Factors predicting a positive capsule endoscopy in past overt obscure gastrointestinal bleeding: a multicenter retrospective study.

OBJECTIVES: Capsule endoscopy (CE) remains the examination of choice for the investigation of obscure gastrointestinal bleeding. Although the factors predicting positive CE findings in the overall obscure gastrointestinal bleeding have been investigated, the clinical characteristics that predict a positive CE in patients with past overt obscure gastrointestinal bleeding (OOGIB) have not been systematically studied. METHODS: Between September 2004 and December 2013, 262 patients underwent CE for evaluation of past OOGIB after negative upper and lower endoscopy, and other diagnostic modalities. Patients' records were retrospectively reviewed to assess the factors that could possibly predict positive CE findings. RESULTS: Two hundred and twenty four patients with a median age of 70 years (range: 17-87) were enrolled in the final analysis and were divided into two groups; those who had positive (group A: 118 patients) and those who had negative CE findings (group B: 106 patients). The overall diagnostic yield of CE was 52.68 %. Multivariate analysis demonstrated that age >65 years, anticoagulant use, antiplatelet use, and non-steroidal anti-inflammatory drugs use were independent predictive factors for positive findings on CE. Of the 118 patients with positive CE, therapeutic interventions were performed in 56 patients (47.46 %). Recurrence of bleeding presented in nine patients of group B compared with 39 patients of group A (p <0.001). CONCLUSIONS: Certain clinical characteristics predict a positive CE in patients with past OOGIB. Patients with OOGIB and negative CE had a considerably lower rebleeding rate, and further invasive investigational procedures may be adjourned or may not be required, though such recommendation warrants further validation. Hippokratia 2016, 20(2): 127-132.

Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial.

BACKGROUND AND STUDY AIMS: Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP). PATIENTS AND METHODS: A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively. RESULTS: There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis. CONCLUSION: Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Can capsule endoscopy be used as a diagnostic tool in the evaluation of nonbleeding indications in daily clinical practice? A prospective study.

OBJECTIVE: To evaluate the diagnostic yield of capsule endoscopy (CE) and its impact on treatment and outcome in patients without bleeding indications. SUBJECTS AND METHODS: One hundred and sixty-five nonbleeding patients were enrolled in the study. The most common indications for CE were chronic abdominal pain alone (33 patients) or combined with chronic diarrhea (31 patients) and chronic diarrhea alone (30 patients). Among the 165 patients, 129 underwent CE for evaluation of gastrointestinal symptoms and 36 for surveillance or disease staging. RESULTS: CE findings were positive, suspicious and negative in 73 (44.2%), 13 (7.9%) and 79 (47.9%) of cases, respectively. The diagnostic yield was highest in patients with refractory celiac disease (10/10, 100%) and suspected Crohn's disease (5/6, 83.3%), followed by patients with chronic abdominal pain and chronic diarrhea (13/31, 41.9%), established Crohn's disease (2/6, 33.3%), chronic diarrhea alone (8/30, 26.7%), chronic abdominal pain alone (8/33, 24.2%) and other indications (3/13, 23.1%) (p < 0.005). The CE findings led to a change of medication in 74 (47.7%) patients, surgery in 15 (9.7%), administration of a strict gluten-free or other special diet in 13 (8.4%) and had other consequences in 11 (6.7%). Management was not modified in 42 (27.1%) patients. Among symptomatic patients (n = 129), 29 (22.5%) were lost to follow-up. The remaining 100 patients were followed up for 8.7 ± 4.0 months (range 2-19). Among the latter, resolution or improvement of symptoms was observed in 86 (86%) patients, no change in 11 (11%) and 3 (3%) died. All 86 patients who experienced resolution or improvement of their symptoms had a modification of their management after CE; only 7/11 patients whose symptoms did not change (63.6%) and 2/3 patients who died (66.7%) had a modification of management (p < 0.001). CONCLUSIONS: CE appears to be a useful tool in the evaluation of patients with nonbleeding indications. The outcome of most patients with negative findings was excellent.

Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older.

BACKGROUND AND STUDY AIM: The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort. PATIENTS AND METHODS: A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed. RESULTS: There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient. CONCLUSION: Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

Diagnostic yield and clinical management after capsule endoscopy in daily clinical practice: A single-center experience.

