Prophylactic Snare Tip Soft Coagulation and Its Impact on Adenoma Recurrence After Colonic Endoscopic Mucosal Resection

Analyzing methods for reducing recurrence rates after EMR of large nonpedunculated colorectal polyps: an indirect pairwise comparison

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.

Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis

(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.

Recurrences of advanced sessile and lateral spreading colorectal adenoma after endoscopic mucosal resection (EMR) thermal ablation versus no adjuvant therapy (RESPECT): a protocol of an international randomized controlled trial

BACKGROUND

Nowadays, large benign lateral spreading lesions (LSLs) and sessile polyps in the colorectum are mostly resected by endoscopic mucosal resection (EMR). A major drawback of EMR is the polyp recurrence rate of up to 20%. Snare tip soft coagulation (STSC) is considered an effective technique to reduce recurrence rates. However, clinical trials on STSC have mainly been conducted in expert referral centers. In these studies, polyp recurrence was assessed optically, and additional adjunctive techniques were excluded. In the current trial, we will evaluate the efficacy and safety of STSC in daily practice, by allowing adjunctive techniques during EMR and the use of both optical and histological polyp recurrence to assess recurrences during follow-up.

METHODS

The RESPECT study is a multicenter, parallel-group, international single blinded randomized controlled superiority trial performed in the Netherlands and Germany. A total of 306 patients undergoing piecemeal EMR for LSLs or sessile colorectal polyps sized 20-60 mm will be randomized during the procedure after endoscopic complete polyp resection to the intervention or control group. Post-EMR defects allocated to the intervention group will be treated with thermal ablation with STSC of the entire resection margin. Primary outcome will be polyp recurrence by optical and histological confirmation at the first surveillance colonoscopy after 6 months. Secondary outcomes include technical success and complication rates.

DISCUSSION

The RESPECT study will evaluate if STSC is effective in reducing recurrence rates after piecemeal EMR of large colorectal lesions in daily clinical practice performed by expert and non-expert endoscopists. Moreover, endoscopists will be allowed to use adjunctive techniques to remove remaining adenomatous tissue during the procedure. Finally, adenomatous polyp recurrence during follow-up will be defined by histologic identification.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05121805. Registered on 16 November 2021. Start recruitment: 17 March 2022. Planned completion of recruitment: 31 April 2025.

Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial

BACKGROUND

Endoscopic resection of adenomas prevents colorectal cancer, but the optimal technique for larger lesions is controversial. Piecemeal endoscopic mucosal resection (EMR) has a low adverse event (AE) rate but a variable recurrence rate necessitating early follow-up. Endoscopic submucosal dissection (ESD) can reduce recurrence but may increase AEs.

OBJECTIVE

To compare ESD and EMR for large colonic adenomas.

DESIGN

Participant-masked, parallel-group, superiority, randomized controlled trial. (ClinicalTrials.gov: NCT03962868).

SETTING

Multicenter study involving 6 French referral centers from November 2019 to February 2021.

PARTICIPANTS

Patients with large (≥25 mm) benign colonic lesions referred for resection.

INTERVENTION

The patients were randomly assigned by computer 1:1 (stratification by lesion location and center) to ESD or EMR.

MEASUREMENTS

The primary end point was 6-month local recurrence (neoplastic tissue on endoscopic assessment and scar biopsy). The secondary end points were technical failure, en bloc R0 resection, and cumulative AEs.

RESULTS

In total, 360 patients were randomly assigned to ESD (n = 178) or EMR (n = 182). In the primary analysis set (n = 318 lesions in 318 patients), recurrence occurred after 1 of 161 ESDs (0.6%) and 8 of 157 EMRs (5.1%) (relative risk, 0.12 [95% CI, 0.01 to 0.96]). No recurrence occurred in R0-resected cases (90%) after ESD. The AEs occurred more often after ESD than EMR (35.6% vs. 24.5%, respectively; relative risk, 1.4 [CI, 1.0 to 2.0]).

LIMITATION

Procedures were performed under general anesthesia during hospitalization in accordance with the French health system.

CONCLUSION

Compared with EMR, ESD reduces the 6-month recurrence rate, obviating the need for systematic early follow-up colonoscopy at the cost of more AEs.

