ASGE Advanced Endoscopic Lesion Resection Course | November 2022-11 Komanduri

11 Komanduri_Managing bleeding, both big and small

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Dr. Sri Komanduri discusses the management of bleeding during endoscopic resection of complex lesions in a presentation. He begins with disclosure information stating that he has no financial conflicts of interest related to the content. <br /><br />The presentation covers various scenarios involving bleeding during colonoscopy, such as when there is no antiplatelet/anticoagulant (AP/AC) therapy, when the patient is on direct oral anticoagulants (DOACs), and when the patient is on dual AP therapy. <br /><br />Dr. Komanduri emphasizes the importance of understanding the role of the electrosurgical generator and bleeding. The type of polyp and resection technique also influence bleeding risk. He discusses the tools that can be used and their efficacy. <br /><br />The presentation then delves into the numbers and predictors of post-polypectomy bleeding (PPB). Cold snare polypectomy is shown to have low rates of incomplete resections and adverse events compared to hot snare polypectomy for polyps ranging from 6-15mm. <br /><br />Predictors of delayed bleeding after resection include polyp size, pedunculated polyps with thick stalks, hamartomatous/inflammatory polyps, right-sided polyps, age/comorbidity, and the use of AP/AC agents. <br /><br />Dr. Komanduri discusses preventative strategies such as submucosal injection, epinephrine applications, snare tip soft coagulation, detachable snares/clipping, and argon plasma coagulation. Prophylactic clipping after endoscopic mucosal resection (EMR) has been shown to reduce delayed PPB. <br /><br />He also covers the various tools available for managing PPB, including thermal hemostasis (bipolar, argon plasma coagulation), mechanical hemostasis (hemoclips, over-the-scope clips, endoloop, suturing), and basic tamponade (pressure, saline/epinephrine, spray/gel/powder). <br /><br />In conclusion, Dr. Komanduri emphasizes that immediate bleeding during polypectomy can usually be managed endoscopically, while delayed PPB is rare in non-complex polyps. Prophylactic clip placement should be considered for complex polyps, especially in patients on AP/AC therapy. He encourages endoscopists to expand their use of cold snare polypectomy and be familiar with a range of tools for bleeding management.

Keywords

endoscopic resection

bleeding management

colonoscopy

antiplatelet/anticoagulant therapy

direct oral anticoagulants

dual antiplatelet therapy

electrosurgical generator

polyp resection

post-polypectomy bleeding

preventative strategies