Cap-assisted endoscopic mucosal resection for colorectal polyps

Cap-assisted endoscopic mucosal resection as a salvage technique for challenging colorectal laterally spreading tumors

BACKGROUND

Cap-assisted endoscopic mucosal resection (EMR-c) has emerged as a potential alternative to standard piecemeal wide-field EMR (WF-EMR) for the resection of laterally spreading tumors (LSTs). However, clear indications for this technique are still lacking. Our objective was to investigate the performance of salvage EMR-c after WF-EMR failure in the resection of large colorectal LSTs.

METHODS

The data of consecutive patients undergoing WF-EMR for large colorectal LSTs (2015-2021) were analyzed in this single-center, retrospective, observational study. In the event of a WF-EMR failure, the procedure was switched to EMR-c in the same session. The efficacy of the two techniques was evaluated in terms of complete endoscopic resection, R0 resection, and recurrence rate. Safety was also assessed.

RESULTS

Overall, the data from 81 WF-EMRs were collected. Eighteen cases of WF-EMR failure were switched to EMR-c in the same session and complete endoscopic resection was achieved in 17/18 patients (94.4%). No statistically significant difference was observed between WF-EMR and salvage EMR-c in terms of macroscopic radicality (P = 0.40) and R0 resection (P = 0.12). However, recurrence was more common with EMR-c (44.4% vs. 23.5%; P = 0.05), as were adverse events, particularly intraprocedural bleeding (27.8% vs. 7.9%; P = 0.04).

CONCLUSION

EMR-c is an effective salvage technique for challenging colorectal LSTs following WF-EMR failure. Due to the elevated risk of adverse events associated with this procedure, careful patient selection, endoscopic expertise, and close follow-up are strongly recommended.

Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos)

BACKGROUND AND AIMS

Piecemeal EMR of colorectal laterally spreading tumors (LSTs) >20 mm is effective. Experience is limited in the use of cap-assisted EMR (EMR-C) for resection of colonic lesions. We compared the efficacy and the safety of EMR-C for the removal of colonic LSTs ≥30 mm with "inject-and-cut" standard EMR (EMR-S).

METHODS

In this randomized trial from 4 Italian centers, 138 patients were treated with EMR-C and 102 with EMR-S. The rates of residual lesions, percentage of recurrence after 12 months, and adverse events were evaluated.

RESULTS

One hundred forty-three lesions were resected with EMR-C and 102 with EMR-S. Argon plasma coagulation (APC) was used as adjunctive treatment in 2.9% of EMR-Cs and in 22.5% of EMR-Ss (P < .001). The median time required was 20 minutes for EMR-C and 30 minutes for EMR-S (P < .001). Adverse events (AEs) occurred in 14 EMR-Cs (10.1%; 2 perforations, 11 bleeding events, and 1 stenosis) and in 22 EMR-Ss (21.6%; 1 perforation and 21 bleeding events) (P = .017). Intraprocedural AEs occurred in 3.6% of EMR-Cs and 16.7% of EMR-Ss (P = .001). Overall, residual lesions within 12 months were found to be significantly higher with EMR-S (32 patients, 31.4%) than with EMR-C (8 patients, 5.8%) (P < .001). Recurrence at follow-up colonoscopy in 12 months occurred in 7 EMR-Cs (5.1%) and 17 EMR-Ss (16.7%; P < .001).

CONCLUSIONS

The study demonstrated the feasibility and safety of EMR-C for removing large colorectal LSTs, with higher eradication rates, shorter resection time, and less use of APC when compared with EMR-S. (Clinical trial registration number: NCT03498664.).

Risk and Time Pattern of Recurrences After Local Endoscopic Resection of T1 Colorectal Cancer: A Meta-analysis

BACKGROUND & AIMS

Growing numbers of patients with T1 CRC are being treated with local endoscopic resection only and as a result, the need for optimization of surveillance strategies for these patients also increases. We aimed to estimate the cumulative incidence and time pattern of CRC recurrences for endoscopically treated patients with T1 CRC.

