Recurrence after endoscopic mucosal resection-therapy failure?

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.

Submucosal injection with waterjet improves endoscopic mucosal resection of colorectal adenoma - a randomised controlled clinical trial

PURPOSE

Endoscopic mucosal resection (EMR) of colorectal adenomas leads to a reduced incidence of, and mortality from, colorectal carcinoma. Large adenomas are especially difficult to resect. Submucosal injection is a key part of EMR, as it allows for complete resection and decreased complications. We previously demonstrated in both animal models and a clinical trial that a focussed fluid beam applied to the mucosa creates selective fluid cushions in the submucosa selective tissue elevation by pressure (STEP). In this study, we examined the potential of this new technique compared to the standard inject and cut technique.

METHODS

This was a monocentric prospective two armed randomised controlled clinical trial comparing the STEP technique to the standard needle injection. We included patients with Yamada I and II adenomas ≥12 mm.

RESULTS

One hundred fifty-five patients were treated in the trial. With the STEP technique there was a significantly higher rate of en-bloc resection, whereas piecemeal resection was more common in the standard arm. The odds ratio of piecemeal resection was 2.422 with a 95% confidence interval of 1.163-5.045 (p value .0195). There was no significant difference in resection time between the two techniques, while there was a significant difference in resections speed for the STEP technique. There was also no difference in complication rates.

CONCLUSIONS

This study demonstrated that the new STEP technique leads to a higher rate of en-bloc resections than the standard injection technique in endoscopic mucosa resection of colorectal adenomas. The STEP technique can play an important role in the future of EMR.

Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia

BACKGROUND AND AIMS

Colorectal EMR for nonpolypoid neoplasia achieves better outcomes when performed by expert endoscopists. The time point at which the endoscopist achieves expert level remains to be defined. The objective of this study was to establish a learning curve of colorectal EMR for nonpolypoid neoplasia based on residual tissue on surveillance colonoscopy and adverse event rate.

METHODS

Five hundred seventy-eight consecutive patients underwent EMR of colorectal neoplasia by 1 of 3 primary endoscopists between December 2004 and September 2013 in a tertiary academic center. Primary analyses focused on the largest lesion for patients with more than 1 lesion (median age, 69 years; median polyp size, 30 mm; 51% en bloc resection). Data on surveillance colonoscopy were available for 74%. Learning curves were calculated for each of the 3 main outcome measurements: the presence of residual neoplasia on surveillance colonoscopy, endoscopic assessment of incomplete EMR, and the occurrence of an immediate bleeding adverse event.

RESULTS

Residual neoplasia on surveillance colonoscopy was present for 23.2% of patients, the rate of endoscopist-assessed incomplete EMR was 27.6%, and immediate bleeding adverse events occurred in 6.9% of patients. Although there was between-endoscopist variability, the overall rates of residual neoplasia and incomplete EMR decreased to below 20% to 25% after 100 EMRs; initial decreases in both rates were observed for earlier EMRs. Immediate bleeding adverse events occurred at a low frequency for each endoscopist across all EMRs. Perforation requiring surgical intervention occurred in 1 patient (0.2%).

CONCLUSIONS

This study demonstrated that an unexpectedly high number of 100 colorectal EMR procedures for large nonpolypoid colorectal neoplasia are required to achieve a plateau phase for crucial outcomes.

Scope or scalpel? A matched study of the treatment of large colorectal polyps

BACKGROUND

Large colorectal polyps can be treated either endoscopically or by formal resection. The aim of this study was to clarify the relative advantages and disadvantages of surgical resection and colonoscopic snaring as means of treating large colorectal polyps.

METHODS

This is a matched cohort study, comparing cases of surgical resection of benign colorectal polyps with endoscopic resection. Cases drawn from pathology and endoscopy databases were matched for the size and site of polyps, and the groups were compared for the end points of complications, length of hospital stay and completeness of the removal of the polyp.

RESULTS

There were 78 patients in each group, with mean ages of 65.6 years (colonoscopy) and 66.8 years (surgery). A total of 39 of the surgery group and 47 of the colonoscopy group were men. Mean polyp size was 34.1 mm (colonoscopy) and 32.1 mm (surgery). There was an exact match for polyp location. Complications occurred in eight colonoscopy patients (10.3%) and 42 surgery patients (56.0%) (P < 0.001, chi-square). Length of hospital stay was 0 days for colonoscopy patients and 7.3 ± 4.7 days for surgery (P < 0.001). The surgery group was separated into laparoscopic (n = 35) and open (n = 43) surgery. There was no difference in complication rates (42.4 versus 53.5%, respectively) but laparoscopic had shorter length of stay (5.8 days ± 4.9 SD versus 8.4 days ± 4.3 SD). Recurrence of surgically resected polyps was zero; at last follow-up 13% of snared polyps persisted.

CONCLUSION

Although resection is a more certain and absolute way of treating benign polyps, endoscopic polypectomy is preferable.

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 mucosal resection of colorectal adenomas > 20 mm: Risk factors for recurrence

AIM: To evaluate risk factors for local recurrence after endoscopic mucosal resection of colorectal adenomas > 20 mm.

METHODS: Retrospective data analysis of 216 endoscopic mucosal resections for colorectal adenomas > 20 mm in 179 patients (40.3% female; median age 68 years; range 35-91 years). All patients had at least 1 follow-up endoscopy with a minimum control interval of 2 mo (mean follow-up 6 mo/2.0-43.4 mo). Possible factors associated with local recurrence were analyzed by univariate and multivariate analysis.

