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Wang X, Wang Y, Cao X, Zhang C, Miao L. Underwater versus conventional endoscopic mucosal resection for ≥10 mm sessile or flat colorectal polyps: A systematic review and meta-analysis. PLoS One 2024; 19:e0299931. [PMID: 38451998 PMCID: PMC10919657 DOI: 10.1371/journal.pone.0299931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND AND AIM Underwater endoscopic mucosal resection (UEMR) has been an emerging substitute for conventional EMR (CEMR). This systematic review and meta-analysis aimed at comparing the efficiency and safety of the two techniques for removing ≥10 mm sessile or flat colorectal polyps. METHODS PubMed, Cochrane Library and Embase databases were searched up to February 2023 to identify eligible studies that compared the outcomes of UEMR and CEMR. This meta-analysis was conducted on the en bloc resection rate, R0 resection rate, complete resection rate, procedure time, adverse events rate and recurrence rate. RESULTS Nine studies involving 1,727 colorectal polyps were included: 881 were removed by UEMR, and 846 were removed by CEMR. UEMR was associated with a significant increase in en bloc resection rate [Odds ratio(OR) 1.69, 95% confidence interval(CI) 1.36-2.10, p<0.00001, I2 = 33%], R0 resection rate(OR 1.52, 95%CI 1.14-2.03, p = 0.004, I2 = 31%) and complete resection rate(OR 1.67, 95%CI 1.06-2.62, p = 0.03, I2 = 0%) as well as a significant reduction in procedure time(MD ‒4.27, 95%CI ‒7.41 to ‒1.13, p = 0.008, I2 = 90%) and recurrence rate(OR 0.52, 95%CI 0.33-0.83, p = 0.006, I2 = 6%). Both techniques were comparable in adverse events rate. CONCLUSION UEMR can be a safe and efficient substitute for CEMR in removing ≥10 mm sessile or flat colorectal polyps. More studies verifying the advantages of UEMR over CEMR are needed to promote its application.
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Affiliation(s)
- Xue Wang
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yue Wang
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xueyan Cao
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chunmei Zhang
- Emergency Department, Luzhou People’s Hospital, Luzhou, Sichuan, China
| | - Lin Miao
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Radadiya D, Desai M, Patel H, Srinivasan S, Chandrasekar VT, Hassan C, Repici A, Rex D, Sharma P. Analyzing methods for reducing recurrence rates after EMR of large nonpedunculated colorectal polyps: an indirect pairwise comparison. Gastrointest Endosc 2024; 99:326-336.e6. [PMID: 38065513 DOI: 10.1016/j.gie.2023.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 11/02/2023] [Accepted: 11/21/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND AIMS Despite advances in EMR techniques, a high polyp recurrence rate remains a challenge. Due to the scarcity of direct comparisons, we performed an indirect comparison of conventional EMR (EMR alone), underwater EMR (U-EMR), and EMR + adjuvant thermal ablation of polypectomy margins to assess polyp recurrence rates. METHODS Electronic databases were searched from inception to January 12, 2023, for studies reporting polyp recurrence rates after EMR for large nonpedunculated polyps (>15 mm) with or without adjuvant techniques (snare tip soft coagulation [STSC]/argon plasma coagulation [APC]). An indirect comparison was performed by using the frequentist method. The p-score was calculated to identify preferred intervention. Publication bias was assessed by using a comparison-adjusted funnel plot. RESULTS A total of 9 full articles were identified. On direct comparisons, EMR + STSC had 82% reduced odds (odds ratio, .18; 95% confidence interval, .13-.26; P < .001), whereas U-EMR alone had 77% reduced odds (odds ratio, .23; 95% confidence interval, .08-.67; P = .007) of polyp recurrence compared with EMR alone. On indirect comparison, all interventions had significantly lower odds of polyp recurrence compared with EMR alone. The p-score ranking showed that EMR + STSC seems a potential first method in reducing the odds of polyp recurrence, followed by U-EMR, EMR + APC, and EMR alone. CONCLUSIONS EMR + STSC seems to provide favorable odds for reducing polyp recurrence postresection for large nonpedunculated polyps. Standardization of methods to detect residual polyp and prevent polyp recurrence at the time of EMR are required.
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Affiliation(s)
- Dhruvil Radadiya
- Division of Gastroenterology, Department of Internal Medicine, University of Kansas-School of Medicine, Kansas City, Kansas, USA.
| | - Madhav Desai
- Division of Gastroenterology hepatology and nutrition, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Harsh Patel
- Division of Gastroenterology, Department of Internal Medicine, University of Kansas-School of Medicine, Kansas City, Kansas, USA
| | - Sachin Srinivasan
- Division of Gastroenterology, Department of Internal Medicine, University of Kansas-School of Medicine, Kansas City, Kansas, USA
| | | | - Cesare Hassan
- Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Rozzano, Italy
| | - Alessandro Repici
- Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Rozzano, Italy
| | - Douglas Rex
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Prateek Sharma
- Division of Gastroenterology, Department of Internal Medicine, University of Kansas-School of Medicine, Kansas City, Kansas, USA; Kansas City VA Medical Center, Kansas City, Missouri, USA
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Okimoto K, Matsumura T, Matsusaka K, Inaba Y, Ishikawa T, Akizue N, Kaneko T, Ota M, Ohta Y, Taida T, Saito K, Ogasawara S, Maruoka D, Kato J, Ikeda JI, Kato N. Outcomes for Underwater Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection of 21-30-mm Colorectal Polyps: A Feasible Study. Dig Dis Sci 2023; 68:3963-3973. [PMID: 37658209 DOI: 10.1007/s10620-023-08093-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/22/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND AND AIMS This randomized controlled trial (RCT) was designed to evaluate the short-term outcomes of underwater endoscopic mucosal resection (UEMR) and endoscopic submucosal dissection (ESD) of 21-30 mm colonic polyps. METHOD We conducted a single-center RCT. Patients diagnosed with suspected colorectal intramucosal carcinoma (21-30 mm and adaptable for both UEMR and ESD) were randomly assigned to the UEMR and ESD groups at a 1:1 ratio. The primary endpoint was the R0 resection rate. We independently performed one-sample tests against the set threshold for each treatment. The significance level was set at p = 0.224. RESULT Eleven polyps each in the UEMR and ESD groups, respectively, were analyzed. The R0 resection rate (%) was 36 (95% confidence interval 11-69) and 100 (72-100) for UEMR and ESD, respectively, with a significant difference between the two groups (p = 0.002). The p-value against the set threshold for UEMR was 0.743, whereas that for ESD was < 0.001 (one-sample binomial test). The en bloc resection rates (%) were 82 (48-97) and 100 (72-100) for UEMR and ESD, respectively; however, no significant difference was observed (p = 0.167). The mean treatment time (min) was significantly shorter in the UEMR group (8 ± 6) than in the ESD group (48 ± 29) (p = 0.001). CONCLUSION ESD could achieve a high R0 resection rate, while the en bloc resection rate was comparable between the two treatment techniques with less burden on patients undergoing UEMR for 21-30-mm colorectal polyps. CLINICAL TRIAL REGISTRATION The study was registered at the Japan Registry of Clinical Trial as jRCT1030210015 and jRCT1030210177.
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Affiliation(s)
- Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | | | - Yosuke Inaba
- Biostatistics Section, Chiba University Hospital Clinical Research Center, Chiba, Japan
| | - Tsubasa Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Tatsuya Kaneko
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Masayuki Ota
- Department of Diagnostic Pathology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
- Kameido Endoscopy and Gastroenterology Clinic, Tokyo, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Jun-Ichiro Ikeda
- Department of Pathology, Chiba University Hospital, Chiba, Japan
- Department of Diagnostic Pathology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
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Chandan S, Bapaye J, Khan SR, Mohan BP, Ramai D, Dahiya DS, Bilal M, Draganov PV, Othman MO, Rodriguez Sánchez J, Kochhar GS. Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs. Endosc Int Open 2023; 11:E768-E777. [PMID: 37593155 PMCID: PMC10431976 DOI: 10.1055/a-2117-8327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/20/2023] [Indexed: 08/19/2023] Open
Abstract
Background and study aims Conventional endoscopic mucosal resection (C-EMR) is limited by low en-bloc resection rates, especially for large (> 20 mm) lesions. Underwater EMR (U-EMR) has emerged as an alternative for colorectal polyps and is being shown to improve en-bloc resection rates. We conducted a systematic review and meta-analysis comparing the two techniques. Methods Multiple databases were searched through November 2022 for randomized controlled trials (RCTs) comparing outcomes of U-EMR and C-EMR for colorectal polyps. Meta-analysis was performed to determine pooled proportions and relative risks (RRs) of R0 and en-bloc resection, polyp recurrence, resection time, and adverse events. Results Seven RCTs with 1458 patients (U-EMR: 739, C-EMR: 719) were included. The pooled rate of en-bloc resection was significantly higher with U-EMR vs C-EMR, 70.17% (confidence interval [CI] 46.68-86.34) vs 58.14% (CI 31.59-80.68), respectively, RR 1.21 (CI 1.01-1.44). R0 resection rates were higher with U-EMR vs C-EMR, 58.1% (CI 29.75-81.9) vs 44.6% (CI 17.4-75.4), RR 1.25 (CI 0.99-1.6). For large polyps (> 20 mm), en-bloc resection rates were comparable between the two techniques, RR 1.24 (CI 0.83-1.84). Resection times were comparable between U-EMR and C-EMR, standardized mean difference -1.21 min (CI -2.57 to -0.16). Overall pooled rates of perforation, and immediate and delayed bleeding were comparable between U-EMR and C-EMR. Pooled rate of polyp recurrence at surveillance colonoscopy was significantly lower with U-EMR than with C-EMR, RR 0.62 (CI 0.41-0.94). Conclusions Colorectal U-EMR results in higher en-bloc resection and lower recurrence rates when compared to C-EMR. Both techniques have comparable resection times and safety profiles.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology & Hepatology, Creighton University School of Medicine, Omaha, NE, United States, Omaha, United States
| | - Jay Bapaye
- Department of Medicine, Rochester General Health System, Rochester, NY, United States, Rochester, United States
| | - Shahab R. Khan
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States, Boston, United States
| | - Babu P. Mohan
- Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States
| | - Dushyant S. Dahiya
- Department of Medicine, Central Michigan University, Mount Pleasant, MI, United States, Saginaw, United States
| | - Mohammad Bilal
- Department of Gastroenterology, Minneapolis VA Health Care System, Minneapolis, MN, United States, Minneapolis, United States
| | - Peter V. Draganov
- Department of Gastroenterology, University of Florida, Gainesville, FL, United States, Gainesville, United States
| | - Mohamed O. Othman
- Department of Gastroenterology, Baylor College of Medicine, Houston, TX, United States, Houston, United States
| | - Joaquin Rodriguez Sánchez
- Endoscopy Unite, Hospital Universitario 12 de Octubre, Madrid, Comunidad de Madrid, Spain, Ciudad Real, Spain
| | - Gursimran S. Kochhar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, United States, Pittsburgh, United States
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Lenz L, Martins B, Andrade de Paulo G, Kawaguti FS, Baba ER, Uemura RS, Gusmon CC, Geiger SN, Moura RN, Pennacchi C, Simas de Lima M, Safatle-Ribeiro AV, Hashimoto CL, Ribeiro U, Maluf-Filho F. Underwater versus conventional EMR for nonpedunculated colorectal lesions: a randomized clinical trial. Gastrointest Endosc 2023; 97:549-558. [PMID: 36309072 DOI: 10.1016/j.gie.2022.10.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 10/06/2022] [Accepted: 10/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Conventional endoscopic mucosal resection (CEMR) is the standard modality for removing nonpedunculated colorectal lesions. Underwater endoscopic mucosal resection (UEMR) has emerged as an alternative method. There are few comparative studies between these techniques, especially evaluating recurrence. Therefore, the purpose of this trial was to compare CEMR and UEMR for the resection of colorectal lesions with respect to efficacy, safety, and recurrence rate. METHODS This was a randomized controlled trial of UEMR versus CEMR for naïve and nonpedunculated lesions measuring between 10 and 40 mm. The primary outcome was adenoma recurrence at 6 months after the resection. Secondary outcomes were rates of technical success, en bloc resection, and adverse events. Block randomization was used to assign patients. Tattooing was performed to facilitate localization of the scars and eventual recurrences. Endoscopic follow-up was scheduled at 6 months after the procedure. The sites of resections were examined with white-light imaging, narrow-band imaging (NBI), and conventional chromoscopy with indigo carmine followed by biopsies. RESULTS One hundred five patients with 120 lesions were included, with a mean size of 17.5 ± 7.1 (SD) mm. Sixty-one lesions were resected by UEMR and 59 by CEMR. The groups were similar at baseline regarding age, sex, average size, and histologic type. Lesions in the proximal colon in the CEMR group corresponded to 83% and in the UEMR group to 67.8% (P = .073). There was no difference between groups regarding success rate (1 failure in each group) and en bloc resection rate (60.6% UEMR vs 54.2% CEMR, P = .48). Intraprocedural bleeding was observed in 5 CEMRs (8.5%) and 2 UEMRs (3.3%) (P = .27). There was no perforation or delayed hemorrhage in either groups. Recurrence rate was higher in the CEMR arm (15%) than in the UEMR arm (2%) (P = .031). Therefore, the relative risk of 6-month recurrence rate in the CEMR group was 7.5-fold higher (95% CI, 0.98-58.20), with a number needed to treat of 7.7 (95% CI, 40.33-4.22). The higher recurrence rate in the CEMR group persisted only for lesions measuring 21 to 40 mm (35.7% vs 0%; P = .04). CONCLUSION This study demonstrated that UEMR was associated with a lower adenoma recurrence rate than was CEMR. Both endoscopic techniques were effective and had similar rates of adverse events for the treatment of nonpedunculated colorectal lesions.