BACKGROUND: Capsule endoscopy is an effective method of examining the small bowel in patients with obscure gastrointestinal bleeding, suspected inflammatory mucosal diseases and neoplasms. We herein evaluate the diagnostic yield of capsule endoscopy and its effect on clinical management in daily clinical practice. PATIENTS AND METHODS: One hundred and one capsule endoscopies performed at the Department of Endoscopy and Motility Unit of G. Gennimatas General Hospital of Thessaloniki from May 2007 to February 2009 were retrospectively reviewed. Clinical management following capsule endoscopy findings was evaluated. The most frequent indication was obscure gastrointestinal bleeding (n=56, overt=20). RESULTS: The overall diagnostic yield was 47.5%. The diagnostic yield was 88.9% in patients with overt bleeding who underwent early capsule endoscopy (within 5 days), versus 36.4% in patients who underwent late capsule endoscopy (p=0.028). Moreover, it reached 81.8% in patients with abdominal pain, with/without diarrhea and abnormal biological markers, versus 8.3% in patients with normal biological markers (p<0.0001). Capsule endoscopy was diagnostic in all patients with symptomatic celiac disease. Adenomas were found in 9 of 14 familial adenomatous polyposis patients. Capsule retention (>72 hours) occurred in two patients. Forty-three of 48 (89.6%) patients with positive capsule endoscopy findings that received intervention or medical treatment had positive clinical outcomes. CONCLUSIONS: Capsule endoscopy has an important diagnostic role and contribution in the clinical management during routine clinical practice; however, it remains to be determined which patients are more likely to benefit from this expensive examination.

Prospective randomized study comparing double layer and Tannenbaum stents in distal malignant biliary stenosis.

BACKGROUND AND STUDY AIMS: This prospective randomized study compared the patency and effective drainage rate of two stents with different materials but similar design, in the palliation of inoperable malignant biliary obstruction. PATIENTS AND METHODS: A total of 49 patients (26 women, mean age 72.55 +/- 10.75 years, range: 48-91 years) with obstructive jaundice due to inoperable malignant stricture of the distal common bile duct without previous drainage procedure, were randomly assigned to receive 10F Double Layer (DLS) (n = 24) or 10F Tannenbaum (TAN) (n = 25) biliary plastic stent. The diagnosis included pancreatic cancer (n = 33), cholangiocarcinoma (n = 8), ampullary cancer (n = 7) and metastatic lymphadenopathy (n = 1). The duration of stent patency, the effective drainage, and the adverse events were analyzed. RESULTS: Stent placement was successful in all patients with minor complications. The overall median patency rates between the two groups did not differ (107.5 days for DLS group vs. 101 days for TAN group ; p = 0.066). Effective drainage rate at the end of second week was 95.8% for DLS group and 96% for TAN group, (p = 1.00). Proximal stent migration occurred in one patient with TAN stent. CONCLUSIONS: The present study demonstrated that both DLS and TAN stents are comparable in terms of placement, overall stent patency, and complications.

Endoscopic closure of a large iatrogenic rectal perforation using endoloop/clips technique.

Retroflexion to evaluate the rectal vault provides significant additional information compared with standard forward view of the rectum. The procedure is easily performed with rare complications and is well tolerated by patients. We describe the first case of a large oval rectal perforation after retroflexion of the colonoscope in a healthy rectum during a follow-up colonoscopy, immediately closed with the endoloop/clips technique. The patient had an uneventful course and was discharged after 5 days. At his 2-month follow-up visit he remained asymptomatic and endoscopy revealed complete healing of the perforation.

Acute upper gastrointestinal bleeding in central Greece: the role of clinical and endoscopic variables in bleeding outcome.

The objectives of this work were to portray the incidence of upper gastrointestinal bleeding in central Greece and to define subsets at higher risk of poor outcome or death. Two hundred and sixty-four cases were recorded. The incidence was 116 per 100,000 per year (95% CI: 102-130). Re-bleeding was noted in 7.9% of patients. The case fatality was 7.2% and population mortality 8 per 100,000 per year (95% CI: 4-12). Independently significant risk factors for re-bleeding were stigmata of bleeding at endoscopy (OR: 3.11; 95% CI: 1.06-9.13, P = 0.04), smoking (OR: 3.39; 95% CI: 1.08-10.62, P = 0.03), and the use of anti-coagulant drugs (OR: 2.64; 95% CI: 1.00-7.13, P = 0.05), while the independently significant risk factor for death was re-bleeding (OR: 5.74; 95% CI: 1.40-23.52, P = 0.03). We conclude that patients with stigmata of bleeding at endoscopy and on anti-coagulant therapy should be under close surveillance because of the higher risk of re-bleeding. Smoking also increases the risk of re-bleeding. Patients with re-bleeding episodes must be managed intensively because of the higher risk of death.

Should inspection of the laryngopharyngeal area be part of routine upper gastrointestinal endoscopy? A prospective study.

