EMR should be the first-line treatment for large laterally spreading colorectal lesions

Underwater cap-suction pseudopolyp formation for endoscopic mucosal resection: a simple technique for treating flat, appendiceal orifice or ileocecal valve colorectal lesions

BACKGROUND

We aimed to evaluate the safety and technical success of an easy-to-use technique that applies underwater cap suction pseudopolyp formation to facilitate the resection of flat lesions or those at the appendiceal orifice or ileocecal valve.

METHODS

We retrospectively analyzed a register of consecutive cap suction underwater endoscopic mucosal resection (CAP-UEMR) procedures performed at two centers between September 2020 and December 2021. Procedures were performed using a cone-shaped cap, extending 7 mm from the endoscope tip, to suction the lesion while submerged underwater, followed by underwater snare resection. Our primary end point was technical success, defined as macroscopic complete resection.

RESULTS

We treated 83 lesions (median size 20 mm; interquartile range [IQR] 15-30 mm) with CAP-UEMR: 64 depressed or flat lesions (18 previously manipulated, 9 with difficult access), 11 from the appendix, and 8 from the ileocecal valve. Technical success was 100 %. There were seven intraprocedural bleedings and two delayed bleedings, all managed endoscopically. No perforations or other complications occurred. Among the 64 lesions with follow-up colonoscopy, only one recurrence was detected, which was treated endoscopically.

CONCLUSIONS

CAP-UEMR was a safe and effective technique for removing nonpolypoid colorectal lesions, including those arising from the appendiceal orifice or ileocecal valve.

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.

From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s

Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.

SMALL AS WELL AS LARGE COLORECTAL LESIONS ARE EFFECTIVELY MANAGED BY ENDOSCOPIC MUCOSAL RESECTION TECHNIQUE

ABSTRACT Background Endoscopic mucosal resection (EMR) is an easy-to-use treatment option for superficial colorectal lesions, including lesions ≥20 mm. Objective To evaluate the effectiveness of EMR. Methods We evaluated 430 lesions removed by EMR in 404 patients. The lesions were analyzed according to their morphology, size, location, and histology. Lesions <20 mm were resected en bloc, whereas lesions ≥20 mm were removed by piecemeal EMR (p-EMR). Adverse events and recurrence were assessed. Results Regarding morphology, 145 (33.7%) were depressed lesions, 157 (36.5%) were polypoid lesions and 128 (29.8%) were laterally spreading lesions, with 361 (84%) lesions <20 mm and 69 (16%) ≥20 mm. Regarding histology, 413 (96%) lesions were classified as neoplastic lesions. Overall, 14 (3.3%) adverse reactions occurred, most commonly in lesions removed by p-EMR (P<0.001) and associated with advanced histology (P=0.008). Recurrence occurred in 14 (5.2%) cases, more commonly in lesions removed by p-EMR (P<0.001). Conclusion EMR is an effective technique for the treatment of superficial colorectal lesions, even of large lesions.

Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence

BACKGROUND AND AIMS

EMR of large (≥2 cm) nonpedunculated colorectal polyps (LNPCPs) is associated with high rates of recurrent/residual adenoma, possibly because of microadenoma left at the margin of resection. Data supporting this mechanism are required. We aimed to determine the incidence of residual microadenoma at the defect margin and base after EMR.

METHODS

We performed a retrospective observational study of patients undergoing EMR of large LNPCPs with the lateral defect margin further resected using the EndoRotor device (Interscope Medical, Inc, Worcester, Mass, USA) after confirming no visible residual adenomatous tissue. Aspects of the defect base were also resected in selected patients. Patients underwent surveillance at 3 to 6 months.

RESULTS

Resection of the normal defect margin was performed in 41 patients and of aspects of the base in 21 patients. Mean lesion size was 43.0 mm (range, 20-130). Microscopic residual lesion was detected in the margin of apparently normal mucosa in 8 cases (19%). In 7 cases this was an adenoma, and in 1 case a serrated lesion was found at the margin of a resected tubular adenoma. Microscopic residual lesion was detected at the base in 5 of 21 cases. Residual/recurrent adenoma was detected in 2 patients. Neither had residual microadenoma at the lateral margin or base detected after the primary resection.

CONCLUSIONS

Microscopic residual adenoma after wide-field EMR was detected in 19% of cases at the apparently normal defect margin and at the resection base in 5 of 21 cases. This study confirms the presence of residual microadenoma after resection of LNPCPs, providing evidence for the mechanism of recurrence.

Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review

Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.

The Coexistence of Colorectal Polyps in the Right Colon Increases the Malignant Risk of Laterally Spreading Tumors

Background

The coexistence of colorectal polyps with laterally spreading tumors (LSTs) is commonly observed during colonoscopy. However, there are rare studies that assess the malignant risks for LSTs with colorectal polyps, which might largely contribute to further strategies of treatment and follow-up plans in LSTs.

