{"id":7346,"date":"2020-02-24T14:21:50","date_gmt":"2020-02-24T13:21:50","guid":{"rendered":"https:\/\/www.endoscopy-campus.com\/?post_type=klassifikationen&p=7346"},"modified":"2025-09-23T14:39:40","modified_gmt":"2025-09-23T12:39:40","slug":"sydney-classification-assessment-of-deep-mural-injury-after-endoscopic-mucosal-resection","status":"publish","type":"klassifikationen","link":"https:\/\/www.endoscopy-campus.com\/en\/classifications\/sydney-classification-assessment-of-deep-mural-injury-after-endoscopic-mucosal-resection\/","title":{"rendered":"Sydney classification- assessment of deep mural injury after endoscopic mucosal resection."},"content":{"rendered":"\n

Classification\npresented by Burgess NG et al. [1] based on retrospective evaluation, clinical\nobservations and image analysis.<\/p>\n\n\n\n

It allows for\nthe assessment of deep mural injury (DMI) after endoscopic mucosal resection\n(EMR) of laterally spreading colorectal lesions with the diameter > 20mm. The\nmost important is accurate, endoscopic post-resection assessment using advanced\nimaging techniques, which determines further proceeding.<\/p>\n\n\n\n

During EMR\nprocedure, extremely important is to properly elevate and stain the lesion\nappropriate solutions with dyes. Injection separates the lesion from muscular\nlayer, reducing thermal injury, risk of perforation and bleeding. Additionally,\nfacilitates en-bloc resection in the technical aspect [2]. <\/p>\n\n\n\n

In turn,\naddition of staining agents to the injection solution, allows identifying the\narea of \u200b\u200bsubmucosal injection and distinguishing between the muscle layer and\nthe submucosa. Morover, identification of the lateral and deep margins of the\ntarget lesion is more detailed during te whole procedure (before and after\nresection). Also, the staining dye may facilitate evaluation of residual lesion\nat the end of endoscopic resection and improve recognition of muscularis\npropria injury as an intraprocedural perforation [2].<\/p>\n\n\n\n

Therefore,\nthe authors used: 1 ml of 0.4% indigo carmine or methylene blue and 1 ml of 1:\n10,000 adrenaline in combination with 8 ml of saline solution [1]. <\/p>\n\n\n\n

In this\nclassification a proper injection is important because it allows for an\naccurate assessment of colon wall layers and further proceeding (clip vs. not\nclip vs. consult with the surgeon).<\/p>\n\n\n\n

The\nclassification is V gradual<\/strong> and concerns the correct view in the site\nafter EMR where mucosa was removed correctly, up to clean \/ contaminated\nperforation [1].<\/p>\n\n\n\n

The\nterms included in the classification:<\/p>\n\n\n\n

Target\nsign<\/strong>\n– a symptom of endoscopic resection of muscularis propria and sites of\npotential perforation (circularly arranged white fibers with a dark spot in the\ncenter).<\/p>\n\n\n\n

Specimen\nsign<\/strong>\n– seen in the removed lesion, in the place of the cut seen from the bottom.<\/p>\n\n\n\n

Whale sign<\/strong> – a circular wrap of white fibers of muscularis propria without injury (compared to the abdomen of a part of the blue whale)<\/p>\n\n\n

\n
\"\"
Sydney classification adapted from Ref 1.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n
<\/div>\n\n\n\n

Type 0<\/strong><\/h3>\n\n\n\n

-mucosal\ndefect after correct resection, blue mat color with visible oblique\nintersecting fibers of the submucosa<\/p>\n\n\n\n

– submucosal vessels may be visible, but they are not damaged<\/p>\n\n\n\n

\n
\n
\"\"<\/figure>\n<\/div>\n\n\n\n
\n
\"\"<\/figure>\n\n\n\n

<\/p>\n<\/div>\n<\/div>\n\n\n\n

<\/div>\n\n\n\n

Type I<\/strong><\/h3>\n\n\n\n

– removed\nsubmucosal layer<\/p>\n\n\n\n

– white, circular muscularis propria fibers visible without damage – whale sign<\/strong><\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n
<\/div>\n\n\n\n

Type II<\/strong><\/h3>\n\n\n\n

– no\ndistinction between the submucosa and muscularis propria, focal loss of the\nsubmucosal plane rising concer for mucularis propria injury<\/p>\n\n\n\n

-damage of muscularis propria difficult to visualize<\/p>\n\n\n\n

\n
\n
\"\"<\/figure>\n<\/div>\n\n\n\n
<\/div>\n<\/div>\n\n\n\n
<\/div>\n\n\n\n

Type III<\/strong><\/h3>\n\n\n\n

-damage of muscularis propria (1) visible as a target sign <\/strong>(2) in the resection site or specimen sign<\/strong> (3) visible in the removed lesion, “from the bottom” at the cut site<\/p>\n\n\n\n

\n
\n
\"\"<\/figure>\n<\/div>\n\n\n\n
\n
\"\"<\/figure>\n<\/div>\n<\/div>\n\n\n\n
\n
\n
\"\"<\/figure>\n<\/div>\n\n\n\n
<\/div>\n<\/div>\n\n\n\n
<\/div>\n\n\n\n