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Affiliation(s)
- Luciano Lenz
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Fleury Medicina e Saude, São Paulo, São Paulo, Brazil.
| | - Bruno Martins
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Fleury Medicina e Saude, São Paulo, São Paulo, Brazil
| | | | - Fabio Shiguehissa Kawaguti
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Fleury Medicina e Saude, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Adriana Vaz Safatle-Ribeiro
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Centro de Diagnóstico em Gastroenterologia, São Paulo, São Paulo, Brazil
| | | | - Ulysses Ribeiro
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Centro de Diagnóstico em Gastroenterologia, São Paulo, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Centro de Diagnóstico em Gastroenterologia, São Paulo, São Paulo, Brazil
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Takeuchi Y, Shichijo S, Uedo N, Ishihara R. Underwater endoscopic mucosal resection for colorectal lesions: Can it be an “Underwater” revolution? DEN OPEN 2022; 2:e84. [PMID: 35310727 PMCID: PMC8828230 DOI: 10.1002/deo2.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/13/2021] [Accepted: 11/20/2021] [Indexed: 11/07/2022]
Abstract
Underwater endoscopic mucosal resection (UEMR) is a newly developed technique for the removal of colorectal, duodenal, esophageal, gastric, ampullary, and small intestinal lesions. We performed a PubMed literature search for articles reporting UEMR outcomes for colorectal polyps. Four randomized controlled trials, nine non‐randomized prospective trials, 16 retrospective studies, and 27 case reports were selected for assessment of the efficacy and safety of UEMR. We summarized the therapeutic outcomes of UEMR in each category according to the lesion characteristics [small size (<10 mm), intermediate size (10–19 mm), large size (≥20 mm), recurrent lesion, and rectal neuroendocrine tumor], and calculated the incidence of adverse events among the included articles. As the treatment outcomes for small polyps appeared similar between UEMR and conventional endoscopic mucosal resection (CEMR), UEMR can be a standard procedure for small colorectal polyps suspicious for high‐grade dysplasia to avoid incomplete removal of occult invasive cancer by cold snare polypectomy. As UEMR showed satisfactory outcomes for intermediate‐size lesions and recurrent lesions after endoscopic resection, UEMR can be a standard procedure for these lesions. Regarding large lesions and rectal neuroendocrine tumors, comparisons of UEMR with current standard methods for them were lacking, and further investigations are warranted. Adverse events appeared comparable or less frequent for UEMR compared with CEMR but still existed. Therefore, careful implementation of this new technique in clinical practice is important for its widespread use.
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Affiliation(s)
- Yoji Takeuchi
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
- Department of Genetic Oncology Division of Hereditary Tumors Osaka International Cancer Institute Osaka Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
- Endoscopy Center Osaka International Cancer Institute Osaka Japan
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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8
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Nagl S, Ebigbo A, Goelder SK, Roemmele C, Neuhaus L, Weber T, Braun G, Probst A, Schnoy E, Kafel AJ, Muzalyova A, Messmann H. Underwater vs Conventional Endoscopic Mucosal Resection of Large Sessile or Flat Colorectal Polyps: A Prospective Randomized Controlled Trial. Gastroenterology 2021; 161:1460-1474.e1. [PMID: 34371000 DOI: 10.1053/j.gastro.2021.07.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/26/2021] [Accepted: 07/29/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Conventional endoscopic mucosal resection (CEMR) with submucosal injection is the current standard for the resection of large, nonmalignant colorectal polyps. We investigated whether underwater endoscopic mucosal resection (UEMR) is superior to CEMR for large (20-40mm) sessile or flat colorectal polyps. METHODS In this prospective randomized controlled study, patients with sessile or flat colorectal polyps between 20 and 40 mm in size were randomly assigned to UEMR or CEMR. The primary outcome was the recurrence rate after 6 months. Secondary outcomes included en bloc and R0 resection rates, number of resected pieces, procedure time, and adverse events. RESULTS En bloc resection rates were 33.3% in the UEMR group and 18.4% in the CEMR group (P = .045); R0 resection rates were 32.1% and 15.8% for UEMR vs CEMR, respectively (P = .025). UEMR was performed with significantly fewer pieces compared to CEMR (2 pieces: 45.5% UEMR vs 17.7% CEMR; P = .001). The overall recurrence rate did not differ between both groups (P = .253); however, subgroup analysis showed a significant difference in favor of UEMR for lesions of >30 mm to ≤40 mm in size (P = .031). The resection time was significantly shorter in the UEMR group (8 vs 14 minutes; P < .001). Adverse events did not differ between both groups (P = .611). CONCLUSIONS UEMR is superior to CEMR regarding en bloc resection, R0 resection, and procedure time for large colorectal lesions and shows significantly lower recurrence rates for lesions >30 mm to ≤40 mm in size. UEMR should be considered for the endoscopic resection of large colorectal polyps.
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Affiliation(s)
- Sandra Nagl
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany.
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Karl Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Christoph Roemmele
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Lukas Neuhaus
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Tobias Weber
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Georg Braun
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Elisabeth Schnoy
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | | | - Anna Muzalyova
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
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9
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Fukuda H, Takeuchi Y, Shoji A, Miyake M, Matsueda K, Inoue T, Waki K, Shimamoto Y, Kono M, Iwagami H, Nakahira H, Matsuura N, Shichijo S, Maekawa A, Kanesaka T, Yamamoto S, Higashino K, Uedo N, Ishihara R. Curative value of underwater endoscopic mucosal resection for submucosally invasive colorectal cancer. J Gastroenterol Hepatol 2021; 36:2471-2478. [PMID: 33788311 DOI: 10.1111/jgh.15513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 01/13/2021] [Accepted: 03/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Occasionally, colorectal tumors without characteristics of deep submucosal invasion are found to be invasive upon pathological evaluation after endoscopic resection (ER). Because the resection depth for underwater endoscopic mucosal resection (UEMR) has not been clarified, we evaluated the feasibility of UEMR for pathologically invasive colorectal cancer (pT1-CRC). METHODS We retrospectively investigated data on the backgrounds and outcomes of patients with pT1-CRC who underwent UEMR between January 2014 and June 2019 at our institute. As a reference standard, the backgrounds and outcomes of pT1-CRCs that had undergone conventional EMR (CEMR) were also investigated. RESULTS Thirty-one patients (median age, 68 years [range, 32-88 years]; 22 men [71%]) were treated with UEMR. Median lesion size was 17 mm (range, 6-50 mm). The endoscopic complete resection rate was 100%. The overall en bloc resection rate was 77%, and the VM0, HM0, and R0 resection rates were 81%, 58%, and 55%, respectively. In cases of pT1a (invasion <1000 μm)-CRC (n = 14), the en bloc, VM0, and R0 resection rates were 92%, 100%, and 71%, respectively. Seventeen patients (five with risk factors for lymph node metastasis and 12 without) were followed up, and no local recurrence and distant metastasis were observed during the follow-up period (median follow-up period, 18 months [range, 6-62 months]) after UEMR. The outcomes of UEMR seemed to be comparable with those of CEMR (n = 32). CONCLUSIONS The VM0 rate of UEMR for pT1-CRC, especially for pT1a-CRC, without characteristics of deep submucosal invasion seems feasible.