PRIMARY FUNDING SOURCE

French Ministry of Health.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

Impact of margin thermal treatment after EMR of giant (≥40 mm) colorectal lateral spreading lesions

BACKGROUND AND AIMS

Increasing lesion size is a risk factor for recurrence after piecemeal EMR (pEMR). Snare-tip soft coagulation (STSC) treatment of the normal-appearing margin after pEMR of lesions ≥ 20 mm has been shown to reduce recurrence rates by 75% to 80%. We sought to evaluate the impact of STSC on giant (≥ 40 mm) lateral spreading lesions treated by pEMR. We describe the relative risk and absolute risks of recurrence with and without STSC margin treatment after EMR of ≥ 40-mm lesions.

METHODS

We performed a retrospective evaluation of a prospectively collected database on large lesions describing lesion size, location, and methods of resection. We excluded lesions < 40 mm in maximum dimension, those that did not undergo follow-up care at our center, and those in which argon plasma coagulation was used for either ablative treatment of residual polyp or margin treatment. Propensity score analysis was used to account for potential differences between patients treated with and without STSC.

RESULTS

There were 68 lesions ≥ 40 mm removed by pEMR without STSC treatment and 133 removed and treated with STSC. There were no differences between groups in demographics, polyp size, location, histologic features, and mean follow-up time. The recurrence rate in the no-treatment group was 35% versus 9% with STSC (P < .00001 by direct comparison and P = .008 by using the propensity score analysis).

CONCLUSION

STSC treatment after pEMR of large lateral spreading lesions in the colorectum reduced recurrences by 75%. However, the absolute recurrence rate of 9% remained clinically significant in the STSC-treated group. Short-term follow-up care after STSC of lesions ≥ 40 mm is still warranted, and additional study of technical factors that eliminate recurrence after pEMR of giant lateral spreading lesions is warranted.

EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos)

BACKGROUND AND AIMS

EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR.

METHODS

Adult patients (aged 18-89 years) undergoing EMR of nonpedunculated colorectal polyps ≥20 mm were enrolled in a prospective multicenter study. h-APC was used to ablate all defect margins and also the resection surface in selected cases. The primary study outcome was recurrence rates found during the first follow-up colonoscopy. Secondary outcomes were technical success and adverse event rates.

RESULTS

EMR with h-APC ablation was used in 101 polyps (84 patients, 46.4% women). EMR with h-APC ablation was technically successful in all cases (median EMR time, 15 minutes; median h-APC ablation time, 4 minutes). Median polyp size was 30 mm (range, 20-60). Resected polyps were either adenomas (68/101 [67.3%]), sessile serrated lesions (27/101 [27%]), or adenocarcinomas (6/101 [6%]). The post-EMR recurrence rate was 2.2% (2/91) (95% confidence interval, .27-7.71). All 6 patients with cancer (intramucosal cancer, 4; T1sm cancer, 2) were found to have complete eradication of the primary tumor after EMR with h-APC, and none had lymph node metastasis. Four serious adverse events occurred in 3 patients (2 delayed bleeding [2.4%], 1 abdominal pain [1.2%], and 1 microperforation [1.2%]. All serious adverse events resolved with either endoscopic or antibiotic treatment only.

CONCLUSIONS

EMR with h-APC showed a high technical success rate, low adverse event rate, and very low post-EMR recurrence rates. (Clinical trial registration number: NCT04015765.).

Post-EMR for colorectal polyps, thermal ablation of defects reduces adenoma recurrence: A meta-analysis

Background and study aims  Adenoma recurrence is one of the key limitations of endoscopic mucosal resection (EMR), which occurs in 15 % to 30 % of cases during first surveillance colonoscopy. The main hypothesis behind adenoma recurrence is leftover micro-adenomas at the margins of post-EMR defects. In this systematic review and meta-analysis, we evaluated the efficacy of snare tip soft coagulation (STSC) at the margins of mucosal defects to reduce adenoma recurrence and bleeding complications. Methods  Electronic databases such as PubMed and the Cochrane library were used for systematic literature search. Studies with polyps only resected by piecemeal EMR and active treatment: with STSC, comparator: non-STSC were included. A random effects model was used to calculate the summary of risk ratio and 95 % confidence intervals. The main outcome of the study was to compare the effect of STSC versus non-STSC with respect to adenoma recurrence at first surveillance colonoscopy after thermal ablation of post-EMR defects. Results  Five studies were included in the systematic review and meta-analysis. The total number patients who completed first surveillance colonoscopy (SC1) in the STSC group was 534 and in the non-STSC group was 514. The pooled adenoma recurrence rate was 6 % (37 of 534 cases) in the STSC arm and 22 % (115 of 514 cases) in the non-STSC arm, (odds ratio [OR] 0.26, 95 % confidence interval [CI], 0.16-0.41, P  = 0.001). The pooled delayed post-EMR bleeding rate 19 % (67 of 343) in the STSC arm and 22 % (78 of 341) in the non-STSC arm (OR 0.82, 95 %CI, 0.57-1.18). Conclusions  Thermal ablation of post-EMR defects significantly reduces adenoma recurrence at first surveillance colonoscopy.

Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis

Background and study aims  Endoscopic mucosal resection of large non-pedunculated colorectal polyps is characterized by a high risk of recurrence. Thermal ablation of the mucosal defect margins may reduce recurrence in these lesions, but a systematic overview of the current evidence is lacking. Methods  We searched PubMed, Embase and Cochrane until July 2021, for studies on thermal ablation of mucosal defect margins of large non-pedunculated colorectal polyps. Main goal of this meta-analysis was to identify pooled risk difference of recurrence between thermal ablation vs. no adjuvant treatment. Secondary goal was to identify pooled recurrence rate after snare tip soft coagulation (STSC) and argon plasma coagulation (APC). Results  Ten studies on thermal ablation of mucosal defect margins were included, with three studies on argon plasma coagulation, six studies on snare tip soft coagulation and one study comparing both treatment modalities, representing a total of 316 APC cases and 1598 STSC cases. Overall pooled risk difference of recurrence was -0.17 (95 % confidence interval [CI] -0.22 to -0.12) as compared to no adjuvant treatment. Pooled risk difference was -0.16 (95 % CI -0.19 to -0.14) for STSC and -0.26 (95 % CI -0.80 to 0.28) for APC. Pooled recurrence rate was 4 % (95 % CI 2 % to 8 %) for STSC and 9 % (95 % CI 4 % to 19 %) for APC. Conclusions  Thermal ablation of mucosal defect margins significantly reduces recurrence rate in large non-pedunculated colorectal lesions compared to no adjuvant treatment. While no evidence for superiority exists, STSC may be preferred over APC, because this method is the most evidence-based, and cost-effective modality.

Endoscopic submucosal dissection or piecemeal endoscopic mucosal resection for large superficial colorectal lesions: A cost effectiveness study

BACKGROUND AND AIMS

Endoscopic management is preferred to surgical management for large superficial colorectal lesions. However, the optimal endoscopic resection strategy (piecemeal endoscopic mucosal resection [pEMR] or endoscopic submucosal dissection [ESD]) is still debated from an economical point of view. To date, in France, there is no Health Insurance reimbursement rate for the hospital stays related to ESD. We searched to estimate the global cost of colorectal ESD and to define the most cost-effectiveness endoscopic strategy.

METHODS

A model was created to compare the cost-effectiveness of ESD and pEMR according to optical diagnosis (Japan NBI Expert Team [JNET], laterally spreading tumour [LST], CONECCT). We distinguished three groups from the same multicentre ESD cohort and compared the medical and economic outcomes: real-life ESD data (Universal-ESD or U-ESD) compared to modelled selective ESD (S-ESD JNET; S-ESD LST; S-ESD CONECCT) and exclusive pEMR strategies (Universal-EMR or U-EMR).

RESULTS

The en-bloc, R0, and curative resection rates were 97.5%, 86.5%, and 82.6%, respectively in the real life French ESD cohort of 833 colorectal lesions. U-ESD was the least-expensive strategy, with a global cost of 2,858,048.17 €, i.e. 3,431.03 €/patient and was also the most effective strategy because it avoided 774 surgeries, which was more than any other strategy. It outperformed S-ESD CONNECT (global cost = 2,951,411.44 €, and 3,543.11 €/patient, 765 surgeries avoided, S-ESD LST (global cost = 3,055,951.53 €, and 3,668.61 €/patient, 749 surgeries avoided), and S-ESD JNET (global cost = 3,547,426.97 € and 4,258.62 €/patient, 704 surgeries avoided) and U-EMR (global cost = 4,060,547.62 € and 4,874.61 €/patient, 620 surgeries avoided). Even though a model which optimized pEMR results (0% technical failure, 0% primary surgery), U-EMR strategy remained the most expansive strategy and the one that avoided the least surgeries.