METHODS

Using a systematic literature search in PubMed, EMBASE, Web of Science and Cochrane Library (from inception till 15 May 2020), we identified and extracted data from studies describing the cumulative incidence of local or distant CRC recurrence for patients with T1 CRC treated with local endoscopic resection only. Pooled estimates were calculated using mixed-effect logistic regression models.

RESULTS

Seventy-one studies with 5167 unique, endoscopically treated patients with T1 CRC were included. The pooled cumulative incidence of any CRC recurrence was 3.3% (209 events; 95% CI, 2.6%-4.3%; I² = 54.9%), with local and distant recurrences being found at comparable rates (pooled incidences 1.9% and 1.6%, respectively). CRC-related mortality was observed in 42 out of 2519 patients (35 studies; pooled incidence 1.7%, 95% CI, 1.2%-2.2%; I² = 0%), and the CRC-related mortality rate among patients with recurrence was 40.8% (42/103 patients). The vast majority of recurrences (95.6%) occurred within 72 months of follow-up. Pooled incidences of any CRC recurrence were 7.0% for high-risk T1 CRCs (28 studies; 95% CI, 4.9%-9.9%; I² = 48.1%) and 0.7% (36 studies; 95% CI, 0.4%-1.2%; I² = 0%) for low-risk T1 CRCs.

CONCLUSIONS

Our meta-analysis provides quantitative outcome measures which are relevant to guidelines on surveillance after local endoscopic resection of T1 CRC.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions

Endoscopic mucosal resection (EMR) is a technique allowing efficacious and minimally invasive resection of precancerous lesions across the entire gastrointestinal tract. However, conventional EMR, involving injection of fluid into the submucosal space, is imperfect, given the high rate of recurrence of post-endoscopic resection adenoma, especially after piecemeal resection. In light of these observations, modifications of the technique have been proposed to overcome the weakness of conventional EMR. Some of them were designed to maximize the chance of en bloc resection—cap-assisted EMR, underwater EMR, tip-in EMR, precutting, assisted by ligation device—while others were designed to minimize the complications (cold EMR). In this review, we present their modes of action and summarize the evidence regarding their efficacy and safety.

Superficial neoplasia involving the Ileocecal valve: Clinical outcomes of endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) is the treatment of choice for colorectal superficial neoplasia, but certain anatomical locations are challenging even for skilled endoscopists. Ileocecal valve (ICV) is considered a technically challenging site for ESD.

OBJECTIVE

Aim of this study was to analyze efficacy and safety of Endoscopic Submucosal Dissection in the treatment of colorectal neoplasia involving the ileocecal valve (ICV) DESIGN: Retrospective study.

PATIENTS

We retrospectively evaluated 1507 consecutive patients undergoing ESD at two tertiary referral centres for ESD (Italy and Japan) from January 2008 to March 2020.

MAIN OUTCOME MEASURES

Demographic, clinical, procedural, and follow-up data was collected, analysed, and compared between patients with ileocecal valve lesions (ICVL) and patients with non-ICVL.

RESULTS

Overall, 1507 patients were enrolled (872 M, 57.8%), of these 53 patients had lesions involving the ICV. Mean age was 70.2 years (range, 53-83 years). En-bloc resection was achieved in 52 (98%) patients. The median specimen size of ICVL was 36.4 mm (range, 8-80 mm), significantly smaller than non-ICVL (p = 0.005). Procedure time was significantly longer in the ICVL group, (71.3 vs. 58.9 min; p = 0.03). Non Granular Type Laterally Spreading Tumors (LST-NG) were significantly more frequent in the ICVL group compared to rectum (52.8% vs. 25.7; p = 0.0001). En-bloc resection rate in the ileocecal region did not differ significantly between groups (p = 0.20). Complications such as perforation and postoperative occurred respectively in 3/53 (5.7%) and 1/53 (2%) patient, and were treated conservatively. At first surveillance colonoscopy performed at 6 months, recurrent adenoma was detected in 2/53 patients (3.9%).