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Affiliation(s)
- Hiromu Fukuda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ayaka Shoji
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Muneaki Miyake
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Katsunori Matsueda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takahiro Inoue
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kotaro Waki
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yusaku Shimamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Mitsuhiro Kono
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyoshi Iwagami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroko Nakahira
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Akira Maekawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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10
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Chandan S, Khan SR, Kumar A, Mohan BP, Ramai D, Kassab LL, Draganov PV, Othman MO, Kochhar GS. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021; 94:471-482.e9. [PMID: 33385463 DOI: 10.1016/j.gie.2020.12.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Major limitations with conventional EMR (C-EMR) include high rates of polyp recurrence and low en-bloc resection rates, especially for lesions >20 mm in size. Underwater EMR (U-EMR) has emerged as an alternate technique for en-bloc resection of larger lesions. We conducted a systematic review and meta-analysis comparing the efficacy and safety of the 2 techniques. METHODS Multiple databases were searched through June 2020 for studies that compared outcomes of U-EMR and C-EMR for colorectal lesions. Meta-analysis was performed to determine pooled odds ratios (ORs) of successful R0, en-bloc, and piecemeal resection of colorectal lesions. We compared the rates of polyp recurrence at follow-up, diagnostic accuracy for colorectal cancer, and adverse events with the 2 techniques. RESULTS Eleven studies, including 4 randomized controlled trials (RCTs) with 1851 patients were included in the final analysis. A total of 1071 lesions were removed using U-EMR, and 1049 lesions were removed using C-EMR. Although U-EMR had an overall superior en-bloc resection rate compared with C-EMR (OR, 1.9; 95% confidence interval [CI], 1-3.5; P = .04), both techniques were comparable in terms of polyps >20 mm in size (OR, 0.8; 95% CI, 0.3-2.1; P = .75), R0 resection (OR, 3.1; 95% CI, 0.74-12.6; P = .14), piecemeal resection (OR, 3.1; 95% CI, 0.74-12.6; P = .13), and diagnostic accuracy for colorectal cancer (OR, 1.1; 95% CI, 0.6-1.8; P = .82). There were lower rates of polyp recurrence (OR, 0.3; 95% CI, 0.1-0.8; P = .01) and incomplete resection (OR, 0.4; 95% CI, 0.2-0.5; P = .001) with U-EMR. Both techniques have comparable resection times and safety profiles. CONCLUSIONS Our results support the use of U-EMR over C-EMR for successful resection of colorectal lesions. Further randomized controlled trials are needed to evaluate the efficacy of U-EMR for resecting polyps >20 mm in size.
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Affiliation(s)
- Saurabh Chandan
- Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Shahab R Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anand Kumar
- Gastroenterology & Hepatology, Lenox Hill Hospital, New York, New York, USA
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daryl Ramai
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, New York, USA
| | - Lena L Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter V Draganov
- Gastroenterology, University of Florida Health, Gainesville, Florida, USA
| | - Mohamed O Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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11
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Paccos JL, de Oliveira DS, de Oliveira FJS, Pereira Junior EMA, Mota FL, da Silva MMC, Corrêa PAFP. Perforation and bleeding during an underwater endoscopic mucosal resection of a large colonic lesion. Endoscopy 2021; 53:E326-E327. [PMID: 33096573 DOI: 10.1055/a-1275-9832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- José Luiz Paccos
- Department of Digestive Endoscopy, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | | | | | - Fernando L Mota
- Department of Digestive Endoscopy, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Mayara M C da Silva
- Department of Digestive Endoscopy, Hospital Sírio-Libanês, São Paulo, Brazil
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12
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Cadoni S, Ishaq S, Hassan C, Falt P, Fuccio L, Siau K, Leung JW, Anderson J, Binmoeller KF, Radaelli F, Rutter MD, Sugimoto S, Muhammad H, Bhandari P, Draganov PV, de Groen P, Wang AY, Yen AW, Hamerski C, Thorlacius H, Neumann H, Ramirez F, Mulder CJJ, Albéniz E, Amato A, Arai M, Bak A, Barret M, Bayupurnama P, Cheung R, Ching HL, Cohen H, Dolwani S, Friedland S, Harada H, Hsieh YH, Hayee B, Kuwai T, Lorenzo-Zúñiga V, Liggi M, Mizukami T, Mura D, Nylander D, Olafsson S, Paggi S, Pan Y, Parra-Blanco A, Ransford R, Rodriguez-Sanchez J, Senturk H, Suzuki N, Tseng CW, Uchima H, Uedo N, Leung FW. Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations. Gastrointest Endosc 2021; 93:1411-1420.e18. [PMID: 33069706 DOI: 10.1016/j.gie.2020.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.
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Affiliation(s)
- Sergio Cadoni
- CTO Hospital, Digestive Endoscopy Unit, Iglesias, Italy
| | - Sauid Ishaq
- Russell Hall, Dept. of Gastroenterology, Birmingham, United Kingdom; Birmingham City University, Birmingham, United Kingdom
| | - Cesare Hassan
- Nuovo Regina Margherita Hospital, Digestive Endoscopy Unit, Rome, Italy
| | - Přemysl Falt
- University Hospital and Faculty of Medicine, Palacky University, Olomouc, Czech Republic; Faculty of Medicine, Charles University, Hradec Králové, Czech Republic
| | - Lorenzo Fuccio
- S. Orsola-Malpighi University Hospital, Department of Medical and Surgical Sciences, Bologna, Italy
| | - Keith Siau
- JAG Clinical Fellow, JAG, Royal College of Physicians, London, United Kingdom
| | - Joseph W Leung
- Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and University of California Davis School of Medicine, Sacramento, California, USA
| | - John Anderson
- Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, United Kingdom
| | - Kenneth F Binmoeller
- California Pacific Medical Center, Interventional Endoscopy Services, San Francisco, California, United States
| | | | - Matt D Rutter
- University Hospital North Tees NHS, Department of Gastroenterology, Stockton-on-Tees, United Kingdom; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom
| | - Shinya Sugimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | | | - Pradeep Bhandari
- Portsmouth University Hospital, Dept. of Gastroenterology, Portsmouth, United Kingdom
| | | | - Piet de Groen
- University of Minnesota, Division of Gastroenterology, Minneapolis, Minnesota, United States
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - Andrew W Yen
- Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and University of California Davis School of Medicine, Sacramento, California, USA
| | - Chris Hamerski
- California Pacific Medical Center, Interventional Endoscopy Services, San Francisco, California, United States
| | - Henrik Thorlacius
- Lund University Surgery, Department of Gastrointestinal Surgery, Malmö, Sweden
| | - Helmut Neumann
- University Medical Center, Interventional Endoscopy Center, Medizinische Klinik und Poliklinik, Mainz, Germany
| | | | - Chris J J Mulder
- VU University Medical Center, Department of Gastroenterology, Amsterdam, The Netherlands
| | - Eduardo Albéniz
- Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Arnaldo Amato
- Ospedale Valduce, Gastroenterology Unit, Como, Italy
| | - Makoto Arai
- Chiba University, Gastroenterology Department, Chiba, Japan
| | - Adrian Bak
- University of British Columbia, Department of Medicine, Kelowna, Canada
| | | | - Putut Bayupurnama
- Division of Gastroenterology and Hepatology, Internal Medicine Department, Faculty of Medicine, Gadjah Mada University, Sardjito General Hospital, Yogyakarta, Indonesia
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, VA Palo Alto, California, United States
| | - Hey-Long Ching
- Sheffield Teaching Hospitals, Gastroenterology Department, Sheffield, United Kingdom
| | - Hartley Cohen
- Department of Medicine, VA Greater Los Angeles Health Care System, Los Angeles, United States; David Geffen School of Medicine at UCLA, Department of Medicine, Los Angeles, California, United States
| | - Sunil Dolwani
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, VA Palo Alto, California, United States
| | - Hideaki Harada
- Department of Gastroenterology, New Tokyo Hospital, Gastroenterology, Matsudo, Chiba, Japan
| | - Yu-Hsi Hsieh
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin Township, Taiwan
| | - Bu Hayee
- King's College Hospital NHS foundation Trust, Gastroenterology Department, London, United Kingdom
| | - Toshio Kuwai
- NHO Kure Medical Center and Chugoku Cancer Center, Gastroenterology Department, Kure, Japan
| | | | - Mauro Liggi
- ASSL Carbonia, Sirai Hospital, Digestive Endoscopy Unit, Carbonia, Italy
| | - Takeshi Mizukami
- NHO Kurihama Medical and Addiction Center, Endoscopy Center, Yokosuka, Japan
| | - Donatella Mura
- ASSL Carbonia, Sirai Hospital, Digestive Endoscopy Unit, Carbonia, Italy
| | - David Nylander
- Newcastle Upon Tyne NHS Foundation Trust, Gastroenterology Department, Newcastle Upon Tyne, United Kingdom
| | - Snorri Olafsson
- Telemark Hospital, Gastroenterology Department, Skien, Norway
| | - Silvia Paggi
- Ospedale Valduce, Gastroenterology Unit, Como, Italy
| | - Yanglin Pan
- Xijing Hospital, Department of Gastroenterology, Xian, Republic of China
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Department of Gastroenterology, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Rupert Ransford
- Endoscopy Department Hereford County Hospital, Hereford, United Kingdom
| | | | - Hakan Senturk
- Bezmialem Vakif University Medicine Faculty, Department of Medicine, Istanbul, Turkey
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | - Chih-Wei Tseng
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin Township, Taiwan
| | - Hugo Uchima
- Hospital Germans Triasi i Pujol, Teknon Medical Center, Gastroenterology, Barcelona, Spain
| | - Noriya Uedo
- Osaka International Cancer Institute, Department of Gastrointestinal Oncology, Osaka, Japan
| | - Felix W Leung
- Department of Medicine, VA Greater Los Angeles Health Care System, Los Angeles, United States; David Geffen School of Medicine at UCLA, Department of Medicine, Los Angeles, California, United States
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13
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Li DF, Lai MG, Yang MF, Zou ZY, Xu J, Peng RM, Xiong F, Wei C, Zhang DG, Xu ZL, Wang LS, Yao J. The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: systematic review and meta-analysis. Endoscopy 2021; 53:636-646. [PMID: 32767283 DOI: 10.1055/a-1234-8918] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a promising strategy for nonpedunculated colorectal polyp removal. However, the efficacy and safety of the technique for the treatment of ≥ 10-mm colorectal polyps remain unclear. We aimed to comprehensively assess the efficacy and safety of UEMR for polyps sized 10-19 mm and ≥ 20 mm. METHODS PubMed, EMBASE, and the Cochrane Library databases were searched for relevant articles from January 2012 to November 2019. Primary outcomes were the rates of adverse events and residual polyps. Secondary outcomes were the complete resection, en bloc resection, and R0 resection rates. RESULTS 18 articles including 1142 polyps from 1093 patients met our inclusion criteria. The overall adverse event and residual polyp rates were slightly lower for UEMR when removing colorectal polyps of 10-19 mm vs. ≥ 20 mm (3.5 % vs. 4.3 % and 1.2 % vs. 2.6 %, respectively). The UEMR-related complete resection rate was slightly higher for colorectal polyps of 10-19 mm vs. ≥ 20 mm (97.9 % vs. 92.0 %). However, the en bloc and R0 resection rates were dramatically higher for UEMR removal of polyps of 10-19 mm vs. ≥ 20 mm (83.4 % vs. 36.1 % and 73.0 % vs. 40.0 %, respectively). In addition, univariate meta-regression revealed that polyp size was an independent predictor for complete resection rate (P = 0.03) and en bloc resection (P = 0.01). CONCLUSIONS UEMR was an effective and safe technique for the removal of ≥ 10-mm nonpedunculated colorectal polyps. However, UEMR exhibited low en bloc and R0 resection rates for the treatment of ≥ 20-mm polyps.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ming-Guang Lai
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Mei-Feng Yang
- Department of Hematology, Yantian District People's Hospital, Shenzhen, Guangdong, China
| | - Zhi-Yuan Zou
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jing Xu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Ru-Mei Peng
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, Hunan, China
| | - Feng Xiong
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Cheng Wei
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
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14
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Garg R, Singh A, Aggarwal M, Bhalla J, Mohan BP, Burke C, Rustagi T, Chahal P. Underwater Endoscopic Mucosal Resection for 10 mm or Larger Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis. Clin Endosc 2021; 54:379-389. [PMID: 33910271 PMCID: PMC8182235 DOI: 10.5946/ce.2020.276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Recent studies have reported the favorable outcomes of underwater endoscopic mucosal resection (UEMR) for colorectal polyps. We performed a systematic review and meta-analysis evaluating the efficacy and safety of UEMR for nonpedunculated polyps ≥10 mm.