Methods

We conducted a retrospective cohort study that enrolled 206 patients with LSTs in the Endoscopy Center and Endoscopy Research Institute, Renji Hospital, Shanghai Jiao Tong University, China. The subjects with LSTs were divided into two groups: the nonpolyp group with 89 patients and the polyp group with 117 patients. Binary logistic regression was used to identify the independent predictors of outcomes of interest.

Results

The risk of the polyps' coexistence phenomenon increased in males compared with females (OR = 2.138, p = 0.047), especially in those between 50 and 75 years old (OR = 7.074, p = 0.036). Tumor size (3–4 cm), LSTs with tubulovillous types, and history of polyps statistically increased the risk of the polyp coexistence phenomenon (OR = 5.768, p = 0.003; OR = 36.345, p = 0.024; OR = 13.245, p < 0.0001, respectively). LST-NG-PD (OR = 20.982, p = 0.017) and LSTs ≥ 5 cm (OR = 37.604, p = 0.038) notably increased the malignant risk of LSTs. When the simultaneous polyps are located in the right colon, the risk of malignant LSTs (OR = 58.540, p = 0.013) positively increased.

Conclusion

The simultaneous colorectal polyps in the right colon were the most important risk factor to predict the malignant risk of LSTs.

Multimodal Endoscopic Assessment Guides Treatment Decisions for Rectal Early Neoplastic Tumors

BACKGROUND

There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment.

OBJECTIVE

We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions.

DESIGN

This was a retrospective study.

SETTING

The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer.

PATIENTS

A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported.

RESULTS

After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up.

LIMITATIONS

This was a retrospective study from a tertiary referral unit.

CONCLUSIONS

Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.

Long-term outcomes of endoscopic treatment for colorectal laterally spreading tumor: a large-scale multicenter retrospective study from China

BACKGROUND

Laterally spreading tumor (LST) is a type of precancerous lesion of colorectal cancer with high malignant potential. The present study aimed to evaluate long-term outcomes of endoscopic treatment for LST in Chinese patients.

METHODS

This study was a retrospective review of data collected from 653 included patients with LST from six regional representative hospitals in China between January 2007 and January 2017. Demographic characteristics, endoscopic features of LST, operation-related data, and follow-up results were collected and analyzed.

RESULTS

LST-granular type (LST-G, 80.3%) was much more common than LST-non-grandular type (LST-NG, 19.7%). The overall submucosal invasion rate of all LSTs was 6.1% and the submucosal invasion rate of LST-NG was significantly higher than that of LST-G (6.79% vs. 3.87%, p = 0.000). The en bloc resection rate of ESD and EMR treatment was 96% and 93.7%, respectively, with pathologic R0 resection rate of 90.1% and 82.8%. After an average duration of follow-up about 34.52 ± 11.76 months, the recurrence rate of ESD was 3.47%, and the recurrence rate of EMR was 8.8% after an average follow-up of about 38.44 ± 4.42 months. However, the recurrence rate of ESD was much lower than piecemeal EMR for LST (3.47% vs. 8.62%, p = 0.017). Retroflexion-assisted technique applied for resection of rectal LST was associated with a significantly shortened operating time (85.40 min vs. 174.18 min, p = 0.002).

CONCLUSION

Endoscopic resection is a safe and efficient modality for the treatment of colorectal LST with a relatively low recurrence rate and shortened operating time with the use of retroflexion.

Endoscopic management of large ileocecal valve lesions over an 18-year interval

Background and study aims  Ileocecal valve (ICV) lesions are challenging to remove endoscopically. Patients and methods  This was a retrospective cohort study, performed at an academic tertiary US hospital. Sessile polyps or flat ICV lesions ≥ 20 mm in size referred for endoscopic mucosal resection (EMR) were included. Successful resection rates, complication rates and recurrence were compared to lesions ≥ 20 mm in size not located on the ICV. Results  During an 18-year interval, there were 118 ICV lesions ≥ 20 mm with mean size 28.6 mm (44.9 % females; mean age 71.6 years), comprising 9.03 % of all referred polyps. Ninety ICV lesions (76.3 %) were resected endoscopically, compared to 91.3 % of non-ICV lesions ( P  < 0.001). However, in the most recent 8 years, successful EMR of ICV lesions increased to 93 %. Conventional adenomas comprised 92.2 % of ICV lesions and 7.8 % were serrated. Delayed hemorrhage and perforation occurred in 3.3 % and 0 % of ICV lesions, respectively, compared to 4.8 % and 0.5 % in the non-ICV group. At first follow-up, rates of residual polyp in the ICV and non-ICV groups were 16.5 % and 13.6 %, respectively ( P  = 0.485). At second follow-up residual rates in the ICV and non-ICV lesion groups were 18.6 % and 6.7 %, respectively ( P  = .005). Conclusions  Large ICV polyps are a common source of tertiary referrals. Over an 18-year experience, risk of EMR for ICV polyps was numerically lower, and risk of recurrence was numerically higher at first follow and significantly higher at second follow-up compared to non-ICV polyps.

Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps

BACKGROUND & AIMS

Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance.

METHODS

We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon.

