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Introduction: Delayed bleeding (DB) is the most common major complication of endoscopic mucosal resection (EMR). Two randomized clinical trials recently demonstrated that clip closure after EMR of large nonpedunculated colorectal polyps (LNPCPs) reduces the risk of DB. We analyzed the cost-effectiveness of this prophylactic measure., Methods: EMRs of LNCPCPs were consecutively registered in the ongoing prospective multicenter database of the Spanish EMR Group from May 2013 until July 2017. Patients were classified according to the Spanish Endoscopy Society EMR group (GSEED-RE2) DB risk score. Cost-effectiveness analysis was performed for both Spanish and US economic contexts. The average incremental cost-effectiveness ratio (ICER) thresholds were set at 54,000 € or $100,000 per quality-adjusted life year, respectively., Results: We registered 2,263 EMRs in 2,130 patients. Applying their respective DB relative risk reductions after clip closure (51% and 59%), the DB rate decreased from 4.5% to 2.2% in the total cohort and from 13.7% to 5.7% in the high risk of the DB GSEED-RE2 subgroup. The ICERs for the universal clipping strategy in Spain and the United States, 469,706 € and $1,258,641, respectively, were not cost effective. By contrast, selective clipping in the high-risk of DB GSEED-RE2 subgroup was cost saving, with a negative ICER of -2,194 € in the Spanish context and cost effective with an ICER of $87,796 in the United States., Discussion: Clip closure after EMR of large colorectal lesions is cost effective in patients with a high risk of bleeding. The GSEED-RE2 DB risk score may be a useful tool to identify that high-risk population., (Copyright © 2020 by The American College of Gastroenterology.)

Objectives: Patients with primary sclerosing cholangitis (PSC) have an increased risk for gallbladder cancer. We aimed to define the postoperative outcomes in PSC patients after cholecystectomy and determine if size of a gallbladder lesion on imaging predicts the presence of neoplasia., Methods: We conducted a retrospective review of patients with PSC who underwent cholecystectomy at Mayo Clinic between 1 January 1995 and 31 December 2008. Patients with a prior history of a liver transplant or cholangiocarcinoma were excluded., Results: A total of 57 patients were included in our primary analysis during the early postoperative period. The most common indication for undergoing a cholecystectomy was the presence of a gallbladder polyp or mass. The sensitivity and specificity of a gallbladder lesion of 0.80 cm and the presence of gallbladder neoplasia was 100% (95% confidence interval (CI) 77-100%) and 70% (95% CI 35-93%), respectively. Of the patients, 23 (40%) had an early postoperative complication. The Child-Pugh score was the only predictor of postoperative outcomes in the multivariate model (odds ratio 1.78, 95% CI 1.11-3.12, P=0.02)., Conclusions: Cholecystectomy in patients with PSC is associated with a high morbidity. Gallbladder polyps <0.80 cm are unlikely to be malignant and observation of these small polyps should be considered. A higher Child-Pugh score was associated with early postoperative complications.

Objective: The management of gallbladder polyps/masses in patients with primary sclerosing cholangitis (PSC) (i.e., cholecystectomy vs observation) remains problematic. Given the risk of biliary tract cancer in PSC in the face of the benign nature of most gallbladder polyps in the general population, our aim was to determine the prevalence of gallbladder cancer in PSC patients with a gallbladder mass who had undergone cholecystectomy., Methods: The case records of all patients with PSC undergoing a cholecystectomy at the Mayo Clinic between 1977-1999 were reviewed., Results: Of the 102 patients with PSC who underwent a cholecystectomy, 14 of 102 (13.7%) had a gallbladder mass. In the subset of patients with gallbladder masses, eight of 14 (57%) had adenocarcinomas (seven primary adenocarcinomas and one metastatic cholangiocarcinoma); the other six had benign masses (five adenomas and one cholesterol polyp). In those patients with benign masses, 33% had associated epithelial cell dysplasia; in patients with primary gallbladder cancers, 57% had associated dysplasia. The patients with primary gallbladder adenocarcinoma had a favorable outcome after cholecystectomy, with a 36-month survival of 66%., Conclusions: In conclusion, gallbladder neoplasms in PSC patients are malignant in approximately 40-60% of the cases. The presence of gallbladder epithelial cell dysplasia suggests a dysplasia-carcinoma sequence in PSC similar to that observed in ulcerative colitis. Consideration should be given to performing a cholecystectomy in PSC patients with gallbladder polyps. If a cholecystectomy is not performed, careful interval follow-up is warranted.