Methods We performed a comprehensive search of multiple databases (through May 2020) to identify studies reporting the outcomes of UEMR for ≥10 mm nonpedunculated colorectal polyps. The assessed outcomes were recurrence rate on the first follow-up, en bloc resection, incomplete resection, and adverse events after UEMR.
Results A total of 1276 polyps from 16 articles were included in our study. The recurrence rate was 7.3% (95% confidence interval [CI], 4.3–12) and 5.9% (95% CI, 3.6–9.4) for nonpedunculated polyps ≥10 and ≥20 mm, respectively. For nonpedunculated polyps ≥10 mm, the en bloc resection, R0 resection, and incomplete resection rates were 57.7% (95% CI, 42.4–71.6), 58.9% (95% CI, 42.4–73.6), and 1.5% (95% CI, 0.8–2.6), respectively. The rates of pooled adverse events, intraprocedural bleeding, and delayed bleeding were 7.0%, 5.4%, and 2.9%, respectively. The rate of perforation and postpolypectomy syndrome was 0.8%.
Conclusions Our systematic review and meta-analysis demonstrates that UEMR for nonpedunculated colorectal polyps ≥10 mm is safe and effective with a low rate of recurrence.
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Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Jaideep Bhalla
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Carol Burke
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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15
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Nogueira PB, Albuquerque W, Nascimento RC, Marianelli BS, Campos FF, Carreiro RA, Rocha RF, Pereira RM, Arantes VN. Underwater endoscopic mucosal resection of adenomas and colorectal serrated lesions: a prospective clinical study. Ann Gastroenterol 2021; 34:552-558. [PMID: 34276195 PMCID: PMC8276360 DOI: 10.20524/aog.2021.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/18/2021] [Indexed: 12/02/2022] Open
Abstract
Background Underwater endoscopic mucosal resection (UEMR) without submucosal injection has been described as an alternative technique to the endoscopic resection of adenomas and colorectal serrated lesions. We aimed to assess the feasibility, safety, and efficacy of UEMR in a Brazilian setting. Methods This was a prospective observational study of consecutive patients who underwent UEMR between January and July 2019, in a single tertiary care center. Inclusion criteria were lesions without endoscopic stigmata of deep submucosal invasion in patients referred for endoscopic resection of colorectal adenomas, and serrated lesions detected in a previous colonoscopy. The following features were assessed: complete resection rate, en bloc resection rate, resection time, adverse events, and resection infeasibility. Results A total of 36 patients underwent UEMR for 51 colorectal lesions. The mean/median lesion size was 16.24/13 mm and the mean/median resection time was 16.97/9.19 min. Histopathology revealed the following: tubular adenoma (43.1%), tubulovillous adenoma (13.7%), serrated lesions (41.2%), and intramucosal adenocarcinoma (2%). Complete resection was achieved in 86.3% of cases; 52.9% of the lesions were removed en bloc, while 47.1% were resected in a piecemeal fashion. UEMR was feasible in 96.1% of cases and failed on 2 occasions, requiring conversion to standard endoscopic mucosal resection. Minor intraoperative bleeding occurred in 5 patients (9.8%) and only 1 presented with delayed bleeding (2%), all controlled endoscopically. Conclusion UEMR for removal of adenomas and colorectal serrated lesions was demonstrated to be feasible, safe and effective.
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Affiliation(s)
- Pedro Bothrel Nogueira
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Walton Albuquerque
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Ricardo Castejon Nascimento
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Bruna Santos Marianelli
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Frederico Fonseca Campos
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Rodrigo Albuquerque Carreiro
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Renata Figueiredo Rocha
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Roberto Motta Pereira
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Vitor Nunes Arantes
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Alfa Institute of Gastroenterolgy (Vitor Nunes Arantes), Belo Horizonte, Minas Gerais, Brazil
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16
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Ni DQ, Lu YP, Liu XQ, Gao LY, Huang X. Underwater vs conventional endoscopic mucosal resection in treatment of colorectal polyps: A meta-analysis. World J Clin Cases 2020; 8:4826-4837. [PMID: 33195650 PMCID: PMC7642536 DOI: 10.12998/wjcc.v8.i20.4826] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/09/2020] [Accepted: 09/03/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) of colorectal lesions is emerging as an alternative method to conventional endoscopic mucosal resection (EMR); however, it is still controversial whether there is a difference in the effectiveness between UEMR and EMR.
AIM To evaluate the effectiveness and safety of UEMR in the treatment of colorectal polyps.
METHODS Clinical studies comparing the effectiveness or safety of UEMR in the treatment of colorectal polyps were searched in medical databases, including PubMed, Embase, Cochrane Library, CNKI, and Wanfang Data, monographs, theses, and papers presented at conferences. Statistical analyses were performed using Revman 5.3 software.
RESULTS Seven non-randomized controlled trials and one randomized controlled trial met the inclusion criteria. In total, 1382 patients (1511 polyps) were included in the study, including 722 who received UEMR and 789 who received EMR. In the UEMR and EMR groups, the en bloc resection rates were 85.87% and 73.89%, respectively, with a relative risk (RR) value of 1.14 (95% confidence interval [CI]: 1.01-1.30; P < 0.05). In the sub-group analysis, the en bloc resection rate showed no statistically significant difference between the EMR and UEMR groups for polyps less than 20 mm in diameter. However, a statistically significant difference was found between the EMR and UEMR groups for polyps equal to or greater than 20 mm in diameter. The post-endoscopic resection recurrence rates at 3-6 mo of the UEMR and EMR groups were 3.26% and 15.17%, respectively, with an RR value of 0.27 (95%CI: 0.09-0.83; P < 0.05). The post-endoscopic resection recurrence rates of UEMR and EMR at 12 mo were 6.25% and 14.40%, respectively, with an RR value of 0.43 (95%CI: 0.20-0.92; P < 0.05). Additionally, the incidence of adverse events was 8.17% and 6.21%, respectively, with an RR value of 1.07 (95%CI: 0.50-2.30; P > 0.05).
CONCLUSION UEMR is an effective technique for colorectal polyps and appears to have some advantages over EMR, particularly with regard to some treatment outcomes.
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Affiliation(s)
- Dong-Qiong Ni
- Department of Gastroenterology, Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Yu-Ping Lu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xi-Qiao Liu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Li-Ying Gao
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xuan Huang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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17
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Effectiveness and safety of underwater techniques in gastrointestinal endoscopy: a comprehensive review of the literature. Surg Endosc 2020; 35:37-51. [PMID: 32856154 DOI: 10.1007/s00464-020-07907-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), represent the standard of care for treatment of superficial gastrointestinal lesions. In 2012 a novel technique called underwater endoscopic mucosal resection (U-EMR) was described by Binmoeller and colleagues. This substantial variation from the standard procedure was afterwards applied at endoscopic submucosal dissection (U-ESD) and recently proposed also for peroral endoscopic myotomy (U-POEM) and endoscopic full-thickness resection (U-EFTR). METHODS This paper aims to perform a comprehensive review of the current literature related to supporting the underwater resection techniques with the aim to evaluate their safety and efficacy. RESULTS Based on the current literature U-EMR appears to be feasible and safe. Comparison studies showed that U-EMR is associated with higher "en-bloc" and R0 resection rates for colonic lesions, but lower "en-bloc" and R0 resection rates for duodenal non-ampullary lesions, compared to standard EMR. In contrast to U-EMR, little evidence supporting U-ESD are currently available. A single comparison study on gastric lesions showed that U-ESD had shorter procedural times and allowed a similar "en-bloc" resection rates compared to standard ESD. No comparison studies between U-ESD and ESD are available for colonic lesions. Finally, only some anecdotal experiences have been reported for U-POEM or U-EFTR, and the feasibility and effectiveness of these techniques need to be further investigated. CONCLUSIONS Further prospective studies are necessary to better explore the advantages of underwater techniques compared to the respective standards of care, especially in the setting of U-ESD where consistent data are lacking and where standardization of the technique is needed.
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18
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Lenz L, Martins B, Kawaguti FS, Tellian A, Pennachi CMPS, Sorbello M, Gusmon C, Paulo GAD, Uemura R, Geiger S, Lima MSD, Safatle-Ribeiro A, Baba E, Hashimoto CL, Maluf-Filho F, Ribeiro U. UNDERWATER ENDOSCOPIC MUCOSAL RESECTION FOR NON-PEDUNCULATED COLORECTAL LESIONS. A PROSPECTIVE SINGLE-ARM STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:193-197. [PMID: 32609162 DOI: 10.1590/s0004-2803.202000000-37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/27/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) has emerged as a revolutionary method allowing resection of colorectal lesions without submucosal injection. Brazilian literature about this technique is sparse. OBJECTIVE The aim of this study was evaluate the efficacy and safety of UEMR technique for removing non-pedunculated colorectal lesions in two Brazilian tertiary centers. METHODS This prospective study was conducted between June 2016 and May 2017. Naïve and non-pedunculated lesions without signs of submucosal invasion were resected using UEMR technique. RESULTS A total of 55 patients with 65 lesions were included. All lesions, except one, were successfully and completely removed by UEMR (success rate 98.5%). During UEMR, two cases of bleeding were observed (3.0%). One patient had abdominal pain on the day after resection without pneumoperitoneum. There was no perforation or delayed bleeding. CONCLUSION This study supports the existing data indicating acceptable rates of technical success, and low incidence of adverse events with UEMR. The results of this Brazilian study were consistent with previous abroad studies.