BACKGROUND: Examination of the laryngopharyngeal area is not always performed during routine upper gastrointestinal (UGI) endoscopy although initial studies reported pathological findings in 0.9-3.5% of cases. The aim of this study was to prospectively evaluate the accuracy of screening the laryngopharyngeal area during routine UGI endoscopy, before insertion of endoscope into the oesophagus, to avoid a misinterpretation of trauma-related hyperaemia or erythema as signs of laryngitis. METHODS: The study included 1297 patients undergoing elective UGI endoscopy, asymptomatic in the laryngopharyngeal area, who underwent a carefully structured examination of the laryngopharyngeal area, videotaped for later blinded review. If pathological findings were suspected, patients were referred to otorhinolaryngologists for additional evaluation. In all cases the DVDs were reviewed by two ear, nose, and throat (ENT) specialists blinded to the endoscopic findings. RESULTS: In 1130 (87.12%) patients the examination was performed successfully before insertion of the endoscope into the oesophagus. Gastro-oesophageal reflux disease (GORD) symptoms were present in 254 (22.5%) patients, and erosive oesophagitis was documented in 89 (7.9%) patients. In 44 (3.89%) patients the pathology was suspected by the endoscopist and confirmed by the otorhinolaryngologists. Moreover, 8 (0.71%) patients were found to have laryngeal pathology in the DVDs reviewed by the ENT specialists, further confirmed by laryngoscopy. Sensitivity, specificity, positive, and negative predictive values were 84.61%, 100%, 100%, and 99.26%, respectively, for detecting laryngeal abnormalities by the endoscopist. The most important findings were leukoplakia (n=4), posterior laryngitis (n=16), Reinke's oedema (n=2), and hyperkeratosis of arytenoid folds (n=2). A strict correlation emerged between GORD and posterior laryngitis (75%) and between GORD and Reinke's oedema (100%), documented by pHmetry. A significant association was also observed between heavy smoking and leukoplakia (75%), and hypertrophy of pharyngeal tonsils (100%), respectively. All other findings were lesions without clinical significance. CONCLUSIONS: Screening examination of the laryngopharyngeal area should be part of each UGI endoscopy revealing important laryngeal pathology.

Capsule endoscopy findings in congenital afibrinogenemia-associated angiopathy.

Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of functional fibrinogen. We report a 22-year-old female who developed nephrogenic arterial hypertension and intestinal ischemia due to congenital afibrinogenemia-associated angiopathy of large abdominal arteries. We describe, for the first time, the capsule findings and discuss the pathophysiology of this unusual condition.

Fatal acute acalculous cholecystitis as an early complication after radiation therapy..

Acute acalculous cholecystitis (AAC) is a life-threatening condition whose incidence is steadily increasing, although it is still very much lower than that of the corresponding calculus form. The severity of the disease is due to the rapid course towards gallbladder necrosis and biliary peritonitis. Traditionally, it has been thought that AAC is associated with recent trauma, overeating or major surgical procedures. We describe a patient who presented acute cholecystitis, two days after completion of radiation therapy for metastatic lymphadenopathy along the hepatoduodenal ligament and distal common bile duct. He underwent exploratory laparotomy but he died from uncontrolled sepsis three days later. Histological study of the resected gallbladder showed findings of acute acalculous cholecystitis.

A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct.

BACKGROUND AND STUDY AIMS: Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD. PATIENTS AND METHODS: A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates. RESULTS: The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality. CONCLUSIONS: The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.

Combination of endoprostheses and oral ursodeoxycholic acid or placebo in the treatment of difficult to extract common bile duct stones.

BACKGROUND: When common bile duct (CBD) stones cannot be removed after conventional endoscopic techniques or mechanical lithotripsy, biliary stenting serves for further planned endoscopic attempt of stone removal or operation. The aim of our study was to investigate the effect of ursodeoxycholic acid (UDCA) or placebo plus endoprostheses on stones' fragmentation or size. METHODS: Forty-one patients with difficult to extract CBD stones were prospectively studied. They were randomised to receive either a 10 Fr straight plastic stent and oral 750 mg UDCA (group A, 21 patients) or placebo (group B, 20 patients) daily for 6 months. RESULTS: A total clearance of CBD was achieved in 16 patients (76.9%) of group A and 15 patients (75%) of group B. The stones remained unchanged in size in five patients (23.8%) of group A and five patients (25%) of group B. In seven patients (33%) of group A and five patients (25%) of group B a repeated ERCP demonstrated fragmentation of CBD stones that were easily extracted. A reduction in stones' size was observed in 8 patients (38%) of group A (1.61 +/- 0.32 cm before treatment vs. 1.21 +/- 0.24 cm after treatment, p = 0.002) and 10 patients (50%) of group B (1.61 +/- 0.35 cm before vs. 1.24+/-0.22 cm after treatment, p = 0.001). There was no statistically significant difference on stone size reduction (p = 0.602) and fragmentation (p=0.558) between the two groups. CONCLUSION: The results of this study suggest that UDCA does not seem to contribute to the reduction in stones' size or stones' fragmentation during the endoprosthetic procedure.