RESULTS: Median size of the lesions was 30 mm (20-70 mm), 69.0% were localized in the right-sided (cecum, ascending and transverse) colon. Most of the lesions (85.6%) showed a non-pedunculated morphology and the majority of resections was in piecemeal technique (78.7%). Histology showed carcinoma or high-grade intraepithelial neoplasia in 51/216 (23.6%) lesions including 4 low risk carcinomas (pT1a, L0, V0, R0 - G1/G2). Histologically proven recurrence was observed in 33/216 patients (15.3%). Patient age > 65 years, polyp size > 30 mm, non-pedunculated morphology, localization in the right-sided colon, piecemeal resection and tubular-villous histology were found as associated factors in univariate analysis. On multivariate analysis, only localization in the right-sided colon (HR = 6.842/95%CI: 1.540-30.394; P = 0.011), tubular-villous histology (HR = 3.713/95%CI: 1.617-8.528; P = 0.002) and polyp size > 30 mm (HR = 2.563/95%CI: 1.179-5.570; P = 0.017) were significantly associated risk factors for adenoma recurrence.

CONCLUSION: Meticulous endoscopic follow-up is warranted after endoscopic mucosal resection of adenomas localized in the right-sided colon larger than > 30 mm, with tubular-villous histology.

Complication and local recurrence rate after endoscopic resection of large high-risk colorectal adenomas of ≥3 cm in size

PURPOSE

Endoscopic resection is a widely used technique for treatment of large colorectal adenomas, but few data are available including only lesions larger than ≥2 cm. The aim of this study is to evaluate the complication and recurrence rate after endoscopic resection of high-risk colorectal adenomas ≥3 cm in size.

METHODS

Retrospective analysis of a prospectively maintained database of patients undergoing polypectomy of large colorectal polyps of ≥3 cm.

RESULTS

In 341 patients, 360 colorectal adenomas with a mean size of 3.9 cm were resected endoscopically. In 25 patients, a complication including 22 delayed bleedings (6.5%) and three perforations (0.9%) occurred. Single-variate analysis showed an increasing risk of complications for larger adenomas (3.9 vs. 4.6 cm; p ≤ 0.05). Two hundred twelve patients with 224 adenomas had undergone at least one documented follow-up endoscopy with a medium follow-up period of 16 months. In 95 resected lesions (42.4%), a residual adenoma occurred in the first follow-up colonoscopy (n = 88, 92.6%) or a recurrent adenoma occurred after at least one negative follow-up colonoscopy (n = 7, 7.4%). In multivariate analysis, risk factors were lesion size, sessile growth pattern, and the performing endoscopist. The complication and recurrence rate correlated inversely between endoscopists.

CONCLUSIONS

The present study is the largest study showing complication and recurrence rates after colorectal polypectomy of advanced colorectal adenomas of ≥3 cm in size. Polyp size was identified as the most important risk factor for complications. For the first time, this study shows that the complication rate after colorectal polypectomy of large adenomas is correlated inversely with the residual and/or recurrence rate.

Advances, problems, and complications of polypectomy

The major role of colonoscopy with polypectomy in reducing the incidence of and mortality from colorectal cancer has been firmly established. Yet there is cause to be uneasy. One of the most striking recent findings is that there is an alarmingly high incomplete polyp removal rate. This phenomenon, together with missed polyps during screening colonoscopy, is thought to be responsible for the majority of interval cancers. Knowledge of serrated polyps needs to broaden as well, since they are quite often missed or incompletely removed. Removal of small and diminutive polyps is almost devoid of complications. Cold snare polypectomy seems to be the best approach for these lesions, with biopsy forcep removal reserved only for the tiniest of polyps. Hot snare or hot biopsy forcep removal of these lesions is no longer recommended. Endoscopic mucosal resection and endoscopic submucosal dissection have proven to be effective in the removal of large colorectal lesions, avoiding surgery in the majority of patients, with acceptably low complication rates. Variants of these approaches, as well as new hybrid techniques, are being currently tested. In this paper, we review the current status of the different approaches in removing polypoid and nonpolypoid lesions of the colon, their complications, and future directions in the prevention of colorectal cancer.

Who Needs Follow-Up after Endoscopic Resection of Colorectal Adenomas?

Background

Surveillance colonoscopy after endoscopic resection of colorectal adenomas is a crucial step in the concept of colorectal cancer screening. After identifying the patients at risk with screening and resection of adenomas, there has to be a tailored surveillance. Surveillance colonoscopy should detect recurrent and metachronal adenomas at a stage where they can be removed endoscopically. In the following, the criteria for a risk-adapted surveillance interval are presented.

Methods

A literature review based on American, European, and German guidelines for surveillance after polypectomy and the German guideline for the diagnosis and treatment of ulcerative colitis, as well as a selective literature search into hereditary colorectal cancer were performed.

Results

State of the art surveillance after endoscopic resection of colorectal adenomas is based on a focused anamnesis and the index colonoscopy. On the basis of existing guidelines, a risk-adapted surveillance strategy can be implemented.

Conclusions

Adherence to surveillance guidelines is a basic part of colorectal cancer screening and should be the starting point for further research.