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Affiliation(s)
- Luciano Lenz
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil.,Fleury Medicina e Saúde, São Paulo, SP, Brasil
| | - Bruno Martins
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil.,Fleury Medicina e Saúde, São Paulo, SP, Brasil
| | - Fabio Shiguehisa Kawaguti
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil.,Fleury Medicina e Saúde, São Paulo, SP, Brasil
| | - Alexandre Tellian
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Centro de Diagnóstico em Gastroenterologia, São Paulo, SP, Brasil
| | - Caterina Maria Pia Simoni Pennachi
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Mauricio Sorbello
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil.,Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Centro de Diagnóstico em Gastroenterologia, São Paulo, SP, Brasil
| | - Carla Gusmon
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Gustavo Andrade de Paulo
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil.,Hospital Israelita Albert Einstein, Serviço de Endoscopia, São Paulo, SP, Brasil
| | - Ricardo Uemura
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Sebastian Geiger
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Marcelo Simas de Lima
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Adriana Safatle-Ribeiro
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil.,Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Centro de Diagnóstico em Gastroenterologia, São Paulo, SP, Brasil.,Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Elisa Baba
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Claudio Lyoiti Hashimoto
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Centro de Diagnóstico em Gastroenterologia, São Paulo, SP, Brasil.,Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Fauze Maluf-Filho
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Ulysses Ribeiro
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
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19
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Li P, Ma B, Gong S, Zhang X, Li W. Underwater endoscopic mucosal resection for colorectal lesions: a meta-analysis. Surg Endosc 2020; 35:3003-3013. [DOI: 10.1007/s00464-020-07745-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/13/2020] [Indexed: 02/08/2023]
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20
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Chen C, Ho C, Hsieh P. Evaluation of factors associated with en bloc colonic underwater endoscopic mucosal resection. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Chien‐An Chen
- Division of Hepatogastroenterology, Department of Internal Medicine Chi Mei Medical Center Tainan Taiwan
- Division of Holistic Care, Department of Internal Medicine Chi Mei Medical Center Tainan Taiwan
| | - Chung‐Han Ho
- Department of Medical Research Chi Mei Medical Center Tainan Taiwan
- Department of Hospital and Health Care Administration Chia Nan University of Pharmacy and Science Tainan Taiwan
| | - Ping‐Hsin Hsieh
- Division of Hepatogastroenterology, Department of Internal Medicine Chi Mei Medical Center Tainan Taiwan
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21
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Hossain E, Alkandari A, Bhandari P. Future of Endoscopy: Brief review of current and future endoscopic resection techniques for colorectal lesions. Dig Endosc 2020; 32:503-511. [PMID: 31242329 DOI: 10.1111/den.13475] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022]
Abstract
Endoscopic treatment of colorectal lesions has seen major developments in the last decade. It is now considered curative for intramucosal and superficial submucosal cancers. Endoscopic Mucosal Resection in expert hands has very good outcomes with low complication rates but recurrence and inadequate treatment of early cancers remain an issue. This has led to a technical evolution that can lead to one piece resection of neoplasia. This includes a range of techniques from knife assisted snare resection (KAR), endoscopic submucosal dissection (ESD) to full thickness resections. This article reviews all the resection techniques and the evidence base behind them.
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22
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Park SS, Han KS, Kim B, Chang Kim B, Hong CW, Sohn DK, Chang HJ. Comparison of underwater endoscopic mucosal resection and endoscopic submucosal dissection of rectal neuroendocrine tumors (with videos). Gastrointest Endosc 2020; 91:1164-1171.e2. [PMID: 31904380 DOI: 10.1016/j.gie.2019.12.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The first choice of treatment for rectal neuroendocrine tumors (NETs) ≤10 mm in size is endoscopic resection. However, because rectal NETs usually invade the submucosal layer, achieving R0 resection is difficult. Endoscopic submucosal dissection (ESD) has a high R0 resection rate, and underwater endoscopic mucosal resection (UEMR) was recently introduced to ensure a negative resection margin easily and safely. The aim of this study was to evaluate the efficacy and safety of UEMR versus ESD for rectal NETs ≤10 mm in size. METHODS This retrospective observational study enrolled 115 patients with rectal NETs ≤10 mm in size who underwent ESD or UEMR between January 2015 and July 2019 at the National Cancer Center, Korea. The differences in R0 resection rate, adverse event rate, and procedure time between the ESD and UEMR groups were evaluated. RESULTS Of the 115 patients, 36 underwent UEMR and 79 underwent ESD. The R0 resection rate was not different between the UEMR and ESD groups (UEMR vs ESD, 86.1% vs 86.1%, P = .996). The procedure time was significantly shorter with UEMR (UEMR vs ESD, 5.8 ± 2.9 vs 26.6 ±13.4 minutes, P < .001). Two patients (2.5%, 2/79) experienced adverse events in the ESD group and but there were no adverse events in the UEMR group; however, this difference was not statistically significant. CONCLUSION UEMR is a safe and effective technique that should be considered when removing small rectal NETs. Further studies are warranted to define its role compared with ESD.
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Affiliation(s)
- Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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23
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Yen AW, Leung JW, Wilson MD, Leung FW. Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video). Gastrointest Endosc 2020; 91:643-654.e2. [PMID: 31628954 PMCID: PMC7039760 DOI: 10.1016/j.gie.2019.09.039] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Incomplete resection of colorectal neoplasia decreases the efficacy of colonoscopy. Conventional resection (CR) of polyps, performed in a gas-distended colon, is the current standard, but incomplete resection rates of approximately 2% to 30% for nondiminutive (>5 mm), nonpedunculated lesions are reported. Underwater resection (UR) is a novel technique. The aim of this study was to determine the incomplete resection rates of colorectal lesions removed by UR versus CR. METHODS In a randomized controlled trial, patients with small (6-9 mm) and large (≥10 mm) nonpedunculated lesions were assigned to CR (gas-distended lumen) or UR (water-filled, gas-excluded lumen). Small lesions in both arms were removed with a dedicated cold snare. For CR, large lesions were removed with a hot snare after submucosal injection. For UR, large lesions were removed with a hot snare without submucosal injection. Four-quadrant biopsy samples around the resection sites were used to evaluate for incomplete resection. RESULTS Four hundred sixty-two eligible polyps (248 UR vs 214 CR) from 255 patients were removed. Incomplete resection rates for UR and CR were low and did not differ (2% vs 1.9%, P = .91). UR was performed significantly faster for lesions ≥10 mm in size (10-19 mm, 2.9 minutes vs 5.6 minutes, P < .0001); ≥20 mm, 7.3 minutes vs 9.5 minutes, P = .015). CONCLUSIONS Low incomplete resection rates are achievable with UR and CR. UR is effective and safe with the advantage of faster resection and potential cost savings for removal of larger (≥10 mm) lesions by avoiding submucosal injection. As an added approach, UR has potential to improve the cost-effectiveness of colonoscopy by increasing efficiency and reducing cost while maintaining quality. (Clinical trial registration number: NCT02889679.).
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Affiliation(s)
- Andrew W. Yen
- Sacramento Veterans Affairs Medical Center, VA Northern California Health Care System, Division of Gastroenterology, Mather, CA 95655,University of California Davis School of Medicine, Sacramento, CA 95817
| | - Joseph W. Leung
- Sacramento Veterans Affairs Medical Center, VA Northern California Health Care System, Division of Gastroenterology, Mather, CA 95655,University of California Davis School of Medicine, Sacramento, CA 95817
| | - Machelle D. Wilson
- Clinical and Translational Science Center, Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento CA 95817
| | - Felix W. Leung
- Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, Division of Gastroenterology, North Hills, CA 91343,David Geffen School of Medicine at UCLA, Los Angeles, CA 90095
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24
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:486-519. [PMID: 32067745 DOI: 10.1016/j.gie.2020.01.029] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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25
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Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:435-464. [PMID: 32058340 DOI: 10.14309/ajg.0000000000000555] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1095-1129. [PMID: 32122632 DOI: 10.1053/j.gastro.2019.12.018] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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27
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Barclay RL, Percy DB. Underwater endoscopic mucosal resection without submucosal injection (UEMR) for large colorectal polyps: A community-based series. Am J Surg 2020; 220:693-696. [PMID: 32061399 DOI: 10.1016/j.amjsurg.2020.01.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Underwater endoscopic mucosal resection without submucosal injection (UEMR) is an appealing therapy for large colorectal polyps. However, this technique is not practiced widely and there are limited data evaluating UEMR in community settings. METHODS The study comprised patients undergoing UEMR of large (≥20 mm) sessile colorectal lesions at a community-based center. Residual neoplasia was assessed via follow-up colonoscopy. RESULTS Among 264 lesions (diameter 38 ± 18 mm; range 20-110 mm) 99% were successfully resected with UEMR. Two lesions involving the cecum/IC valve required multiple sessions. There were no cases of perforation or post-polypectomy syndrome. Delayed bleeding occurred in 1.6%, all managed conservatively. Residual neoplasia was present in 5.7% and was amenable to UEMR. CONCLUSION This large community-based series demonstrated high efficacy and safety of UEMR for large sessile colorectal lesions. The results support UEMR as first-line therapy for these lesions. SUMMARY Underwater endoscopic mucosal resection without submucosal injection (UEMR) is a recently developed method that has advantages over conventional EMR for treatment of large colorectal lesions. However, UEMR is not practiced widely and there are limited data evaluating this technique in everyday practice. This large community-based series demonstrated high efficacy and safety of UEMR for large sessile colorectal lesions.
