Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors
ObjectivesPerforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries w...
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| Published in: | Gut Vol. 66; no. 10; pp. 1779 - 1789 |
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| Main Authors: | , , , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
England
BMJ Publishing Group LTD
01.10.2017
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| ISSN: | 0017-5749, 1468-3288, 1468-3288 |
| Online Access: | Get full text |
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| Abstract | ObjectivesPerforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.DesignEndoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III–V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists’ discretion.ResultsEMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III–V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III–V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).ConclusionsIn this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III–V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.Trial registration numberNCT01368289; results. |
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| AbstractList | Perforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.
Endoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III-V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists' discretion.
EMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III-V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III-V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).
In this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III-V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.
NCT01368289; results. Perforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.OBJECTIVESPerforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.Endoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III-V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists' discretion.DESIGNEndoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III-V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists' discretion.EMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III-V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III-V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).RESULTSEMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III-V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III-V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).In this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III-V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.CONCLUSIONSIn this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III-V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.NCT01368289; results.TRIAL REGISTRATION NUMBERNCT01368289; results. ObjectivesPerforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.DesignEndoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III–V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists’ discretion.ResultsEMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III–V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III–V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).ConclusionsIn this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III–V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.Trial registration numberNCT01368289; results. Objectives Perforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed. Design Endoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III-V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists' discretion. Results EMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III-V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III-V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014). Conclusions In this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III-V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification. Trial registration number NCT01368289; results. |
| Author | Williams, Stephen J Byth, Karen Burgess, Nicholas G Bourke, Michael J McLeod, Duncan Bassan, Milan S |
| Author_xml | – sequence: 1 givenname: Nicholas G surname: Burgess fullname: Burgess, Nicholas G email: michael@citywestgastro.com.au organization: University of Sydney, Sydney, New South Wales, Australia – sequence: 2 givenname: Milan S surname: Bassan fullname: Bassan, Milan S email: michael@citywestgastro.com.au organization: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia – sequence: 3 givenname: Duncan surname: McLeod fullname: McLeod, Duncan email: michael@citywestgastro.com.au organization: Department of Pathology, ICPMR, Westmead Hospital, Sydney, New South Wales, Australia – sequence: 4 givenname: Stephen J surname: Williams fullname: Williams, Stephen J email: michael@citywestgastro.com.au organization: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia – sequence: 5 givenname: Karen surname: Byth fullname: Byth, Karen email: michael@citywestgastro.com.au organization: NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia – sequence: 6 givenname: Michael J surname: Bourke fullname: Bourke, Michael J email: michael@citywestgastro.com.au organization: University of Sydney, Sydney, New South Wales, Australia |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/27464708$$D View this record in MEDLINE/PubMed |