CONCLUSIONS

ESD is safe and effective for the treatment of colorectal neoplasia involving the ileocecal valve if performed by expert endoscopist in referral centres.

Endoscopic techniques to reduce recurrence rates after colorectal EMR: systematic review and meta-analysis

Background

Colorectal endoscopic mucosal resection (EMR) is an effective, safe, and minimally invasive treatment for large lateral spreading and sessile polyps. The reported high recurrence rate of approximately 20% is however one of the major drawbacks. Several endoscopic interventions have been suggested to reduce recurrence rates. We conducted a systematic review and meta-analysis to assess the efficacy of endoscopic interventions targeting the EMR margin to reduce recurrence rates.

Methods

We searched in PubMed and Ovid for studies comparing recurrence rates after interventions targeting the EMR margin with standard EMR. The primary outcome was the recurrence rate at the first surveillance colonoscopy (SC1) assessed histologically or macroscopically. For the meta-analysis, risk ratios (RRs) were calculated and pooled using a random effects model. The secondary outcome was post-procedural complication rates.

Results

Six studies with a total of 1335 lesions were included in the meta-analysis. The techniques performed in the intervention group targeting the resection margin were argon plasma coagulation, snare tip soft coagulation, extended EMR, and precutting EMR. The interventions reduced the adenoma recurrence rate with more than 50%, resulting in a pooled RR of 0.37 (95% CI 0.18, 0.76) comparing the intervention group with the control groups. Overall post-procedural complication rates did not increase significantly in the intervention arm (RR 1.30; 95% CI 0.65, 2.58).

Conclusion

Interventions targeting the EMR margin decrease recurrence rates and may not result in more complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08574-z.

Efficacy and safety of cap-assisted endoscopic mucosal resection of ileocecal valve polyps

Background and study aims  Standard endoscopic mucosal resection (EMR) of ileocecal valve (ICV) polyps is challenging. Cap-assisted endoscopic mucosal resection (C-EMR) can be performed when polyps are not easily amenable to standard EMR. Current literature is limited regarding its efficacy and safety for ICV polyps. The objectives of this study were to assess the efficacy and safety of C-EMR for ICV polyps. Patients and methods  A retrospective review was conducted from September 2008 to November 2018 at a tertiary care center. Patients included in the study underwent C-EMR for ICV polyps by a single gastroenterologist (LHJ). Polyps were successfully eradicated if they were removed en-bloc as confirmed by pathology, or had a negative biopsy on follow-up colonoscopy. Outcomes of the procedures were evaluated, including complete adenoma clearance and adverse events. Results  Twenty-one ICV polyps were removed with C-EMR. Median polyp size was 15 mm (range, 5-45). The rate of complete adenoma clearance was 100 %. Procedure-related complications occurred in five patients (24 %): delayed GI bleeding (4.8 %) and deep mucosal resection/visible vessel (14.3 %). Three patients had subsequent surveillance colonoscopies at 8, 56, and 67 months, respectively. The third patient was found to have a 6-mm flat polyp at the edge of the previous polypectomy site. This was treated with C-EMR and repeat colonoscopy 6 months later did not show residual. Conclusion  C-EMR is highly effective in treating ICV polyps with a low complication rate. It is our suggested method in approaching ICV polyps that are difficult to remove via standard freehand snare EMR technique.

Chromoendoscopy Plus Mucosal Resection Versus Conventional Electrocoagulation for Intestinal Polyps in Children: Two Case Series

BACKGROUND

Conventional high-frequency electrocoagulation (HFEC) of intestinal polyps may be difficult in children and endoscopic mucosal resection (EMR) could be a less invasive option. Chromoendoscopy improves tissue localization during endoscopy, but its exact influence on the outcomes of children with intestinal lesions is still unknown.

AIMS

To analyze a series of children treated with EMR or HFEC and assess the value of chromoendoscopy.

METHODS

This was a retrospective analysis of two case series of patients treated at the Gastroenterology Department of the Guiyang Children's Hospital between February 2014 and November 2016. The children underwent EMR (n = 34) or conventional HFEC (n = 120). Demographic, clinical, and perioperative data were analyzed.