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Affiliation(s)
- Robert L Barclay
- Vancouver General Hospital, 899 W.12th Avenue, Vancouver, BC, V5Z 1M9, Canada; Pacific Digestive Health, 1590 Cedar Hill Cross Road, Suite 230, Victoria, BC, V8P 2P5, Canada.
| | - Dean B Percy
- Vancouver General Hospital, 899 W.12th Avenue, Vancouver, BC, V5Z 1M9, Canada
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28
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Chien HC, Uedo N, Hsieh PH. Comparison of underwater and conventional endoscopic mucosal resection for removing sessile colorectal polyps: a propensity-score matched cohort study. Endosc Int Open 2019; 7:E1528-E1536. [PMID: 31681832 PMCID: PMC6823098 DOI: 10.1055/a-1007-1578] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/28/2019] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is a standard method for removing sessile colorectal polyps ≥ 10 mm. Recently, underwater EMR (UEMR) has been introduced as a potential alternative. However, the effectiveness and safety of UEMR compared with conventional EMR is un clear. Patients and methods In this 1:1 propensity score (PS) matched retrospective cohort study, we compared the en bloc resection rates, procedure time, intraprocedural and delayed bleeding rates, and incidence of muscle layer injury. We also performed subgroup analyses by sizes of polyps (< 20 mm and ≥ 20 mm). Results Among 350 polyps in 315 patients from August 2012 to November 2017, we identified 121 PS-matched pairs. Mean polyp size was 16.8 mm. With similar en bloc resection rates (EMR: 82.6 % vs. UEMR: 87.6 %, rate difference: 5.0, 95 % confidence interval [95 % CI]: - 4 to 13.9 %), UEMR demonstrated a shorter resection time (10.8 min vs. 8.6 min, difference: - 2.2 min, 95 % CI: - 4.1 to - 0.3 min) and a lower intraprocedural bleeding rate (15.7 % vs. 5.8 %, rate difference: - 9.9 %, 95 % CI: - 17.6 to - 2.2 %). Incidence of delayed bleeding and muscle layer injury were low in both groups. For polyps < 20 mm, effectiveness and safety outcomes were similar in both groups. For polyps ≥ 20 mm (42 PS-matched pairs), the UEMR group has a comparable en bloc resection rate with shorter procedure time and superior safety outcomes Conclusions UEMR achieved an en bloc resection rate comparable to conventional EMR with less intraprocedural bleeding and a shorter procedure time.
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Affiliation(s)
- Hsu-Chih Chien
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ping-Hsin Hsieh
- Department of Gastroenterology, Chimei Medical Center, Tainan, Taiwan.,Department of Gastroenterology, Fujen Catholic University Hospital, New Taipei City, Taiwan
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Abstract
Although an established standard, conventional endoscopic mucosal resection (EMR) has disseminated despite an absence of studies demonstrating the value of submucosal injection. Several consequences of poorly executed submucosal injection may increase the difficulty and risk of EMR. Underwater EMR (UEMR), an alternative resection method for colonic neoplasms, avoids the need for submucosal injections. In comparison with reported outcomes of EMR, UEMR achieves similar rates of complete resection with comparable safety, with lower rates of recurrence and fewer repeat procedures. UEMR also compares favorably with endoscopic submucosal dissection in terms of procedure time and rates of complete resection, recurrence, and complications.
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Affiliation(s)
- Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, 1101 Van Ness Ave. Floor 3, San Francisco, CA 94109, USA.
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, 1101 Van Ness Ave. Floor 3, San Francisco, CA 94109, USA
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Yamashina T, Uedo N, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, Kawamura T, Takeuchi Y, Fujii S, Kusaka T, Shimokawa T. Comparison of Underwater vs Conventional Endoscopic Mucosal Resection of Intermediate-Size Colorectal Polyps. Gastroenterology 2019; 157:451-461.e2. [PMID: 30981791 DOI: 10.1053/j.gastro.2019.04.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic mucosal resection (EMR) with submucosal injection is an established method for removing colorectal polyps, although the en bloc resection rate decreases when polyp size exceeds 10 mm. Piecemeal resection increases local recurrence. Underwater EMR (UEMR) is an effective technique for removal of sessile colorectal polyps and we investigated whether it is superior to conventional EMR (CEMR). METHODS We conducted a multicenter randomized controlled trial at 5 institutions in Japan. Patients with endoscopically diagnosed, intermediate-size (10-20 mm) sessile colorectal lesions were randomly assigned to undergo UEMR or CEMR. Only the most proximal lesion was registered. The UEMR procedure included immersion of the entire lumen in water and snare resection of the lesion without submucosal injection of normal saline. We analyzed outcomes of 108 colorectal lesions in the UEMR group and 102 lesions in the CEMR group. R0 resection was defined as en bloc resection with a histologically confirmed negative resection margin. The primary endpoint was the difference in the R0 resection rates between groups. RESULTS The proportions of R0 resections were 69% (95% confidence interval [CI] 59%-77%) in the UEMR group vs 50% (95% CI 40%-60%) in the CEMR group (P = .011). The proportions of en bloc resections were 89% (95% CI 81%-94%) in the UEMR group vs 75% (95% CI 65%-83%) in the CEMR group (P = .007). There was no significant difference in median procedure time (165 vs 175 seconds) or proportions of patients with adverse events (2.8% in the UEMR group vs 2.0% in the CEMR group). CONCLUSIONS In a multicenter randomized controlled trial, we found that UEMR significantly increased the proportions of R0 resections for 10- to 20-mm sessile colorectal lesions without increasing adverse events or procedure time. Use of this procedure should be encouraged. Trials registry number: UMIN000018989.
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Affiliation(s)
- Takeshi Yamashina
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan; Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan; Department of Gastroenterology and Hepatology, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Taro Iwatsubo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuki Nakatani
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuji Akamatsu
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuji Kawamura
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shigehiko Fujii
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshihiro Kusaka
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshio Shimokawa
- Department of Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
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31
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Spadaccini M, Fuccio L, Lamonaca L, Frazzoni L, Maselli R, Di Leo M, Galtieri PA, Craviotto V, D'Amico F, Hassan C, Repici A. Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video). Gastrointest Endosc 2019; 89:1109-1116.e4. [PMID: 30862352 DOI: 10.1016/j.gie.2018.10.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Underwater EMR is an alternative way to have nonpedunculated colorectal lesions lifted before being resected. The endoscopist takes advantage of the behavior of mucosal lesions floating away from the muscular layer, once immersed in liquid. We performed a systematic review with meta-analysis to evaluate the efficacy and safety of this technique. METHODS Electronic databases (Medline, Scopus, EMBASE) were searched up to May 2018. Full articles including patients with colorectal lesions resected by the underwater EMR technique were eligible. The complete resection (primary outcome), en bloc resection, recurrence, and adverse event rates were pooled by means of a random or fixed-effect model. RESULTS Ten studies were eligible, providing data on 508 lesions removed from 433 patients (male/female = 239/194; mean age range 62.2-75.0 years). Six studies were performed in the United States and the other in Europe; 7 studies were prospective. The specific indications for performing underwater EMR varied widely across studies. The complete resection rate was 96.36% (95% confidence interval [CI], 91.77-98.44), with a rate of en bloc resection of 57.07% (95% CI, 43.20%-69.91%). The recurrence rate was 8.82% (95% CI, 5.78-13.25) in a mean endoscopy surveillance period of 7.7 months (range 4-15 months). The postprocedural bleeding rate was 2.85% (95% CI, 1.64-4.90). Bleeding during the procedure was always mild and was considered as part of the procedure in all series. The overall adverse event rate was 3.31% (95% CI, 1.97%-5.52%). No cases of perforation were reported. CONCLUSION According to the results of this systematic review, underwater EMR appears to be an effective and extremely safe technique for resecting nonpolypoid colorectal lesions.
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Affiliation(s)
- Marco Spadaccini
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy; Humanitas University, Department of Biomedical Sciences, Rozzano (Milano), Italy
| | - Lorenzo Fuccio
- S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Laura Lamonaca
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy; Humanitas University, Department of Biomedical Sciences, Rozzano (Milano), Italy
| | - Leonardo Frazzoni
- S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberta Maselli
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy
| | - Milena Di Leo
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy; Humanitas University, Department of Biomedical Sciences, Rozzano (Milano), Italy
| | - Piera Alessia Galtieri
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy
| | - Vincenzo Craviotto
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy; Humanitas University, Department of Biomedical Sciences, Rozzano (Milano), Italy
| | - Ferdinando D'Amico
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy; Humanitas University, Department of Biomedical Sciences, Rozzano (Milano), Italy
| | - Cesare Hassan
- Nuovo Regina Margherita Hospital, Digestive Endoscopy Unit, Rome, Italy
| | - Alessandro Repici
- Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (Milano), Italy; Humanitas University, Department of Biomedical Sciences, Rozzano (Milano), Italy
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Chaves DM, Brito HP, Chaves LT, Rodrigues RA, Sugai BM. Underwater endoscopic mucosal resection of serrated adenomas. Clinics (Sao Paulo) 2018; 73:e339. [PMID: 30304298 PMCID: PMC6152183 DOI: 10.6061/clinics/2018/e339] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/08/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Serrated polyps, which are considered to be precursors of colorectal carcinoma, include hyperplastic polyps, sessile serrated adenomas and traditional serrated adenomas. With the exception of hyperplastic polyps, all of these lesions must be removed. This study sought to examine whether underwater endoscopic mucosal resection is a safe and effective technique for treating serrated polyps. METHODS Cases in which patients were submitted for underwater endoscopic mucosal resection and histologically diagnosed with sessile serrated adenoma were prospectively registered. RESULTS The median patient age was 54.5 years (range, 48 to 72 years), and the patients included 4 men (28.5%) and 10 women (71.5%). One lesion (6.2%), 10 lesions (62.5%), 1 lesion (6.2%), 3 lesions (18.8%) and 1 lesion (6.2%) were found in the cecum, the ascending colon, the hepatic flexure, the transverse colon and the descending colon, respectively. The median lesion size was 20 mm (range, 10 to 35 mm). Eight lesions (50%) were removed en bloc, and the remaining eight lesions (50%) were removed using a piecemeal technique. None of the cases were complicated by perforation or delayed bleeding. CONCLUSION Underwater resection could be a feasible, safe and effective alternative for the resection of sessile serrated adenomas.
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Affiliation(s)
- Dalton Marques Chaves
- Endoscopia, Fleury Medicina e Saude, Sao Paulo, SP, BR
- Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Cadoni S, Liggi M, Gallittu P, Mura D, Fuccio L, Koo M, Ishaq S. Underwater endoscopic colorectal polyp resection: Feasibility in everyday clinical practice. United European Gastroenterol J 2018; 6:454-462. [PMID: 29774160 PMCID: PMC5949973 DOI: 10.1177/2050640617733923] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/03/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection is well-established for resecting flat or sessile benign colon polyps. The novel underwater endoscopic mucosal resection eschews submucosal injection prior to endoscopic mucosal resection. Reports about underwater endoscopic mucosal resection were limited to small series of single and/or tertiary-care referral centers, with single or supervised operators. OBJECTIVE The purpose of this study was to determine feasibility and efficacy of underwater resection of polyps of any morphology (underwater polypectomy, here includes underwater endoscopic mucosal resection) in routine clinical practice. METHODS This study involved a comparison of colonoscopy records of two community hospitals (January 2015-December 2016) for underwater polypectomy (n = 195) and gas insufflation polypectomy (n = 186). RESULTS Comparable demographics, procedural data, overall distribution, morphology and size of resected lesions, number of en bloc and R0 resections (any polyp morphology and size); exception: overall, underwater polypectomy pedunculated polyps were significantly larger than those in the gas insufflation polypectomy group, p = 0.030. Underwater polypectomy (median, min) resection time was significantly shorter than gas insufflation polypectomy: sessile and flat polyps 6-9 mm, 0.8 vs 2.7 (p = 0.040); 10-19 mm, 2.0 vs 3.3 (p = 0.025), respectively; pedunculated polyps 6-19 mm, 0.8 vs 3.3 (p < 0.001). Underwater polypectomy resection of pedunculated polyps 6-19 mm showed significantly less immediate bleeding: 11.1% vs 1.5%, respectively (p = 0.031). CONCLUSIONS Underwater polypectomy can be efficaciously used in routine clinical practice for the complete resection of colon polyps, with several advantages over gas insufflation polypectomy.
