Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (2024)

Katarzyna Pawlak, Hospital of the Ministry of Interior and Administration, Department of Internal Medicine, Cardiology, Gastroenterology and Endocrinology, Szczecin, Poland

Hospital of the Ministry of Interior and Administration, Department of Internal Medicine, Cardiology, Gastroenterology and Endocrinology, Szczecin, Poland

Classificationpresented by Burgess NG et al. [1] based on retrospective evaluation, clinicalobservations and image analysis.

It allows forthe assessment of deep mural injury (DMI) after endoscopic mucosal resection(EMR) of laterally spreading colorectal lesions with the diameter > 20mm. Themost important is accurate, endoscopic post-resection assessment using advancedimaging techniques, which determines further proceeding.

During EMRprocedure, extremely important is to properly elevate and stain the lesionappropriate solutions with dyes. Injection separates the lesion from muscularlayer, reducing thermal injury, risk of perforation and bleeding. Additionally,facilitates en-bloc resection in the technical aspect [2].

In turn,addition of staining agents to the injection solution, allows identifying thearea of ​​submucosal injection and distinguishing between the muscle layer andthe submucosa. Morover, identification of the lateral and deep margins of thetarget lesion is more detailed during te whole procedure (before and afterresection). Also, the staining dye may facilitate evaluation of residual lesionat the end of endoscopic resection and improve recognition of muscularispropria injury as an intraprocedural perforation [2].

Therefore,the authors used: 1 ml of 0.4% indigo carmine or methylene blue and 1 ml of 1:10,000 adrenaline in combination with 8 ml of saline solution [1].

In thisclassification a proper injection is important because it allows for anaccurate assessment of colon wall layers and further proceeding (clip vs. notclip vs. consult with the surgeon).

Theclassification is V gradual and concerns the correct view in the siteafter EMR where mucosa was removed correctly, up to clean / contaminatedperforation [1].

Theterms included in the classification:

Targetsign– a symptom of endoscopic resection of muscularis propria and sites ofpotential perforation (circularly arranged white fibers with a dark spot in thecenter).

Specimensign– seen in the removed lesion, in the place of the cut seen from the bottom.

Whale sign – a circular wrap of white fibers of muscularis propria without injury (compared to the abdomen of a part of the blue whale)

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (1)

Type 0

-mucosaldefect after correct resection, blue mat color with visible obliqueintersecting fibers of the submucosa

– submucosal vessels may be visible, but they are not damaged

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (2)
Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (3)

Type I

– removedsubmucosal layer

– white, circular muscularis propria fibers visible without damage – whale sign

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (4)

Type II

– nodistinction between the submucosa and muscularis propria, focal loss of thesubmucosal plane rising concer for mucularis propria injury

-damage of muscularis propria difficult to visualize

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (5)

Type III

-damage of muscularis propria (1) visible as a target sign (2) in the resection site or specimen sign (3) visible in the removed lesion, „from the bottom“ at the cut site

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (6)
Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (7)
Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (8)

Type IV

-clearlyvisible perforation (whole with a white cautery ring) without stool residuecontamination

– perforationshould be closed immediately, however, if possible, complete resection beforeplacing the clip

– if thelesion is not completely removed before clipping, further resection attemptsmay be hindered by submucosal fibrosis due to the clip

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (9)

Type V

-perforationcontaminated with stools

– hole shouldbe closed and surgically consulted

– surgical intervention is required adequate to the clinical condition, in case of peritonitis, peritoneal fluid, or unsuccessful endoscopic resection

Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (10)

Conclusionsfrom the study [1]:

  • Potential DMI (typeI and II) is associated with increasing lesion size, SMF and transverse colonlocation.
  • DMI type III–V:(target signs and perforations) are associated with en bloc resection,transverse colon location and HGD or SMIC.
  • Type I injuries donot require clip placement
  • DMI type III–Vrequire closure of the injured MP
  • All type IIinjuries should also ideally be clipped
  • The majority of patients with target signs(type III DMI) can be managed with same day discharge if they are well and theinjury is securely closed.
  • Intraproceduralperforation occurs in 0.5% and clinically significant perforation occurs in0.2%.
  • Potentially serious DMI syndromes are not infrequent,but if recognised they may be managed safely and effectivelywithoutserious clinical sequelae, in many cases on an outpatient basis.
  • type III – V DMI (target signor perforation) occurs in 3.0% and mainly affects lesions located in the transversecolon, en bloc resection, HGD and invasive cancer,
  • lesions ≥25 mm removed entirelyare particularly associated with a high DMI risk, therefore risk
  • and the advantagesof en bloc resection before EMR should be assessed.

Figures adapted from Ref. 1.

References

  1. Burgess NG, et al. Deep muralinjury and perforation after colonic endoscopic mucosal resection: a newclassification and analysis of risk factors. Gut 2016; 0:1–11.
  2. Castro R, Libânio D, Pita I, Dinis-Ribeiro M.Solutions for submucosal injection: What to choose and how to do it.World J Gastroenterol.2019; 25: 777–788.

Author: Pawlak K. (1)
Hospital of the Ministry of Interior and Administration, Department of Internal Medicine,
Cardiology, Gastroenterology and Endocrinology, Szczecin, Poland

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Sydney classification- assessment of deep mural injury after endoscopic mucosal resection. - Endoscopy Campus (2024)
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