RESULTS

The polyps were larger in the HFEC group [median, 3.9 (0.1-27.0) versus 1.3 (0.03-64.0) mm, P = .03]. There was a higher frequency of multiple polyps in the EMR group (50.0% versus 15.1%, P < .001). Operation time and intraoperative bleeding were similar between the two groups (both P > .05). Hospital stay was longer with EMR than with HFEC [median, 5 (3-12) versus 4 (2-14) days, P = .02]. There was no intestinal perforation in either group. Postoperative bleeding amount was similar in both groups (P = .73). In the EMR group, 19 patients were operated using chromoendoscopy, whereas only 2 patients in the HFEC group were operated.

CONCLUSION

EMR could be appropriate for the treatment of intestinal polyps in children.

Combining eastern and western practices for safe and effective endoscopic resection of large complex colorectal lesions

BACKGROUND

Endoscopic resection of large colorectal polyps is well established. However, significant differences in technique exist between eastern and western interventional endoscopists. We report the results of endoscopic resection of large complex colorectal lesions from a specialist unit that combines eastern and western techniques for assessment and resection.

PATIENTS AND METHODS

Endoscopic resections of colorectal lesions of at least 2 cm were included. Lesions were assessed using magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion-specific approach to resection with endoscopic mucosal resection or endoscopic submucosal dissection (ESD) was used. Surveillance endoscopy was performed at 3 (SC1) and 12 (SC2) months.

RESULTS

Four hundred and sixty-six large (≥20 mm) colorectal lesions (mean size 54.8 mm) were resected. Three hundread and fifty-six were resected using endoscopic mucosal resection and 110 by ESD or hybrid ESD. Fifty-one percent of lesions had been subjected to previous failed attempts at resection or heavy manipulation (≥6 biopsies). Nevertheless, endoscopic resection was deemed successful after an initial attempt in 98%. Recurrence occurred in 15% and could be treated with endoscopic resection in most. Only two patients required surgery for perforation. Nine patients had postprocedure bleeding; only two required endoscopic clips. Ninety-six percent of patients without invasive cancer were free from recurrence and had avoided surgery at last follow-up.

CONCLUSION

Combining eastern and western practices for assessment and resection results in safe and effective organ-conserving treatment of complex colorectal lesions. Accurate assessment before and after resection using magnification chromoendoscopy and a lesion-specific approach to resection, incorporating ESD where appropriate, are important factors in achieving these results.

Colorectal endoscopic mucosal resection (EMR)

Colonoscopy has the benefit of detecting and treating precancerous adenomatous polyps and thus reduces mortality associated with CRC. Screening colonoscopy is the keystone for prevention of colorectal cancer. Over the last 20 years there has been increased in the management of large colorectal polyps from surgery to endoscopic removal techniques which is less invasive. Traditionally surgical resection was the treatment of choice for many years for larger polyps but colectomy poses significant morbidity of 14-46% and mortality of up to 7%. There are several advantages of endoscopic resection technique over surgery; it is less invasive, less expensive, has rapid recovery, and preserves the normal gut functions. In addition patient satisfaction and efficacy of EMR is higher with minor complications. Thus, this has facilitated the development of advanced resection technique for the treatment of large colorectal polyps called as endoscopic mucosal resection (EMR).

Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions

A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.

Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection

Endoscopic mucosal resection (EMR) has been used in western countries to remove colonic polyps for at least the last two decades. Significant experience has been accumulated and the efficacy of the method has recently been evaluated in a large meta-analysis. A number of variations to modify the technique, including knife-assisted, cap-assisted, ligation devices, and underwater EMR, have been developed in an attempt to improve outcomes. However, to date there are only limited data comparing these techniques or demonstrating the superiority of any one of them. This article reviews the current evidence on the efficacy of each of these modified techniques.

Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review

AIM

To assess the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for the treatment of colorectal lesions.