CONCLUSION

ESD for all LSTs upper than 20 mm is more cost-effective than pEMR, and S-ESD.

Margin marking before colorectal endoscopic mucosal resection and its impact on neoplasia recurrence (with video)

BACKGROUND AND AIMS

Ablation of resection margins after EMR of large nonpedunculated colorectal polyps decreases recurrence. Margin marking before EMR (EMR-MM) may represent an alternative method to achieve a healthy resection margin. We aimed to determine the efficacy of EMR-MM in reducing neoplasia recurrence.

METHODS

We conducted a single-center historical control study of EMR cases (EMR-MM vs conventional EMR) for nonpedunculated polyps ≥20 mm between 2016 and 2021. For EMR-MM, cautery marks were placed along the lateral margins of the polyp with the snare tip. EMR was then performed to include resection of the healthy mucosa containing the marks. We compared recurrence at surveillance colonoscopy after EMR-MM versus historical control subjects. Multivariable logistic regression was performed to identify factors associated with recurrence.

RESULTS

Two hundred ten patients with 210 polyps (median size, 30 mm; interquartile range: 25-40) underwent EMR-MM (n = 74) or conventional EMR (n = 136). Patient and lesion characteristics were similar between the groups. At a median follow-up of 6 months, the recurrence rate was lower with EMR-MM (6/74; 8%) compared with historical control subjects (39/136; 29%) (P < .001). EMR-MM was not associated with an increased rate of adverse events. On multivariable analysis, EMR-MM remained the strongest predictor of recurrence (odds ratio, .20; 95% confidence interval, .13-.64; P = .003) aside from polyp size (odds ratio, 2.81; 95% confidence interval, 1.35-6.01; P = .008).

CONCLUSIONS

In this single-center historical control study, EMR-MM of large nonpedunculated colorectal polyps reduced the recurrence risk by 80% when compared with conventional EMR. This simple technique may provide an alternative to margin ablation.

Advanced Endoscopic Resection Techniques: Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection

Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.

Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (> 20 mm) non pedunculated colorectal polyps: a systematic review and meta-analysis

Background and study aims  Endoscopic mucosal resection (EMR) of laterally spreading tumors (LSTs) > 20 mm in size can be challenging. Piecemeal EMR of these lesions results in high rates of adenoma recurrence at first surveillance colonoscopy (SC1). Snare tip soft coagulation (STSC) of post resection margins is a safe and effective technique to prevent adenoma recurrence. We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of this technique. Patients and methods  Multiple databases were searched through April 2021 for studies that reported on outcomes of post EMR STSC for LSTs > 20 mm in size. Meta-analysis was performed to determine pooled odds of adenoma recurrence as well as pooled proportion of adverse events including intraprocedural and delayed bleeding as well as intraprocedural perforation events. Results  Six studies including two randomized controlled trials (RCT) and four cohort studies with 2122 patients were included in the final analysis. Overall pooled odds of adenoma recurrence at SC1 with post EMR STSC compared to no STSC was 0.27 (95 % 0.18-0.42; I2 = 0 %), P < 0.001. Pooled rate of adenoma recurrence at SC1 in post EMR STSC cohort was 6 %. Rates of intraprocedural bleeding, delayed bleeding and intraprocedural perforation were 10.3 %, 6.5 % and 2 % respectively. Conclusions  Our results show that thermal ablation of resection margins with STSC in LSTs > 20 mm is a safe and effective technique in reducing the incidence of adenoma recurrence.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Previously Attempted Large Nonpedunculated Colorectal Polyps Are Effectively Managed by Endoscopic Mucosal Resection

INTRODUCTION

Endoscopic mucosal resection (EMR) is an effective therapy for naive large nonpedunculated colorectal polyps (N-LNPCPs). The best approach for the treatment of previously attempted LNPCPs (PA-LNPCPs) is undetermined.

METHODS

EMR performance for PA-LNPCPs was evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by technical success (removal of all visible polypoid tissue during index EMR) and recurrence at first surveillance colonoscopy (SC1). Safety was assessed by clinically significant intraprocedural bleeding, deep mural injury types III-V, clinically significant post-EMR bleeding, and delayed perforation.

