm in diameter, peridiverticular or located in areas that are difficult to access with a colonoscope, by flattening the colonic folds and improving stability and visibility for the endoscopist.

References:
1. Saowanee Ngamruengphong et al, Update on Difficult Polypectomy Techniques. Curr Gastroenterol Rep 2016.
2. Juan F. Gallegos-Orozco et al , Complex Colon Polypectomy. Gastroenterology & Hepatology 2010.
3. Shareef Tholoor et al , Managing difficult polyps: techniques and pitfalls. Annals of Gastroenterology 2013.
4. Puli SR et al, Meta-analysis and systematic review of colorectal endoscopic mucosal resection. World J Gastroenterol 2009.
5. Rashmee Patil et al , Endocuff-Assisted Colonoscopy¿A Novel Accessory in Improving Adenoma Detection Rate: A Review of the Literature. Clinical Endoscopy 2016.
6. Martin Floer et al , Higher Adenoma Detection Rates with Endocuff-Assisted Colonoscopy ¿ A Randomized Controlled Multicenter Trial. Plos One 2014.
7. Mathieu Pioche et al, Endocuff-assisted colonoscopy increases polyp detection rate:a simulated randomized study involving an anatomic colorectal model and 32 international endoscopists. Surgical Endoscopy 2016.
8. Tsiamoulos ZP et al, A new accessory, endoscopic cuff, improves colonoscopic access for complex polyp resection and scar assessment in the sigmoid colon (with video). Gastrointest Endosc. 2012.