METHODS

A literature search was conducted from January 2000 to May 2015. The main outcomes were: recurrence after "en bloc" and "piecemeal" resection; procedure related adverse events; the EMR endoscopic success rate and the completely eradicated resection rate (R0) after ESD.

RESULTS

A total of 66 studies were included in the analysis. The total number of lesions was 17950 (EMR: 11.873; ESD: 6077). Recurrence rate was higher in the EMR than ESD group (765/7303l vs. 50/3910 OR 8.19, 95% CI 6.2-10.9 p<0.0001). EMR-en bloc resection was achieved in 6793/10803 lesions (62.8%) while ESD-en bloc resection was obtained in 5500/6077 lesions (90.5%) (OR 0.18, p<0.0001, 95% CI 0.16-0.2). Perforation occurred more frequently in ESD than in EMR group (p<0.0001, OR 0.19, 95% CI 0.15-0.24).

CONCLUSIONS

Endoscopic resection of large colorectal lesions is safe and effective. Compared with EMR, ESD results in higher "en bloc" resection rate and lower local recurrence rate, however ESD has high procedure-related complication rates.

Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis

BACKGROUND AND AIMS

Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP.

METHODS

A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges.

RESULTS

LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000.

CONCLUSIONS

Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.

Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of endoscopic resection of large colorectal polyps.

DESIGN

Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed.

RESULTS

50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%).

CONCLUSIONS

Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.

Cap-assisted Endoscopic Mucosal Resection is Highly Effective for Nonpedunculated Colorectal Lesions

GOALS

To assess the safety and efficacy of cap-assisted endoscopic mucosal resection (C-EMR) for nonpedunculated colorectal lesions.

BACKGROUND

There are little data supporting the safety and efficacy of C-EMR for colorectal polyps.

STUDY

A retrospective review was conducted on the medical records of 97 consecutive patients who underwent C-EMR for nonpedunculated colorectal lesions in a tertiary center by a single gastroenterologist (L.H.J.). Reported outcomes were: overall eradication rate that included all attempted C-EMRs, endoscopist-reported eradication rate that included C-EMRs reported as a success, and complications rate.

RESULTS

A total of 134 C-EMRs were performed on 124 nonpedunculated colorectal lesions within a 55-month period, with a median follow-up of 4.2 (1.6 to 46.8) months. Among the polyps with available follow-up, the overall eradication rate was 91% (81/89); the endoscopist-reported eradication rate was 98.8% (81/82). The complications rate was 10.2%: perforation (3.9%), intraprocedural bleeding (3.9%), and delayed bleeding (2.4%); all but 2 perforation cases that required surgical interventions (both occurring early in the time period in which procedures were performed), were treated endoscopically or conservatively with complete recovery.

CONCLUSIONS

C-EMR is highly effective in treating nonpedunculated colorectal lesions, which can be learned and practiced in the appropriate setting. Decline in the complications rate was observed as the endoscopist gained experience. Although perforation remains a relatively high risk, this may be decreased by increasing the fluid cushion, and decreasing suction pressure. Immediate recognition and endoscopic management of perforation can be highly successful. C-EMR is our suggested method in approaching nonpedunculated colon polyps, especially flat polyps that are not easily accessible by other endoscopic techniques.

Improved Techniques for Endoscopic Mucosal Resection (EMR) in Colorectal Adenoma

Background

Endoscopic therapy of colorectal adenomas and early cancers is a standard method. Besides oncological criteria, the method is limited by polyp location, size, and texture.

Method

Based on the current literature, technical modifications and developments in endoscopic mucosal resection are described.

Results

Numerous approaches exist to improve the conditions of resection, including optimisation of mucosal elevation and modification of techniques, tools, and devices.

Conclusion

Endoscopic therapy of sessile and flat colorectal polyps remains a challenge. Some of the presented modifications can help to address this challenge.

Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions

BACKGROUND & AIMS

Wide-field endoscopic mucosal resection (WF-EMR) of large sessile colonic polyps is a safe and cost-effective outpatient treatment. Bleeding is the main complication. Few studies have examined risk factors for bleeding during the procedure (intraprocedural bleeding [IPB]) or after it (clinically significant post-endoscopic bleeding [CSPEB]). We investigated factors associated with IPB and CSPEB in a large prospective study.