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| ContentType | Journal Article |
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| DOI | 10.1136/gutjnl-2015-309848 |
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| Keywords | COLONIC POLYPS COLONOSCOPY ENDOSCOPIC PROCEDURES COLONIC NEOPLASMS ENDOSCOPIC POLYPECTOMY |
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| References | Moss, Bourke, Metz 2010; 105 Cotton, Eisen, Aabakken 2010; 71 Bourke 2011; 13 Heldwein, Dollhopf, Rösch 2005; 37 Holt, Bourke 2012; 10 Oka, Tanaka, Saito 2015; 110 2003; 58 Masci, Viale, Notaristefano 2013; 27 Swan, Bourke, Alexander 2009; 70 Hassan, Repici, Sharma 2016; 65 Swan, Bourke, Moss 2011; 73 Raju, Saito, Matsuda 2011; 74 Rutter, Chattree, Barbour 2015; 64 Holt, Jayasekeran, Sonson 2013; 77 Baron, Wong Kee Song, Zielinski 2012; 76 Singh, Penfold, DeCoster 2009; 69 Moss, Bourke, Kwan 2010; 71 Raju (key-10.1136/gutjnl-2015-309848-3) 2011; 74 Swan (key-10.1136/gutjnl-2015-309848-4) 2011; 73 Holt (key-10.1136/gutjnl-2015-309848-16) 2013; 77 Holt (key-10.1136/gutjnl-2015-309848-2) 2012; 10 Singh (key-10.1136/gutjnl-2015-309848-9) 2009; 69 Swan (key-10.1136/gutjnl-2015-309848-1) 2009; 70 Bourke (key-10.1136/gutjnl-2015-309848-5) 2011; 13 Cotton (key-10.1136/gutjnl-2015-309848-8) 2010; 71 Heldwein (key-10.1136/gutjnl-2015-309848-10) 2005; 37 Moss (key-10.1136/gutjnl-2015-309848-6) 2010; 105 Rutter (key-10.1136/gutjnl-2015-309848-14) 2015; 64 Oka (key-10.1136/gutjnl-2015-309848-12) 2015; 110 Hassan (key-10.1136/gutjnl-2015-309848-13) 2016; 65 Baron (key-10.1136/gutjnl-2015-309848-17) 2012; 76 Masci (key-10.1136/gutjnl-2015-309848-11) 2013; 27 Paris Workshop Participants (key-10.1136/gutjnl-2015-309848-7) 2003; 58 Moss (key-10.1136/gutjnl-2015-309848-15) 2010; 71 |
| References_xml | – volume: 105 start-page: 2375 year: 2010 article-title: A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon publication-title: Am J Gastroenterol doi: 10.1038/ajg.2010.319 – volume: 27 start-page: 3799 year: 2013 article-title: Endoscopic mucosal resection in high- and low-volume centers: a prospective multicentric study publication-title: Surg Endosc doi: 10.1007/s00464-013-2977-5 – volume: 110 start-page: 697 year: 2015 article-title: Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan publication-title: Am J Gastroenterol doi: 10.1038/ajg.2015.96 – volume: 74 start-page: 1380 year: 2011 article-title: Endoscopic management of colonoscopic perforations (with videos) publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2011.08.007 – volume: 71 start-page: 446 year: 2010 article-title: A lexicon for endoscopic adverse events: report of an ASGE workshop publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2009.10.027 – volume: 10 start-page: 969 year: 2012 article-title: Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions publication-title: Clin Gastroenterol Hepatol doi: 10.1016/j.cgh.2012.05.020 – volume: 77 start-page: 949 year: 2013 article-title: Topical submucosal chromoendoscopy defines the level of resection in colonic EMR and May improve procedural safety (with video) publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2013.01.021 – volume: 37 start-page: 1116 year: 2005 article-title: The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies publication-title: Endoscopy doi: 10.1055/s-2005-870512 – volume: 73 start-page: 79 year: 2011 article-title: The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2010.07.003 – volume: 13 start-page: 35 year: 2011 article-title: Endoscopic mucosal resection in the colon: a practical guide publication-title: Tech Gastrointest Endosc doi: 10.1016/j.tgie.2011.01.002 – volume: 64 start-page: 1847 year: 2015 article-title: British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps publication-title: Gut doi: 10.1136/gutjnl-2015-309576 – volume: 58 start-page: S3 year: 2003 article-title: The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002 publication-title: Gastrointest Endosc doi: 10.1016/S0016-5107(03)02159-X – volume: 65 start-page: 806 year: 2016 article-title: Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis publication-title: Gut doi: 10.1136/gutjnl-2014-308481 – volume: 71 start-page: 589 year: 2010 article-title: Succinylated gelatin substantially increases en bloc resection size in colonic EMR: a randomized, blinded trial in a porcine model publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2009.10.033 – volume: 76 start-page: 838 year: 2012 article-title: A comprehensive approach to the management of acute endoscopic perforations (with videos) publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2012.04.476 – volume: 69 start-page: 665 year: 2009 article-title: Colonoscopy and its complications across a Canadian