Objective: Gastric polyps are recognized as either an incidental finding on routine gastroscopy or a frequent occurrence in patients with polyposis syndromes. The aim of this study is to determine the prevalence, clinical presentation, and histological subclassification of gastric polyps identified on esophagogastroduodenoscopy in pediatric patients., Methods: We performed an 18-yr retrospective study of all pediatric (<21 yr) patients with gastric polyps diagnosed between 1983 and 2000 at The Johns Hopkins Children's Center. The histology slides were all evaluated at the time of the study according to the accepted histological classification of gastric polyps., Results: Gastric polyps were reported in 40 procedures (0.7%) [corrected] performed in 35 (male:female 1.3:1) patients with a mean (SEM) age at diagnosis of 14.4 (0.9) yr. Polyps were more frequent in white than in black patients (adjusted ratio 1.4:1). The histological subtypes included hyperplastic-inflammatory (42%), fundic gland (40%), hamartomatous (10%), adenomatous (5%), and heterotopic polyps (3%). Fundic gland polyps were frequently encountered in patients with familial adenomatous polyposis (81%). These patients tended to be asymptomatic at the time of their surveillance esophagogastroduodenoscopy, and frequently harbored histological changes of either dysplasia (31%) or indeterminate of dysplasia (19%)., Conclusions: Hyperplastic polyps are the most frequently identified gastric polyps in our pediatric population. Fundic gland polyps are common in patients with familial adenomatous polyposis wherein they tend to harbor histological changes of dysplasia. Future longitudinal studies are needed to evaluate the temporal progression of dysplasia to gastric cancer in patients with fundic gland polyps, and to establish esophagogastroduodenoscopy surveillance guidelines.

Objectives: The inflammatory fibroid polyp (IFP) is a rare benign lesion that can occur throughout the digestive tract. The aim of this study is to describe endoscopic features of gastric IFPs and to determine the clinical value of endoscopic removal., Methods: Upper gastrointestinal endoscopy was performed in 13 patients with gastric IFPs. The IFPs were resected either by endoscopic removal or gastrectomy, and confirmed histologically as IFPs. To evaluate the diagnostic value, endoscopic features of the lesions were analyzed., Results: The most frequent features were semi-pedunculated protrusions (61.5%), covered with a smooth surface of normal mucosa (100%), and located in the antrum or prepyloric region (100%). Bridging folds were observed in three of the 13 lesions (23.1%). The central surface of all 10-mm or larger lesions had an erythematous depression (three lesions), ulceration (five lesions), or white cap on the polyp (one lesion). Endoscopic biopsies failed to confirm IFP in any lesions., Conclusions: IFPs are commonly visualized as semi-pedunculated elevations, covered with a smooth surface of normal mucosa, and located in the antrum or prepyloric region. The 10-mm or larger lesions have central changes. Endoscopic removal of gastric IFPs is a useful method for both accurate diagnosis and treatment in view of negative results with the use of standard biopsy forceps.