METHODS

We analyzed data from WF-EMRs of sessile colorectal polyps ≥ 20 mm in size (mean size, 35.5 mm), which were performed on 1172 patients (mean age, 67.8 years) from June 2008-March 2013 at 7 tertiary hospitals as part of the Australian Colonic Endoscopic Resection Study. Data were collected on characteristics of patients and lesions, along with outcomes of procedures and clinical and histologic analyses. Independent predictors of IPB and CSPEB were identified by multiple logistic regression analysis.

RESULTS

Of the patients studied, 133 (11.3%) had IPB. Independent predictors included increasing lesion size (odds ratio, 1.24/10 mm; P < .001), Paris endoscopic classification of 0-IIa + Is (odds ratio, 2.12; P = .004), tubulovillous or villous histology (odds ratio, 1.84; P = .007), and study institutions that performed the procedure on fewer than 75 patients (odds ratio, 3.78; P < .001). All IPB was successfully controlled endoscopically. IPB prolonged procedures and was associated with early recurrence (relative risk, 1.68; P = .011). Seventy-three patients (6.2%) had CSPEB. On multivariable analysis, CSPEB was associated with proximal colon location (odds ratio, 3.72; P < .001), use of an electrosurgical current not controlled by a microprocessor (odds ratio, 2.03; P = .038), and IPB (odds ratio, 2.16; P = .016). Lesion size and comorbidities did not predict CSPEB.

CONCLUSIONS

In a prospective study of patients undergoing WF-EMR of large sessile colonic polyps, IPB is associated with larger lesions, lesion histology, and Paris endoscopic classification of type 0-IIa + Is. IPB prolongs the duration of the procedure, is a marker for recurrence, and is associated with CSPEB. CSPEB occurs most frequently in the proximal colon and less when current is controlled by a microprocessor.

Endoscopic resection for superficial colorectal neoplasia in Italy: a prospective multicentre study

BACKGROUND

Since there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.

METHODS

Prospective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥10mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.

RESULTS

Overall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. En bloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16-4.26]; p=0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56-4.87]; p=0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions<20mm, follow-up limited to 1 year.

CONCLUSION

In this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.

Advanced imaging in colonoscopy and its impact on quality

Detecting and resecting colonic polyps during endoscopy has been shown to reduce CRC. At the same time, endoscopy has faced substantial technical improvements and continues to undergo major changes. Detection of colorectal neoplasias is facilitated by using high-definition endoscopy, and characterization of lesions is more accurate by using virtual CE. High-definition endoscopy has found widespread use, whereas virtual CE is still more often used in tertiary centers and for high-risk patient groups. Endomicroscopy has opened the door for in vivo histology and functional as well as molecular imaging. Thorough training of the endoscopists is necessary, and redefined reimbursement codes may help make these techniques available in the clinical arena for high-risk patients who are most probable to benefit from the more advanced diagnostic endoscopy techniques. Over recent years, there has also been an increasing push by healthcare payors and providers to improve the quality of healthcare services. The ultimate goal of monitoring quality measures is to improve the overall health of the population and, for colon cancer screening, to reduce the incidence and mortality of colon cancer. However, the development of an appropriate quality measure and ensuring the accuracy of the data on which we base our efforts are among the first challenges that we must meet (Table 1). The continued technologic advancements in colonoscopy and endoscopic imaging may result in improvements in the quality of colonoscopy and should lead to a decrease in the incidence and mortality from colon cancer.

Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer

BACKGROUND

Despite advances in endoscopic treatment, many colonic adenomas are still referred for surgical resection. There is a paucity of data on the suitability of these lesions for endoscopic treatment.

OBJECTIVE

To analyze the results of routine repeat colonoscopy in patients referred for surgical resection of colon polyps without biopsy-proven cancer.

DESIGN

Retrospective review.

SETTING

University hospital.

PATIENTS

Patients referred to a colorectal surgeon for surgical resection of a polyp without biopsy-proven cancer.