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Affiliation(s)
| | - Mauro Liggi
- Digestive Endoscopy Unit, Sirai
Hospital, Italy
| | | | | | | | - Malcolm Koo
- Department of Medical Research, Dalin
Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan
- Dalla Lana School of Public Health,
University of Toronto, Canada
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley
Group Hospitals NHS Foundation Trust, UK
- Department of health and science,
Birmingham City University, Birmingham, UK
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Kawamura T, Sakai H, Ogawa T, Sakiyama N, Ueda Y, Shirakawa A, Okada Y, Sanada K, Nakase K, Mandai K, Suzuki A, Morita A, Tanaka K, Uno K, Yasuda K. Feasibility of Underwater Endoscopic Mucosal Resection for Colorectal Lesions: A Single Center Study in Japan. Gastroenterology Res 2018; 11:274-279. [PMID: 30116426 PMCID: PMC6089589 DOI: 10.14740/gr1021w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022] Open
Abstract
Background Underwater endoscopic mucosal resection (U-EMR) has emerged as an alternative technique for the resection of colorectal lesions. This study aimed to evaluate our initial experience using U-EMR. Methods This is a single-center, retrospective case series study. We analyzed the clinical outcomes of consecutive patients who underwent U-EMR in our endoscopy center, from December 2015 to February 2017. Results Our analysis included 64 lesions, contributed by 38 patients, with a mean age of 68.6 years (range, 25 to 90 years). The study sample included 33 right-sided and 25 left-sided colon lesions, and seven rectal lesions, with an average size of 16.2 mm (6 - 40 mm). Of these, 46 lesions were polypoid and 18 ones non-polypoid. Histologically, 31 lesions were low-grade adenomas, eight ones were high-grade adenomas, 11 were mucosal cancers, four were submucosal cancers, and 10 were classified as “others”. En bloc resection was achieved in 52 (81%) lesions, with an en bloc resection rate of 95% for lesions < 20 mm and 55% for lesions ≥ 20 mm. Complete resection of neoplastic epithelial lesions, defined by a negative pathological margin, was achieved in 32 of 59 neoplastic epithelial lesions (54%). We identified three cases (5%) of post-procedural bleeding and one case of perforation (2%). Conclusions U-EMR can be feasibly used for resection of colonic lesions, including lesions ≥ 20 mm, although the en bloc resection rate for these lesions was lower than for lesions < 20 mm.
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Affiliation(s)
- Takuji Kawamura
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Hiroaki Sakai
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Tomoya Ogawa
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Naokuni Sakiyama
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Yuki Ueda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Atsushi Shirakawa
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Yusuke Okada
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Kasumi Sanada
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Kojiro Nakase
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Koichiro Mandai
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Azumi Suzuki
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Atsuhiro Morita
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Kiyohito Tanaka
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Koji Uno
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Kenjiro Yasuda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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Siau K, Ishaq S, Cadoni S, Kuwai T, Yusuf A, Suzuki N. Feasibility and outcomes of underwater endoscopic mucosal resection for ≥ 10 mm colorectal polyps. Surg Endosc 2017; 32:2656-2663. [PMID: 29101560 DOI: 10.1007/s00464-017-5960-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/23/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is an emerging strategy for the management of colorectal polyps. We aimed to evaluate the efficacy and safety of UEMR for clinically significant (≥ 10 mm) colorectal polyps. METHODS We performed a prospective dual-centre study of polyps ≥ 10 mm undergoing UEMR between June 2014 and March 2017. Outcomes measured comprised: (1) completeness of resection at index UEMR, (2) intraprocedural and 30-day complications, (3) rates and predictors of submucosal lift, en bloc resection, polyp/adenoma recurrence and (4) pain score. Endoscopy records were correlated with histology. RESULTS 85 patients underwent UEMR of 97 polyps. Resection was endoscopically complete at index UEMR in 97.9%. The median pain score was 0 (no pain). Submucosal lift was required in 29.9% and correlated with polyp size ≥ 30 mm (p = 0.03) and clip placement (p = 0.004). En bloc resection was achieved in 45.4%, and inversely correlated with polyp size ≥ 20 mm (p < 0.001). 30-day complications (4.1%) were minor and consisted of intraprocedural bleeding (n = 2) and delayed bleeding (n = 2). 60.8% attended endoscopy post-UEMR after a median interval of 6 months, with 20.3% polyp and 13.6% adenoma recurrence. Polyp recurrence was associated with piecemeal resection (p = 0.04), recurrent polyp (p = 0.02), female sex (p = 0.01) and poor access (p = 0.005). Predictors for adenoma recurrence included female gender (p = 0.01) and difficult access (p < 0.001). Recurrence rates did not differ with polyp size, site, morphology, dysplasia status, submucosal injection, patient age, or study centre. CONCLUSIONS UEMR is an effective, safe and well tolerated option for significant colorectal polyps. Piecemeal resection, recurrent polyp, female gender, and difficult access are predictors of post-UEMR polyp recurrence.
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Affiliation(s)
- Keith Siau
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, UK
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, UK.
- Department of Medicine, Birmingham City University, Birmingham, B5 5JU, UK.
| | - Sergio Cadoni
- Digestive Endoscopy Unit, CTO Hospital, Iglesias, Italy
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization, Kure Medical Centre and Chugoku Cancer Centre, Kure, Japan
| | | | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK
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Leung FW. Incomplete resection after macroscopic radical endoscopic resection of T1 colorectal cancer-should a paradigm-changing approach to address the risk be considered? Transl Gastroenterol Hepatol 2017; 2:69. [PMID: 28905010 PMCID: PMC5590022 DOI: 10.21037/tgh.2017.08.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/17/2017] [Indexed: 08/30/2023] Open
Affiliation(s)
- Felix W. Leung
- Sepulveda Ambulatory Care Center, North Hill, CA, USA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Oka S, Uraoka T, Tamai N, Ikematsu H, Chino A, Okamoto K, Takeuchi Y, Imai K, Ohata K, Shiga H, Raftopoulos S, Lee BI, Matsuda T. Standardization of endoscopic resection for colorectal tumors larger than 10 mm in diameter. Dig Endosc 2017; 29 Suppl 2:40-44. [PMID: 28425665 DOI: 10.1111/den.12829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 01/30/2017] [Indexed: 01/13/2023]
Abstract
Currently, several endoscopic resection (ER) methods for colorectal tumors are available, including polypectomy, conventional endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and modified ER. In the present review, we mainly focus on the current status of ER for colorectal tumors as well as the report from the Endoscopic Forum Japan (EFJ) 2016, which was held in Tokyo in August 2016. The proposed ER methods for colorectal tumors larger than 10 mm in diameter are as follows. (i) Pedunculated-type tumor is an indication for polypectomy, regardless of size. (ii) Non-pedunculated-type tumor larger than 20 mm in diameter is an indication for ESD in which en bloc resection using conventional EMR is difficult or impossible. (iii) Non-pedunculated-type tumor from 10 mm to 20 mm in diameter is an indication for conventional EMR. However, ESD or modified ER methods are acceptable according to the procedure and the condition of the tumor.
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Affiliation(s)
- Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Uraoka
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naoto Tamai
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroaki Ikematsu
- Department of Gastrointestinal Oncology & Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koichi Okamoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Hisashi Shiga
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Spiro Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bo-In Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Takahisa Matsuda
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
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Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 2017; 31:4174-4183. [PMID: 28342125 DOI: 10.1007/s00464-017-5474-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies comparing the efficacy and safety of conventional saline-assisted piecemeal endoscopic mucosal resection (EMR) to underwater EMR (UEMR) without submucosal lifting of colorectal polyps are lacking. The objective of this study was to compare the efficacy and safety of EMR to UEMR of large colorectal polyps. METHODS Two hundred eighty-nine colorectal polyps were removed by a single endoscopist from 7/2007 to 2/2015 using EMR or UEMR. 135 polyps (EMR: 62, UEMR: 73) that measured ≥15 mm and had not undergone prior attempted polypectomy were evaluated for rates of complete macroscopic resection and adverse events. 101 of these polyps (EMR: 46, UEMR: 55) had at least 1 follow-up colonoscopy and were studied for rates of recurrence and the number of procedures required to achieve curative resection. RESULTS The rate of complete macroscopic resection was higher following UEMR compared to EMR (98.6 vs. 87.1%, p = 0.012). UEMR had a lower recurrence rate at the first follow-up colonoscopy compared to EMR (7.3 vs. 28.3%, OR 5.0 for post-EMR recurrence, 95% CI: [1.5, 16.5], p = 0.008). UEMR required fewer procedures to reach curative resection than EMR (mean of 1.0 vs. 1.3, p = 0.002). There was no significant difference in rates of adverse events. CONCLUSIONS UEMR appears superior to EMR for the removal of large colorectal polyps in terms of rates of complete macroscopic resection and recurrent (or residual) abnormal tissue. Compared to conventional EMR, UEMR may offer increased procedural effectiveness without compromising safety in the removal of large colorectal polyps without prior attempted resection.
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Gaglia A, Sarkar S. Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection. Ann Gastroenterol 2016; 30:145-151. [PMID: 28243034 PMCID: PMC5320026 DOI: 10.20524/aog.2016.0104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/04/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Asimina Gaglia
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Sanchoy Sarkar
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
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Ngamruengphong S, Pohl H, Haito-Chavez Y, Khashab MA. Update on Difficult Polypectomy Techniques. Curr Gastroenterol Rep 2016; 18:3. [PMID: 26714965 DOI: 10.1007/s11894-015-0476-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endoscopists often encounter colon polyps that are technically difficult to resect. These lesions traditionally were managed surgically, with significant potential morbidity and mortality. Recent advances in endoscopic techniques and instruments have allowed endoscopists to safely and effectively remove colorectal lesions with high technical and clinical success and potentially avoid invasive surgery. Endoscopic mucosal resection (EMR) has gained acceptance as the first-line therapy for large colorectal lesions. Endoscopic submucosal dissection (ESD) has been reported to be associated with higher rate of en bloc resection and less risk of short-time recurrence, but with an increased risk of adverse events. Therefore, the role of colorectal ESD should be restricted to lesions with high-risk morphologic features of submucosal invasion. In this article, we review the recent literature on the endoscopic management of difficult colorectal neoplasms.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA
| | - Heiko Pohl
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Gastroenterology, VA Medical Center White River Junction, White River Junction, VT, USA
| | - Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA.
