Selective tissue elevation by pressure for endoscopic mucosal resection of colorectal adenoma: first clinical trial

Management of colorectal laterally spreading tumors: a systematic review and meta-analysis

Objective and study aims  To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST). Methods  Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model. Results  Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 - 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 - 92.9 %, I ²  = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 - 95.5 %, vs. 84 % 95 % CI 78.1 - 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 - 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 - 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 - 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 - 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 - 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 - 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 - 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST. Conclusions  EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.

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.

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.

Recurrence after endoscopic mucosal resection-therapy failure?

PURPOSE

To evaluate the success and complication rates of endoscopic mucosal resections (EMR) for large flat adenomas and to identify risk factors for adenoma recurrence.

METHODS

We evaluated all consecutive patients treated with EMR at our institution between 2003 and 2005 that fulfilled the following criteria: >10-mm diameter, Paris 0-Is and 0-IIa-c, and endoscopic follow-up. We conducted univariate analysis and multivariate analysis using a non-stratified logistic regression model to identify possible influencing factors.

RESULT

In a median follow-up period of 6 years, we analyzed 177 EMR procedures, with a mean size of 21 mm. The majority of the resections were in the right colon. Recurrence occurred in 29 patients. Further treatment of patients with recurrence was endoscopic in 27 patients, whereas 1 patient was treated with transanal endoscopic microsurgery and one underwent surgery. The variables influencing the multivariate model were resection technique, immediate complication age, and histology.

CONCLUSIONS

We show that EMR can achieve a long-term clearance of large flat adenomas. A recurrence after EMR does not equal to failed therapy. The possibility of recurrence has to be considered in the clinical implementation of EMR. An important part of the stratifying factors for follow-up is the procedural assessment of the effectiveness of the resection and the resection technique.

Endoscopic Submucosal Dissection (ESD) in Colorectal Tumors

Background

Endoscopic submucosal dissection (ESD) – initially developed for the treatment of early gastric cancer in Japan – is an attractive option for en bloc resection of larger sessile or flat colorectal neoplasia.

Methods

A review of the current literature on colorectal ESD was carried out.

Results

In contrast to conventional endoscopic mucosal resection (EMR), ESD for larger colorectal neoplasia yields high en bloc resection rates and very low recurrence rates. The frequency of delayed bleeding is similar for EMR and ESD. Higher perforation rates during ESD are mostly due to microperforations identified and treated during the intervention, and are therefore of minor clinical relevance. A major disadvantage of ESD is the necessity for high-level endoscopic skills and long procedure times. ESD also has the potential to replace laparoscopic surgery or transanal endoscopic microsurgery mainly due to its lower complication rates.

Conclusion

ESD for the resection of larger flat or sessile colorectal lesions has potential advantages over conventional EMR or minimally invasive surgery. Due to the low incidence of early gastric cancer, experience with ESD will remain limited in Western countries. The spread of colorectal ESD will depend on adequate training opportunities and also on modifications yielding a reduction in procedure time.