INTERVENTIONS

Repeat colonoscopy.

MAIN OUTCOME MEASUREMENTS

The rate of successful endoscopic treatment.

RESULTS

There were 38 lesions in 36 patients; 71% of the lesions were noncancerous and were successfully treated endoscopically. In 26% of the lesions, previous removal was attempted by the referring physician but was unsuccessful. The adenoma recurrence rate was 50%, but all recurrences were treated endoscopically and none were cancerous. Two patients were admitted for overnight observation. There were no major adverse events.

LIMITATIONS

Single center, retrospective.

CONCLUSIONS

In the absence of biopsy-proven invasive cancer, it is appropriate to reevaluate patients referred for surgical resection by repeat colonoscopy at an expert center.

Advanced colorectal polyp detection techniques

A long-term follow-up of the landmark National Polyp Study recently showed that colonoscopy was associated with critical clinical benefit, including reduced overall death rate, colorectal cancer (CRC) death rate, and CRC incidence Zauber et al. (N Engl J Med 366(8):687-96, 2012). This and other recent studies emphasize the need for high-quality colonoscopy to realize maximal benefit. Adenoma detection has emerged as an important predictor of quality colonoscopy. Studies from Europe have shown that individuals whose colonoscopy was performed by a physician with high adenoma detection have a much lower likelihood of interval CRC. Studies now suggest that it is possible to train endoscopists to improve their adenoma detection rate. The specific methods associated with higher quality colonoscopy include careful inspection behind folds, washing the colon surface, adequate insufflation, and recognition of subtle flat polyps. Use of high-definition white light colonoscopy, chromoendoscopy, and cap-fitted colonoscopy has also been studied as potential methods for increasing adenoma detection. We will review these methods and techniques in this article.

Cap-assisted EMR of large, sporadic, nonampullary duodenal polyps

BACKGROUND

EMR is an effective alternative to surgery for the removal of nonampullary duodenal polyps (NADPs). Cap-assisted EMR (EMR-C) has been rarely performed in the duodenum because of the risk of perforation.

OBJECTIVE

To evaluate the safety and effectiveness of EMR-C for the removal of large (≥ 15 mm) NADPs.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral center.

PATIENTS

Between 2000 and 2010, 26 consecutive patients with sporadic NADPs underwent EMR-C.

INTERVENTION

EMR with the cap technique.

MAIN OUTCOME MEASUREMENTS

Complete eradication of polyps, complications, and recurrence.

RESULTS

A total of 14 sessile polyps (53.8%), 7 lateral spreading type nongranular tumors (26.9%), and 5 lateral spreading type granular tumors (19.2%) were treated. The median size of lesions was 15 mm. Five lesions involved one-half of the luminal circumference. Post-EMR histologic assessment showed low-grade dysplasia in 5 patients (19.2%) and high-grade dysplasia in 18 patients (69.2%). Three patients (11.5%) had well-differentiated endocrine tumors. Complete eradication was obtained in 25 of 26 (96%) patients. No perforations occurred. Three cases of intraprocedural bleeding were managed endoscopically. Median follow-up was 6 years (range 1-10 years). Residual adenomatous tissue was observed in 3 patients in lesions of 50 mm. In one of these cases, an adenocarcinoma occurred after 8 months, which was managed surgically.

LIMITATIONS

Retrospective design, single center.

CONCLUSION

This study supports the efficacy and safety of EMR-C for removing NADPs. Regular follow-up is mandatory because of the high risk of residual or recurrent adenomatous tissue and even cancer.

Colonoscopy: new approaches to better outcomes

PURPOSE OF REVIEW

Prevention of colorectal cancer relies on the detection and removal of colorectal neoplasia. Recent advances in mucosal imaging and inspection techniques have increased the detection of small and diminutive colorectal polyps with unknown clinical impact. The ability to accurately predict whether a polyp is neoplastic may allow for an optical triage approach to polyp management, improving efficiency while reducing the cost and risk of polypectomy.