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Saunders BP, Tsiamoulos ZP. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 2016; 13:486-96. [PMID: 27353401 DOI: 10.1038/nrgastro.2016.96] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.
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Affiliation(s)
- Brian P Saunders
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
| | - Zacharias P Tsiamoulos
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
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De Ceglie A, Hassan C, Mangiavillano B, Matsuda T, Saito Y, Ridola L, Bhandari P, Boeri F, Conio M. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review. Crit Rev Oncol Hematol 2016; 104:138-55. [PMID: 27370173 DOI: 10.1016/j.critrevonc.2016.06.008] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/23/2016] [Accepted: 06/14/2016] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | - Cesare Hassan
- Gastroenterology Department, Nuovo Regina Margherita Hospital, Rome, Italy
| | | | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Lorenzo Ridola
- Gastroenterology Unit, "Sapienza" University, Rome, Italy
| | - Pradeep Bhandari
- Gastroenterology Department, Portsmouth Hospital NHS Trust, Portsmouth, Hampshire, UK
| | - Federica Boeri
- Gastroenterology Department, General Hospital, Sanremo, Italy
| | - Massimo Conio
- Gastroenterology Department, General Hospital, Sanremo, Italy.
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Gaspar JP, Stelow EB, Wang AY. Approach to the endoscopic resection of duodenal lesions. World J Gastroenterol 2016; 22:600-17. [PMID: 26811610 PMCID: PMC4716062 DOI: 10.3748/wjg.v22.i2.600] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 10/14/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.
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How to deal with large colorectal polyps: snare, endoscopic mucosal resection, and endoscopic submucosal dissection; resect or refer? Curr Opin Gastroenterol 2016; 32:26-31. [PMID: 26627920 DOI: 10.1097/mog.0000000000000228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The importance of accurate polyp detection and removal is paramount to preventing colon cancer. Resection of large polyps can be challenging to the endoscopist based on their size, shape, or location. Large polyps have the potential of harboring malignancy and a higher risk of complications with resection. Careful assessment of each lesion and meticulous resection using the appropriate tools and techniques is essential. RECENT FINDINGS Over the last 15 years, the development of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) techniques has presented the endoscopist with the opportunity to manage patients with large and flat lesions thereby avoiding the need for surgery. However, these techniques are complex and require extensive knowledge and skill in the use of various devices to resect a lesion completely and manage bleeding and perforation associated with these procedures. SUMMARY Large colon polyps manifest as either polypoid or nonpolypoid (flat) lesions. Polypoid lesions, especially those with pedicles, are removed with snare resection, whereas flat lesions may require the use of EMR or ESD. Resection of large polyps (>1 cm) requires additional tools and techniques to ensure safe and complete resection. We will discuss our approach to dealing with large colorectal polyps: snare, EMR, and ESD; resect or refer?
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Amato A, Radaelli F, Spinzi G. Underwater endoscopic mucosal resection: The third way for en bloc resection of colonic lesions? United European Gastroenterol J 2015; 4:595-8. [PMID: 27536370 DOI: 10.1177/2050640615617635] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/24/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection without submucosal injection has been described for removing large flat colorectal lesions. OBJECTIVE We aim to evaluate the reproducibility of this technique in terms of ease of implementation, safety and efficacy. METHODS A prospective observational study of consecutive underwater endoscopic mucosal resection in a community hospital was performed. RESULTS From September 2014 to April 2015, 25 flat or sessile colorectal lesions (median size 22.8 mm, range 10-50 mm; 18 placed in the right colon) were removed in 25 patients. Two of the lesions were adenomatous recurrences on scar of prior resection and one was a recurrence on a surgical anastomosis. The resection was performed en bloc in 76% of the cases. At the pathological examination, 14 lesions (56%) had advanced histology and seven (28%) were sessile serrated adenomas (two with high-grade dysplasia). Complete resection was observed in all the lesions removed en bloc. Intra-procedural bleeding was observed in two cases; both were managed endoscopically and were uneventful. No major adverse events occurred. CONCLUSION Underwater endoscopic mucosal resection appears to be an easy, safe and effective technique in a community setting. Further studies evaluating the efficacy of the technique (early and late recurrence), as well as comparing it with traditional mucosal resection, are warranted.
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Affiliation(s)
- Arnaldo Amato
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
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Sugimoto S, Mizukami T. Diagnostic and therapeutic applications of water-immersion colonoscopy. World J Gastroenterol 2015; 21:6451-6459. [PMID: 26074684 PMCID: PMC4458756 DOI: 10.3748/wjg.v21.i21.6451] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/15/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy techniques combining or replacing air insufflation with water infusion are becoming increasingly popular. They were originally designed to reduce colonic spasms, facilitate cecal intubation, and lower patient discomfort and the need for sedation. These maneuvers straighten the rectosigmoid colon and enable the colonoscope to be inserted deeply without causing looping of the colon. Water-immersion colonoscopy minimizes colonic distension and improves visibility by introducing a small amount of water. In addition, since pain during colonoscopy indicates risk of bowel perforation and sedation masks this important warning, this method has the potential to be the favored insertion technique because it promotes patient safety without sedation. Recently, this water-immersion method has not only been used for colonoscope insertion, but has also been applied to therapy for sigmoid volvulus, removal of lesions, lower gastrointestinal bleeding, and therapeutic diagnosis of abnormal bowel morphology and irritable bowel syndrome. Although a larger sample size and prospective head-to-head-designed studies will be needed, this review focuses on the usefulness of water-immersion colonoscopy for diagnostic and therapeutic applications.
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Curcio G, Granata A, Ligresti D, Tarantino I, Barresi L, Liotta R, Traina M. Underwater colorectal EMR: remodeling endoscopic mucosal resection. Gastrointest Endosc 2015; 81:1238-42. [PMID: 25746979 DOI: 10.1016/j.gie.2014.12.055] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/21/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Underwater EMR (UEMR) has been reported as a new technique for the removal of large sessile colorectal polyps without need for submucosal injection. OBJECTIVE To evaluate (1) outcomes of UEMR, (2) whether UEMR can be easily performed by an endoscopist skilled in traditional EMR without specific dedicated training in UEMR, and (3) whether EUS is required before UEMR. DESIGN Prospective, observational study. SETTING Single, tertiary-care referral center. INTERVENTION Underwater EMR. MAIN OUTCOME MEASUREMENTS Complete resection and adverse events. RESULTS A total of 72 consecutive patients underwent UEMR of 81 sessile colorectal polyps. EUS was performed before UEMR in 9 cases (11.1%) with a suspicious mucosal/vascular pattern. The mean polyp size was 18.7 mm (range 10-50 mm); the mean UEMR time was 11.8 minutes. Fifty-five polyps (68%) were removed en bloc, and 26 (32%) were removed with a piecemeal technique. Histopathology consisted of tubular adenomas (25.9%), tubulovillous adenomas (5%), adenomas with high-grade dysplasia (42%), serrated polyps (4.9%), carcinoma in situ (13.6%), and hyperplastic polyps (8.6%). Surveillance colonoscopy was scheduled at 3 months. Complete resection was successful in all patients. No adverse events or recurrence was recorded in any of the patients. LIMITATIONS Limited follow-up; single-center, uncontrolled study. CONCLUSION Interventional endoscopists skilled in conventional EMR performed UEMR without specific dedicated training. EUS may not be required for lesions with no invasive features on high-definition narrow-band imaging. UEMR appears to be an effective and safe alternative to traditional EMR and could eventually improve the way in which we can effectively and safely treat colorectal lesions.
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Affiliation(s)
- Gabriele Curcio
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Rosa Liotta
- Pathology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
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Attempted underwater en bloc resection for large (2-4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc 2015; 81:713-8. [PMID: 25708759 DOI: 10.1016/j.gie.2014.10.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 10/28/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the feasibility and outcomes of attempted underwater en bloc resection (UEBR) of large colorectal laterally spreading tumors (LSTs). DESIGN Prospective, observational study. SETTING Tertiary academic referral center. PATIENTS Fifty patients meeting the inclusion and exclusion criteria. INTERVENTIONS Standardized UEBR technique involving attempted en bloc resection without submucosal injection by using a large 33-mm snare. MAIN OUTCOME MEASUREMENTS Complete endoscopic en bloc resection, histologic complete resection, procedure time, adverse events, and follow-up data. RESULTS Over 13 months, UEBR was attempted in 50 patients (median age, 68 years) with 53 LSTs 2 to 4 cm in size. The median LST size was 30 mm (range 20-40 mm). The median procedure and resection times were 38 minutes (range 17-87 minutes) and 3 minutes (range 1-32 minutes), respectively. Complete endoscopic en bloc resection with the 33-mm snare was successful in 29 of 53 lesions (55%). Of these, histology showed neoplasia-free margins in 79%. Final histology was tubular adenoma (n = 26), sessile serrated adenoma (n = 10), tubulovillous adenoma (n = 14), villous adenoma (n = 2), and intramucosal carcinoma (n = 1). Adverse events (4%) were delayed bleeding in 1 and abdominal pain in 1 patient each. There were no perforations. Forty patients with a total of 43 adenomas had follow-up colonoscopy with biopsies of the resection site after a median of 31 weeks (range 7-71 weeks) after resection. Residual adenoma was found in 2 of 43 (5%). LIMITATIONS Single-center, limited follow-up. CONCLUSION On an intention-to-treat basis, complete endoscopic en bloc resection was achieved in 55% of lesions with complete histologic resection verified in 79% of the en bloc specimens. UEBR without submucosal injection appears safe. Refinements are needed to improve UEBR success rates.
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Sessile serrated polyps: detection, eradication, and prevention of the evil twin. ACTA ACUST UNITED AC 2015; 13:156-70. [PMID: 25623474 DOI: 10.1007/s11938-015-0046-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT The sessile serrated polyp (SSP), also known as sessile serrated adenoma, is the evil twin among the colorectal cancer precursors. As will be described, these lesions have multiple aliases (serrated adenoma, serrated polyp, or serrated lesion among others), they hang out in a bad neighborhood (the poorly prepped right colon), they hide behind a mask of mucus, they are difficult for witnesses (pathologists) to identify, they are difficult for police (endoscopists) to find, they are difficult to permanently remove from the society (high incomplete resection rate), they can be impulsive (progress rapidly to colorectal cancer (CRC)), and enforcers (gastroenterologists) do not know how best to control them (uncertain surveillance recommendations). There is no wonder that there is a need to understand these lesions well, learn how best to prevent the colonic mucosa from going down this errant path or, if that fails, detect these deviants and eradicate them from the colonic society. These lesions should be on endoscopists' most wanted list.
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