Background: In view of the popular acceptance of the adenoma-carcinoma sequence, endoscopic polypectomy is indicated for the removal of colorectal adenomas. Larger or sessile lesions should be removed by an experienced endoscopist, but complications such as hemorrhage and perforation still may occur., Methods: To render the removal of sessile lesions feasible by endoscopic polypectomy and to reduce the risk of complications, we attempted local submucosal injection of hypertonic saline-epinephrine solution [(HSE) a mixture of 4.7% sodium chloride and 0.005% epinephrine] before electrosurgical snare excision; 0.5-2 ml HSE were injected into the base and immediate vicinity of polyps to produce mucosal bulging., Results: Between August 1990 and April 1992, 645 polyps in 403 patients were removed by this method; sessile lesions could be more readily removed. Of these, 17 (2.6%) revealed invasive carcinoma and 19 (3.0%) carcinoma in situ. The largest sessile polyp removed was 40 mm in diameter and 7 mm in height and contained a carcinoma in situ. Even a 6-mm depressed adenoma and two rectal carcinoid tumors could be excised completely. No serious complications were encountered with this method., Conclusion: We conclude that local injection of HSE makes the endoscopic removal of colorectal polyps much easier and safer.

Three cases of gastric inflammatory fibroid polyp removed by endoscopic polypectomy are reported. All lesions were located in the gastric antrum or prepyloric region, and their depth was restricted to the submucosa. The correct diagnosis was obtained, and the digestive symptoms disappeared after polypectomy. In contrast to observations in previous reports, we believe these lesions are suitable for removal by endoscopic means, provided they are small in size and strictly submucosal in location.

A 77-yr-old man with chest discomfort and progressive dysphagia was found to have an intraluminal esophageal lesion of remarkable size. A giant fibrovascular polyp (11 x 7 x 3.5 cm) was successfully removed surgically by a transcervical approach. This unusual benign esophageal lesion is discussed in terms of classification and clinical presentation from a historical perspective. Particular attention is focused on the current approach to diagnosis and management. Endoscopic ultrasonography was employed as part of the evaluation.

After the introduction of fiberoptic endoscopy and its fully accepted use as an instrument of great diagnostic ability, we are now in an era where the same instrument is providing us with a route for a mode of therapy. Colonic polypectomies are now being performed by a majority of the endoscopists. There have only been three instances reported in the literature, however, where the polypectomies have been performed for the removal of symptomatic polyps in the stomach and duodenum. This communication describes the removal of such a pedunculated distal antral polyp which not only caused intermittent pyloric obstruction but also a moderately severe iron deficiency anemia in an 82-year old female. The benign procedure of endoscopic polypectomy, which took only 25 minutes to perform, was a means of total cure for this patient. To the best of our knowledge, this case represents the second reported one from this country of the endoscopic polypectomy of a symptomatic benign gastric polyp.

Surgically resected polypoid lesions of the gallbladder from 97 patients were evaluated to determine both the shape (pedunculated or sessile) and diameter of the polypoid lesions, in association with malignancy. At the time of analysis, the largest polypoid lesion examined was when two or more lesions were detected in one patient because they were histologically the same. Carcinoma was noted in 9 (13%) of the 67 pedunculated lesions and in 10 (33%) of the 30 sessile lesions. The sessile carcinoma was 14 +/- 4 mm (8-20 mm) in maximum diameter, which was not significantly larger than the 8 +/- 4 mm of the benign polyps, but significantly smaller than the 22 +/- 8 mm (14-35 mm) of pedunculated carcinomas (p less than 0.05). Cancer invasion extended beyond the muscular layer in eight cases (80%) of sessile carcinoma, and two of them were 10 mm or less in diameter. On the other hand, cancer invasion was beyond the muscular layer in two cases (22%) of pedunculated carcinoma (p less than 0.05), and these two were 30 mm or more in diameter. Likewise, sessile carcinoma was characterized by both a higher incidence of nodal involvement and poorer prognosis, compared with pedunculated carcinoma. These findings indicate that surgery should be undertaken when sessile polyps are detected by ultrasonography, even though the polyp may be less than 10 mm in diameter. On the other hand, with regard to the pedunculated type, malignancy should be suspected when the polyp is more than 10 mm in diameter.