RESULTS

We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER, 19.53 QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was dominated by TEM. TEM became cost effective when the mortality from ER exceeded 0.63%, or if the loss to follow up rate exceeded 25.5%.

CONCLUSIONS

Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER.

Risk factors for early and late adenoma recurrence after advanced colorectal endoscopic resection at an expert Western center

BACKGROUND AND AIMS

Few large Western series examine risk factors for recurrence after endoscopic resection (ER) of large (≥20 mm) colorectal laterally spreading tumors. Recurrence beyond initial surveillance is seldom reported, and differences between residual/recurrent adenoma and late recurrence are not scrutinized. We report the incidence of recurrence at successive surveillance intervals, identify risk factors for recurrent/residual adenoma and late recurrence, and describe the outcomes of ER of recurrent adenomas.

METHODS

Recurrence was calculated for successive surveillance periods after colorectal ER. Multiple logistic regression was used to identify independent risk factors for recurrent/residual adenoma and late recurrence (≥12 months).

RESULTS

Six hundred twenty colorectal ERs were performed, and 456 eligible patients (98%) had completed 3- to 6-month surveillance. Residual/recurrent adenoma (3-6 months) was detected in 8.3%, at 12 months in 6.1%, between 24 and 36 months in 6.4%, and after 36 months in 13.5%. Independent risk factors for residual/recurrent adenoma were piecemeal resection (odds ratio [OR], 13.0; P = .01), adjunctive argon plasma coagulation (OR, 2.4; P = .01), and lesion occupying ≥75% of the luminal circumference (OR, 5.6; P < .001) and for late recurrence were lesion size >60 mm (OR, 6.3; P < .001) and piecemeal resection (OR, 4.4; P = .04). Of 66 patients with recurrence, 5 required surgery, 8 left the treatment pathway, 20 are still receiving ER or surveillance, and 33 had ER with normal subsequent surveillance.

CONCLUSIONS

Recurrence occurs at successive periods of surveillance after ER even beyond 3 years. Aside from piecemeal resection, risk factors for residual/recurrent adenoma and late recurrence are different. Recurrence can be challenging to treat, but surgery is rarely required.

Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center

BACKGROUND

Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm.

OBJECTIVE

We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted in a tertiary referral unit for interventional endoscopy.

PATIENTS

A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm.

MAIN OUTCOME MEASURES

Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission.

RESULTS

Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%).

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.

Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice

Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.

Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): Clinical experience from two tertiary referral centers in Switzerland

Background

Endoscopic full thickness resection (EFTR) by the Full Thickness Resection Device (FTRD) has recently been introduced as a method to allow resection of certain lesions such as adenomatous polyps that would not be resectable by standard polypectomy techniques. We report our clinical experience with FTRD procedures, assessing technical success, completeness of resection (R0 status), rate of histologically proven FTR and safety.

Patients and methods

We conducted a retrospective analysis of 33 consecutive patients with colonic polyps treated with FTRD from May 2015 to November 2016.

Results

Indications mainly were adenoma recurrence or residual adenoma with nonlifting sign after previous polypectomy. In the 31 cases amenable to EFTR, resection was en bloc and histologically complete (R0) in 87.9% (29/33) of patients. Histologically confirmed complete full thickness resection (FTR) was achieved in 80.6% (25/31). Three post-procedure bleedings and one perforation were seen.

Conclusion

FTRD offers an additional endoscopic approach to treat nonlifting colorectal lesions. EFTR by FTRD appears to be feasible and efficacious in the resection of benign neoplasms of up to 30 mm in diameter and may be an alternative to surgery in selected patients. Given a significant rate of complications, safety is a concern and needs to be assessed in larger prospective studies.

Optimizing Resection of Large Colorectal Polyps

OPINION STATEMENT

Polypectomy reduces the incidence and mortality of colorectal cancer (CRC). The widespread adoption of CRC screening, more rigorous colonoscopy techniques, and advancements in endoscopic imaging have led to a greater awareness of complex polyps. Whereas surgery was once considered necessary for many large sessile or laterally spreading lesions (LSLs) in the colorectum, the majority can now be removed endoscopically. Endoscopic mucosal resection (EMR) is an established technique for treatment of colorectal LSLs. When performed by experts, EMR is highly effective and safe and can be completed in an outpatient or day-stay setting. Advancements in EMR effectiveness encompass a better understanding of the factors leading to post-EMR recurrence, protocols to recognize and treat it, and interventions that prevent recurrent or residual adenoma. New techniques for treating intra-procedural bleeding and a novel classification system to identify and inform proactive management of deep mural injury enhance the safety profile of EMR. However, each of these incremental advancements necessitates a meticulous and systematic approach that only committed and properly trained endoscopists can master. While alternative interventions such as endoscopic submucosal dissection (ESD) offer potential advantages over EMR, the added procedural complexity, risks, and costs limit the relevance of ESD to a minority of lesions in the colorectum. This article reviews the expanding body of evidence supporting EMR as the first-line treatment of colorectal LSLs ≥20 mm.