regional health authority publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2008.09.046 – volume: 70 start-page: 1128 year: 2009 article-title: Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos) publication-title: Gastrointest Endosc doi: 10.1016/j.gie.2009.05.039 – volume: 76 start-page: 838 year: 2012 ident: key-10.1136/gutjnl-2015-309848-17 article-title: A comprehensive approach to the management of acute endoscopic perforations (with videos) publication-title: Gastrointest Endosc – volume: 73 start-page: 79 year: 2011 ident: key-10.1136/gutjnl-2015-309848-4 article-title: The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection publication-title: Gastrointest Endosc – volume: 27 start-page: 3799 year: 2013 ident: key-10.1136/gutjnl-2015-309848-11 article-title: Endoscopic mucosal resection in high- and low-volume centers: a prospective multicentric study publication-title: Surg Endosc – volume: 71 start-page: 446 year: 2010 ident: key-10.1136/gutjnl-2015-309848-8 article-title: A lexicon for endoscopic adverse events: report of an ASGE workshop publication-title: Gastrointest Endosc – volume: 110 start-page: 697 year: 2015 ident: key-10.1136/gutjnl-2015-309848-12 article-title: Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan publication-title: Am J Gastroenterol – volume: 74 start-page: 1380 year: 2011 ident: key-10.1136/gutjnl-2015-309848-3 article-title: Endoscopic management of colonoscopic perforations (with videos) publication-title: Gastrointest Endosc – volume: 70 start-page: 1128 year: 2009 ident: key-10.1136/gutjnl-2015-309848-1 article-title: Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos) publication-title: Gastrointest Endosc – volume: 13 start-page: 35 year: 2011 ident: key-10.1136/gutjnl-2015-309848-5 article-title: Endoscopic mucosal resection in the colon: a practical guide publication-title: Tech Gastrointest Endosc – volume: 65 start-page: 806 year: 2016 ident: key-10.1136/gutjnl-2015-309848-13 article-title: Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis publication-title: Gut – volume: 64 start-page: 1847 year: 2015 ident: key-10.1136/gutjnl-2015-309848-14 article-title: British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps publication-title: Gut – volume: 71 start-page: 589 year: 2010 ident: key-10.1136/gutjnl-2015-309848-15 article-title: Succinylated gelatin substantially increases en bloc resection size in colonic EMR: a randomized, blinded trial in a porcine model publication-title: Gastrointest Endosc – volume: 10 start-page: 969 year: 2012 ident: key-10.1136/gutjnl-2015-309848-2 article-title: Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions publication-title: Clin Gastroenterol Hepatol – volume: 77 start-page: 949 year: 2013 ident: key-10.1136/gutjnl-2015-309848-16 article-title: Topical submucosal chromoendoscopy defines the level of resection in colonic EMR and May improve procedural safety (with video) publication-title: Gastrointest Endosc – volume: 58 start-page: S3 year: 2003 ident: key-10.1136/gutjnl-2015-309848-7 article-title: The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002 publication-title: Gastrointest Endosc – volume: 37 start-page: 1116 year: 2005 ident: key-10.1136/gutjnl-2015-309848-10 article-title: The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies publication-title: Endoscopy – volume: 105 start-page: 2375 year: 2010 ident: key-10.1136/gutjnl-2015-309848-6 article-title: A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon publication-title: Am J Gastroenterol – volume: 69 start-page: 665 year: 2009 ident: key-10.1136/gutjnl-2015-309848-9 article-title: Colonoscopy and its complications across a Canadian regional health authority publication-title: Gastrointest Endosc |
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| SubjectTerms | Adenoma - surgery Adolescent Adult Aged Aged, 80 and over Cancer Classification Colon Colon - diagnostic imaging Colon - injuries Colonic Neoplasms - surgery Colonic Polyps - surgery Colonoscopy Colorectal cancer Complications Contamination Defects Dysplasia Endoscopic Mucosal Resection - adverse effects Endoscopy Female Fibrosis Humans Injuries Intestinal Mucosa - diagnostic imaging Intestinal Mucosa - injuries Intestinal Perforation - classification Intestinal Perforation - diagnostic imaging Intestinal Perforation - etiology Intestinal Perforation - therapy Intraoperative Complications - classification Intraoperative Complications - diagnostic imaging Intraoperative Complications - etiology Intraoperative Complications - therapy Invasiveness Male Middle Aged Mucosa Patients Postoperative Complications - classification Postoperative Complications - diagnostic imaging Postoperative Complications - etiology Retrospective Studies Risk Factors Wounds and Injuries - classification Wounds and Injuries - diagnostic imaging Wounds and Injuries - etiology Wounds and Injuries - therapy Young Adult |
| Title | Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors |
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