RECENT FINDINGS

High-definition white light colonoscopy, cap-fitted colonoscopy, and dye-based pan-chromoendoscopy have each shown to increase polyp detection. Virtual chromoendoscopy, although not beneficial for polyp detection, allows for accurate in-vivo prediction of polyp pathology. Endoscopists' behaviors, independent of patient factors, strongly influence adenoma detection. Training methods focused on the techniques of high adenoma detectors also increase adenoma and polyp detection.

SUMMARY

Advances in mucosal imaging and improvements in inspection technique have allowed us to detect more polyps and to predict their pathology with greater accuracy. An optical triage approach to either 'diagnose and discard' or 'diagnose and leave behind' has the potential to reduce the risk and cost of polypectomy.

Individualization of surgical management for early-stage colonic cancer

A significant number of patients each year undergo radical segmental colectomy for node-negative colonic cancer in the UK. They are likely to represent 50% of our colonic cancer population in the future due to the implementation of the National Bowel Cancer Screening Programme. Short-term morbidity rates of up to 40% are associated with the current surgical treatment and need serious consideration. In this article, we discuss a combination of two techniques that will allow minimally invasive treatment in an increasing number of patients with early colonic cancer.

Endoscopic mucosal resection with the grasp-and-snare technique through a double-channel endoscope in humans

BACKGROUND

EMR is being used to manage premalignant lesions of the GI tract. Lifting of the lesion is required to perform EMR. Earlier biopsy or snare may cause scarring and preclude adequate lifting.

OBJECTIVE

We report our experience with a novel grasp-and-snare EMR technique that can be used when a good lifting is not achieved or the location of the lesion is challenging for standard EMR, such as in a fold.

DESIGN

Single-center case series.

SETTING

Tertiary referral academic gastroenterology unit.

PATIENTS

Patients referred for endoscopic treatment of flat gastrointestinal polyps.

INTERVENTIONS

Single-session EMR performed with a grasp-and-snare technique through a double-channel gastroscope or colonoscope.

MAIN OUTCOME MEASUREMENTS

Technical success, complication rates, and recurrence rates.

RESULTS

Seventeen patients with flat gastrointestinal polyps were referred: mean age 70 years, 11 (65%) male, polyp size 0.8 to 6 cm; 13 colonic, 2 duodenal, 1 gastric, and 1 esophageal EMR performed with grasp-and-snare technique in single sessions. Six polyps (35%) did not lift after injection of hydroxypropylmethylcellulose. Fourteen polyps (82%) were resected completely. Two complications occurred (12%): 1 bleeding treated medically and 1 perforation treated surgically. Residual disease at 1 year was 18%, but 8 patients (47%) had not yet had their 1-year follow-up.

LIMITATIONS

Single-center, uncontrolled, not randomized. Limited follow-up.

CONCLUSIONS

The grasp-and-snare technique can be used to perform EMR with good outcomes and low complication rates in areas where poor lifting and accessibility are problems.

Endoscopic colorectal imaging and therapy

PURPOSE OF REVIEW

Colorectal cancer screening and prevention is a pivotal element in every gastroenterologist practice. Recent advances in imaging technology and treatment opened the field for endoscopic management of large flat colorectal polyps and early cancer.

RECENT FINDINGS

High-definition white light colonoscopy allowed for better characterization of colon polyps, particularly flat lesions. Chromoendoscopy facilitated the identification of colon polyps as well as better endoscopic polyp characterization, with strong correlation with final pathological diagnosis, opening the field of 'virtual' biopsy. One particular technology, confocal endomicroscopy can magnify an image approximately 1000 times resembling optical microscopy with very good correlation with histology. Endoscopic mucosal resection has gained great acceptance to manage flat colorectal polyps with the two major complications being bleeding and perforation, both now under 5% in experienced hands. Endoscopic submucosal resection was developed to increase en-bloc resection (less residual disease) of a flat colorectal lesion but one has to accept a higher perforation rate around 10%.

SUMMARY

Current technology allows for better polyp identification and characterization, which can be managed endoscopically.