Su1322 Clip Closure After Endoscopic Mucosal Resection (EMR) of ≥ 20 mm Lateral Spreading Tumors of the Colon Allows Discharge of Patients Immediately After the Procedure

Clip Closure After Endoscopic Mucosal Resection (EMR) of > 20 mm Lateral Spreading Tumors of the Colon Allows Discharge of Patients Immediately After the Procedure Vikram Vadyala*, Somashekar G. Krishna, Lisa K. Walker, Liben Mahometano, Marta L. Davila, Jeffrey H. Lee, William A. Ross, Manoop S. Bhutani, Sushovan Guha, John R. Stroehlein, Patrick M. Lynch, Gottumukkala S. Raju Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX Background: EMR is useful in the removal of lateral spreading tumors of the colon, but it is associated with a higher risk of complications such as bleeding & perforation. Hence, in Japan, patients are observed for a couple of days after the procedure in the hospital; & in Australia, EMR is scheduled early in the morning & the patients are observed for 6 hours in the recovery area before they are discharged. EMR is relatively new to the United States. Most endoscopy units in the United States are not equipped with recovery space for extended observation of patients after EMR; & the insurance companies do not cover prolonged hospital stay for observation after an uncomplicated outpatient procedure. We hypothesized that clip closure of an EMR defect (instead of leaving the resection defect without closure), like surgical wound closure, might avoid the risk of wound dehiscence & related complications & thereby allow us to discharge these patients without the need for extended observation.Aim: We report the outcome of clip closure of defects after EMR of 20 mm lateral spreading colon tumors on discharge of patients 30 minutes after the procedure. Methods: Endoscopist: All the procedures were performed by a single operator (2009-11). Patients: 41 consecutive patients with 45 polyps 20 mm were included in the study. EMR Procedure: After submucosal injection of Indigo Carmine & dilute epinephrine solution, a stiff snare was used for snare resection. After Argon Plasma Coagulation of the edges of the resection, the defect was closed with clips from one end to the other end at 2-3 mm intervals. The site was marked with a tattoo & the specimen with retrieved in a net; the rest of the colon was decompressed & the procedure was completed. Colonoscopy Report: The data was recorded in a structured colonoscopy report with well-defined fields to capture all the data. Main Outcome Measurements: We analyzed the ability to discharge the patients without extended observation in the recovery unit. Results: Demographics: Age: 62.18 9.2; Men: 24. Comorbid medical illnesses: 92.7%. Indication: Screening:24%; Surveillance: 29%; Symptoms: 7%; Referral for EMR: 39%. EMR Procedure: EMR site: Right colon: 53.3%; Transverse colon, including flexures: 24.4%; Left colon: 8.9%; & Rectum: 11.1%. EMR type: En-bloc resection: 60%; Clip Closure of the Resection Base: 95.6% of the resections; Duration of procedure: 64 20.5 min. Procedural Complications: 0%; Patient discharge from the recovery unit without extended stay: 100%. Pathology: Serrated adenomas: 21 (46.7%), tubular adenomas: 10 & tubulovillous adenomas: 14. Readmissions: 3 for delayed bleeding about 7 days later; & no delayed perforations. Conclusions: Clip closure of the defect after EMR of large lesions permits discharge of patients without the need for extended observation, with substantial cost savings.