RESULTS

From January 2012 to October 2019, 158 PA-LNPCPs and 1,134 N-LNPCPs underwent EMR. Median PA-LNPCP size was 30 mm (interquartile range 25-46 mm). Technical success was 93.0% and increased to 95.6% after adjusting for 2-stage EMR. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) was required for nonlifting polypoid tissue in 73 (46.2%). Median time to SC1 was 6 months (interquartile range 5-7 months). Recurrence occurred in 9 (7.8%). No recurrence was identified among 65 PA-LNPCPs which underwent margin thermal ablation at SC1 vs 9 (18.0%; P < 0.001) which did not. There were significant differences in resection duration (35 vs 25 minutes; P < 0.001), technical success (93.0% vs 96.6%; P = 0.026), and use of CAST (46.2% vs 7.6%; P < 0.001), between PA-LNPCPs and N-LNPCPs. When adjusting for 2-stage EMR, no difference in technical success was identified (95.6% vs 97.8%; P = 0.100). No differences in adverse events or recurrence were identified.

DISCUSSION

EMR, using auxillary techniques where necessary, can achieve high technical success and low recurrence frequencies for PA-LNPCPs.

Incomplete endoscopic resection of colorectal polyps: a prospective quality assurance study

BACKGROUND

 Endoscopic screening with polypectomy has been shown to reduce colorectal cancer incidence in randomized trials. Incomplete polyp removal and subsequent development of post-colonoscopy cancers may attenuate the effect of screening. This study aimed to quantify the extent of incomplete polyp removal.

METHODS

 We included patients aged 50-75 years with nonpedunculated polyps ≥ 5 mm removed during colonoscopy at four hospitals in Norway. To evaluate completeness of polyp removal, biopsies from the resection margins were obtained after polypectomy. Logistic regression models were fitted to identify factors explaining incomplete resection.

RESULTS

 246 patients with 339 polyps underwent polypectomy between January 2015 and June 2017. A total of 12 polyps were excluded due to biopsy electrocautery damage, and 327 polyps in 246 patients (mean age 67 years [range 42-83]; 52 % male) were included in the analysis. Overall, 54 polyps (15.9 %) in 54 patients were incompletely resected. Histological diagnosis of the polyp (sessile serrated lesions vs. adenoma, odds ratio [OR] 10.9, 95 % confidence interval [CI] 3.9-30.1) and polyp location (proximal vs. distal colon, OR 2.8, 95 %CI 1.0-7.7) were independent risk factors for incomplete removal of polyps 5-19 mm. Board-certified endoscopists were not associated with lower rates of incomplete resection compared with trainees (14.0 % vs. 14.2 %), OR 1.0 (95 %CI 0.5-2.1).

CONCLUSION

Incomplete polyp resection was frequent after polypectomy in routine clinical practice. Serrated histology and proximal location were independent risk factors for incomplete resection. The performance of board-certified gastroenterologists was not superior to that of trainees.

Prediction of adenoma recurrence after piecemeal endoscopic mucosal resection: interobserver agreement and utilization of the Sydney EMR recurrence tool

Background and aims: Piecemeal endoscopic mucosal resection (pEMR) allows resection of larger non-invasive colorectal lesions. Adenoma recurrence is an important limitation and occurs in ≤20%. The present study aimed to validate the Sydney EMR recurrence tool (SERT) score as a predictor of both endoscopic and histologic recurrence and evaluate interobserver agreement in adenoma recurrence based on endoscopic scar assessment, among nonexperts in EMR.Methods: Retrospective cohort and cross-sectional study, in which all patients submitted to pEMR in a tertiary care center in Portugal, between 2012 and 2018 were included. SERT-score was calculated for all lesions and compared with the SMSA (size, morphology, site, access) score already validated as a predictor of adenoma recurrence. Image based offline analysis was performed to evaluate adenoma recurrence prediction and assess the interobserver agreement within a heterogeneous group of participants, mostly composed by nonexperts in EMR.Results: There was a moderate positive correlation between the SERT and SMSA scores (p <.001; r = 0.61). SERT-score was significantly associated with endoscopic recurrence (p =.005) and histologic recurrence (p = .015). Endoscopic prediction of recurrence had high coefficient of agreement (k-0.806; p < .001).Conclusion: Histologic recurrence after pEMR can be predicted by SERT score and optical diagnosis of recurrent adenoma has high interobserver agreement between nonexperts in EMR.

Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction

OBJECTIVE

The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs.

DESIGN

EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC).

RESULTS

Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027).

CONCLUSION

EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.