Four hundred and seventy-seven hyperplastic polyps, removed by endoscopic polypectomy, were reviewed with special reference to the appearance of dysplastic foci and their malignant transformation. Focal carcinomas were found in 10 hyperplastic polyps, which corresponded to 2.1% of the total of 477 hyperplastic polyps. The location of cancer was at the head or at the surface of the polyp, and was intramucosal. Dysplastic foci equivalent in the degree of histological atypia to adenoma were found adjacent to the cancerous foci in these 10 polyps. Dysplastic foci were also found in 19 hyperplastic polyps without cancerous foci, which corresponded to 4.0% of the total hyperplastic polyps. In connection with the histogenesis of malignant transformation of hyperplastic polyps, the results of clinicopathological examination and immunohistochemical stains strongly suggested that cancer cells arose from the dysplastic area in hyperplastic polyps, rather than directly from nondysplastic hyperplastic epithelium.

Hyperplastic polyps of the colon have been previously reported as frequent incidental asymptomatic lesions limited to 1 cm. in size. To our knowledge, this is the first recorded case of a hyperplastic polyp of such magnitude as to cause obstructive symptoms and clinically simulate adenocarcinoma of the colon.

Polyps of the colon are premalignant lesions that should be resected whenever encountered. The techniques of snare polypectomy and hot-biopsy polypectomy have been explained. The complication rate is currently acceptable.

A nine-year old boy with Addison's disease had a long history of epigastric pain. When a large polyp was found in the distal esophagus, it was surgically removed. To our knowledge, this is the youngest patient to undergo surgery for esophagogastric junction polyp. The literature on the subject is reviewed.

Because of rapid technological advances in endoscopic instrumentation, electrosurgical polypectomy and electrocoagulation has become a reality in the upper gastrointestinal tract. Twenty gastric polyps and three duodenal polyps have been removed. Six additional hyperplastic gastric polyps were electrodesiccated. Nine gastric ulcers, four duodenal ulcers, one hemorrhagic gastritis, one gastric varix and three Mallory-Weiss tears were successfully electrocoagulated. One duodenal ulcer and one Mallory-Weiss tear was unsuccessfully electrocoagulated. No morbidity nor mortality occurred as a result of electrosurgical polypectomy or electrocoagulation.

In 138 patients of 215 gastric polyps were removed by electroresection through a fiberscope and the polyps recovered in toto by suction or special grasper-forceps. Discepancies of histological findings in the biopsy specimens and in the tissue of the whole polyps were often found. Follow-up examinations of the cases were presented. Based on our experiences a new histological classification of gastric polyps is neccessary.

A 59-year old white female swallowed chicken gizzards, without chewing, producing severe dysphagia. She was operated on for vagotomy, pyloroplasty and Nissen's fundoplication. A procedure is described where a polypectomy snare was used through the biopsy channel of a flexible fiberoptic esophagoscope to remove the foreign bodies.

The electrosurgical removal of polypoid lesions from the upper gastrointestinal tract with the esophagogastroduodenoscope has proven to be safe, effective and relatively inexpensive procedure. Thirty polypectomies performed on 26 different patients are presented. Polyps were removed from the distal esophagus, stomach, duodenum and jejunum. There were no significant complications.

Review of the literature finds a strong point made for polyps of the stomach to be considered as "sentinels" of malignancy. The controversy over the transformation of gastric polyps into malignant tumors is coming to an end. Apparently, everyone agrees with a high incidence of malignant transformation in adenomatous polyps. The recent case report by Papp and Joseph of a hyperplastic polyp with malignant changes, seems to demonstrate that all polyps can undergo neoplastic transformation. We believe that every gastrectomized patient should be gastroscoped once a year, even with an absence of symptoms or lack of x-ray findings. Any polyp, adenomatous or hyperplastic, should be removed endoscopically and studied histopathologically for possible association with or development of carcinoma.