Endoscopic sphincterotomy for acute relapsing pancreatitis associated with periampullary diverticula: a long-term follow-up.

BACKGROUND AND STUDY AIMS: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. Data concerning the association of PAD with biliopancreatic disease are inconsistent, but an association between acute pancreatitis and PAD has been reported. The aim of this retrospective study was to evaluate the outcome of endoscopic sphincterotomy (ES) in a Greek cohort of patients with acute relapsing pancreatitis associated with PAD. PATIENTS AND METHODS: A total of 344 patients who had undergone ERCP between 1994 and 2005 for investigation of acute pancreatitis were retrospectively entered into a database. Of these patients, 11 (3.19% ; median age: 69 years; range: 58-78; 3 men, 8 women) were found to have acute relapsing pancreatitis associated with PAD. All patients underwent ES and were followed for new episodes of acute pancreatitis or other complications. RESULTS: No further episodes of acute pancreatitis occurred after ES, during a long-term follow-up (median: 4.3 years, range: 1.9-10.4). Two patients (18.2%) presented post-procedure mild pancreatitis and one patient (9.1%) post-ES stenosis with two small common bile duct stones and was treated with ES and extraction of stones. CONCLUSION: ES is the treatment of choice for patients with acute relapsing pancreatitis associated with PAD.

A novel technique of injection treatment for endoscopic sphincterotomy-induced hemorrhage.

BACKGROUND: We prospectively investigated the efficacy and safety of double injection of dextrose 50 % plus epinephrine (D (50)+E) solution in endoscopic hemostasis of postendoscopic sphincterotomy (ES) hemorrhage. PATIENTS AND METHODS: The study included 1331 consecutive patients who underwent 1331 ES procedures between March 2002 and June 2006. Bleeding patterns (trickle, oozing, pulsatile, none) were recorded. Patients with oozing or trickle bleeding who did not respond to spray irrigation of D (50)+E solution and all the patients with pulsatile bleeding, received double injection of D (50)+E solution at 2 - 3 cm proximal and into the bleeding point with a sclerotherapy needle. Risk factors for post-ES hemorrhage were also assessed. RESULTS: ES-induced hemorrhage occurred in 63 patients (4.73 %). Visible bleeding patterns immediately following ES were: 44 trickle (69.84 %), 13 oozing (20.63 %) and six pulsatile (9.52 %). Hemostasis was achieved by spray irrigation of solution in 41 of 44 patients (93.18 %) with trickle, and in three of 13 patients (23.07 %) with ooze bleeding. Double injection was required in all patients with pulsatile bleeding, in 10 patients (76.92 %) with oozing, and in three patients (6.82 %) with trickle bleeding. Overall, successful hemostasis was achieved with double injection in 18 of 19 patients (94.74 %). The "zipper" cut was revealed to be a sole significant risk factor to the occurrence of bleeding ( P < 0.001). Five non-bleeding patients (0.37 %) presented with delayed hemorrhage. The difference in the incidence of other complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant. CONCLUSION: Double injection of the readily available and inexpensive D (50)+E solution is a safe and effective treatment and is recommended for post-ES hemorrhage.

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness.

BACKGROUND: Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. METHODS: In this study, 47 patients (median age, 73 years, range, 56-86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. RESULTS: The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). CONCLUSIONS: Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.

Endoloop-assisted polypectomy for large pedunculated colorectal polyps.

BACKGROUND: The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps. This study aimed to assess the safety and efficacy of colonoscopic ligation of the stalk of large pedunculated polyps by means of an endoloop technique, and to focus particular attention on the instances in which the use of this device was unsuccessful. METHODS: This study retrospectively evaluated attempted endoloop endoscopic polypectomy in 33 patients (19 men and 14 women; mean age, 62.5 years) with large pedunculated polyps. RESULTS: Application of the endoloop was impossible in four patients, and the snare became entangled with the loop in one patient. The remaining 28 patients underwent endoloop-assisted polypectomy. Bleeding occurred in four patients, either because the loop slipped of the stalk after polypectomy (2 patients) or because a thin stalk (< or = 4 mm) was transected by the loop before polypectomy (2 patients). CONCLUSION: Colonoscopic polypectomy with an endoloop may be safer than conventional polypectomy. The reasons for technical failure of this technique include a narrow left colon lumen, a thin stalk (< or = 4 mm), and close cutting in relation to the site of encirclement by the loop.