Type IV<\/strong><\/h3>\n\n\n\n

-clearly\nvisible perforation (whole with a white cautery ring) without stool residue\ncontamination<\/p>\n\n\n\n

– perforation\nshould be closed immediately, however, if possible, complete resection before\nplacing the clip<\/p>\n\n\n\n

– if the\nlesion is not completely removed before clipping, further resection attempts\nmay be hindered by submucosal fibrosis due to the clip<\/p>\n\n\n\n

\n
\n
\"\"<\/figure>\n<\/div>\n\n\n\n
<\/div>\n<\/div>\n\n\n\n
<\/div>\n\n\n\n

Type V<\/strong><\/h3>\n\n\n\n

-perforation\ncontaminated with stools<\/p>\n\n\n\n

– hole should\nbe closed and surgically consulted<\/p>\n\n\n\n

– surgical intervention is required adequate to the clinical condition, in case of peritonitis, peritoneal fluid, or unsuccessful endoscopic resection<\/p>\n\n\n\n

\n
\n
\"\"<\/figure>\n<\/div>\n\n\n\n
<\/div>\n<\/div>\n\n\n\n
<\/div>\n\n\n\n

Conclusions\nfrom the study [1]:<\/strong><\/h3>\n\n\n\n
    \n
  • Potential DMI (type
    I and II) is associated with increasing lesion size, SMF and transverse colon
    location. <\/li>\n\n\n\n
  • DMI type III\u2013V:
    (target signs and perforations) are associated with en bloc resection,
    transverse colon location and HGD or SMIC. <\/li>\n\n\n\n
  • Type I injuries do
    not require clip placement<\/li>\n\n\n\n
  • DMI type III\u2013V
    require closure of the injured MP<\/li>\n\n\n\n
  • All type II
    injuries should also ideally be clipped<\/li>\n\n\n\n
  • \u00a0The majority of patients with target signs
    (type III DMI) can be managed with same day discharge if they are well and the
    injury is securely closed.<\/li>\n\n\n\n
  • \u00a0Intraprocedural
    perforation occurs in 0.5% and clinically significant perforation occurs in
    0.2%.<\/li>\n\n\n\n
  • Potentially serious DMI syndromes are not infrequent,
    but if recognised they may be managed safely and effectivelywithout
    serious clinical sequelae, in many cases on an outpatient basis.<\/li>\n\n\n\n
  • type III – V<\/strong> DMI (target sign
    or perforation) occurs in 3.0% and mainly affects lesions located in the transverse
    colon, en bloc resection, HGD and invasive cancer,<\/li>\n\n\n\n
  • lesions \u226525 mm<\/strong> removed entirely
    are particularly associated with a high DMI risk, therefore risk<\/li>\n\n\n\n
  • and the advantages
    of en bloc resection before EMR should be assessed.<\/li>\n<\/ul>\n\n\n\n

    Figures adapted from Ref. 1.<\/p>\n\n\n\n

    References<\/strong><\/h2>\n\n\n\n
      \n
    1. Burgess NG, et al. Deep mural
      injury and perforation after colonic endoscopic mucosal resection: a new
      classification and analysis of risk factors. Gut 2016; 0:1\u201311. <\/li>\n\n\n\n
    2. Castro R, Lib\u00e2nio D, Pita I, Dinis-Ribeiro M.
      Solutions for submucosal injection: What to choose and how to do it.\u00a0World J Gastroenterol.
      2019; 25: 777\u2013788.<\/li>\n<\/ol>\n\n\n\n

      Author: Pawlak K. (1)
      Hospital of the Ministry of Interior and Administration, Department of Internal Medicine,
      Cardiology, Gastroenterology and Endocrinology, Szczecin, Poland <\/p>\n","protected":false},"excerpt":{"rendered":"

      Classification presented by Burgess NG et al. based on retrospective evaluation, clinical observations and image analysis. It allows for the assessment of deep mural injury (DMI) after endoscopic mucosal resection (EMR) of laterally spreading colorectal lesions with the diameter > 20mm.<\/p>\n","protected":false},"featured_media":7357,"template":"","categories":[94,78],"tags":[1905,1904,268,1437,1907,1908,1906],"ec-magazin-ausgaben":[],"sponsoren-erwaehnung":[],"autor":[],"class_list":["post-7346","klassifikationen","type-klassifikationen","status-publish","has-post-thumbnail","hentry","category-classifications","category-lower-gi-tract","tag-deep-mural-injury","tag-dmi","tag-emr","tag-mucosal-resection","tag-specimen-sign","tag-target-sign","tag-whale-sign"],"_links":{"self":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/klassifikationen\/7346","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/klassifikationen"}],"about":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/types\/klassifikationen"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/media\/7357"}],"wp:attachment":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/media?parent=7346"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/categories?post=7346"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/tags?post=7346"},{"taxonomy":"ec-magazin-ausgaben","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/ec-magazin-ausgaben?post=7346"},{"taxonomy":"sponsoren-erwaehnung","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/sponsoren-erwaehnung?post=7346"},{"taxonomy":"autor","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/autor?post=7346"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}