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

Soft Coagulation Versus Argon Plasma Coagulation After Large Non-pedunculated Colorectal Polyp Resection: A Meta-analysis

INTRODUCTION

Thermal ablative methods (such as argon plasma coagulation (APC) and soft tip snare coagulation (STSC) are commonly used to treat polyp margins. We aim to appraise the current literature and compare clinical outcomes between patients with treated (with APC vs. STSC) and non-treated endoscopic mucosal resection (EMR) margins.

METHODS

We searched major databases from inception until November 2023 for randomly controlled trials (RCTs) comparing EMR of large non-pedunculated colorectal polyps with and without treated margins. Pooled data were analyzed for the primary outcome of recurrence at first screening colonoscopy, and adverse events. Analysis was performed using a random effects model and data were reported using 95% CIs.

RESULTS

A total of 5 RCT's were found, which included 1020 polyps (577 in treatment and 443 in control groups). Three studies included treatment with STSC and 3 studies used APC as the modality for margin ablation. Of the included patients, 53% were female and the average age was similar between treatment and control groups (65.9 vs. 66.1 y). Seventy-one percent of lesions were proximal to the splenic flexure. The mean follow-up to the first colonoscopy and average polyp size were comparable (6.3 vs. 6.2 mo; 28.2 vs. 28.0 mm, respectively). Pooled analysis showed that margin ablation was associated with significantly lower rates of recurrence [odds ratio (OR) 0.267, 95% CI 0.18-0.4, P<0.001] with low heterogeneity between studies (I2=0%, P=0.47). Pooled analysis showed no significant difference between STSC and APC in terms of recurrence (OR 0.6, 95% CI 0.27-1.7, I2=0%, P=0.3) or adverse events (OR 0.67, 95% CI 0.3-1.6, I2 13%, P=0.46).

CONCLUSION

Our study shows that ablation of EMR margins is very effective at preventing recurrence at first surveillance colonoscopy. We found no difference between STSC or APC in terms of polyp recurrence or adverse outcomes.

International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study

OBJECTIVES

There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices.

METHODS

Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale.

RESULTS

Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care.

CONCLUSIONS

An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices.

Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis

BACKGROUND

There is increasing evidence that cold endoscopic mucosal resection (c-EMR) can effectively treat large colorectal polyps. We aim to appraise the current literature and evaluate outcomes following c-EMR for nonpedunculated colonic polyps ≥20 mm.

METHODS

Major databases were searched. Primary outcomes included recurrence rate and adverse events. Meta-analysis was performed using a random-effects model.

RESULTS

Nine articles were included in the final analysis, which included 817 patients and 1077 colorectal polyps. Average polyp size was 28.8 (±5.1) mm. The pooled recurrence rate of polyps of any histology at 4 to 6 months was 21.0% (95% CI: 9.0%-32.0%, P <0.001, I2 =97.3, P <0.001). Subgroup analysis showed that recurrence was 10% for proximal lesions (95% CI: 0.0%-20.0%, P =0.054, I2 =93.7%, P =0.054) and 9% for distal lesions (95% CI: 2.0%-21.0%, P =0.114, I2 =95.8%, P =0.114). Furthermore, subgroup analysis showed that recurrence was 12% for adenoma (95% CI: 4.0%-19.0%, P =0.003, I2 =98.0%, P =0.003), and 3% for sessile serrated polyps (95% CI: 1.0%-5.0%, P =0.002, I2 =34.4%, P =0.002). Post-polypectomy bleeding occurred in 1% (n=8/817) of patients, whereas abdominal pain occurred in 0.2% (n=2/817) of patients.

CONCLUSIONS

C-EMR for nonpedunculated colorectal polyps ≥20 mm shows an excellent safety profile with a very low rate of delayed bleeding as well as significantly less recurrence for sessile serrated polyps than adenomas.

Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm

Background

Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors.

Summary

A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection.

Key Messages

Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.

Purse-string suture with nylon cords and metal clips for the treatment of duodenal fistulae under the endoscope: a case report

Purse-string suture with nylon cords and metal clips under the endoscope is a novel therapeutic technique which is minimally invasive and it is particularly indicated for the closure and repair of gastrointestinal fistula or perforations such as duodenal fistulae. Duodenal fistulae are often caused by medical manipulation, disease progression or trauma. Once this occurs, it leads to a series of pathophysiologic changes and a variety of complications. In most cases, these complications will exacerbate the damage to the organism, and the complications are difficult to treat and can lead to infections, nutrient loss, multi-organ dysfunction and many other adverse effects. In this case report, the use of endoscopic nylon cords combined with purse-string suture and metal clips in the treatment of duodenal fistula is presented and discussed. The patient was treated with endoscopic purse-string suture and the duodenal fistula was significantly improved. The results indicate that endoscopic purse-string suture is an effective strategy for the treatment of duodenal fistulae.

A new through-the-scope clip with anchor prongs is safe and successful for a variety of endoscopic uses

Background and study aims Endoscopic through-the-scope clips (TTSC) are used for hemostasis and closure. We documented the performance of a new TTSC with anchor prongs. Patients and methods We conducted a prospective case series of the new TTSC in 50 patients with an indication for endoscopic clipping at three hospitals in the United States and Canada. Patients were followed for 30 days after the index procedure. Outcomes included defect closure and rate of serious adverse events (SAEs) related to the device or procedure. Results Fifty patients had 56 clipping procedures. Thirty-four procedures were clipping after endoscopic mucosal resection (EMR) in the colon (33) or stomach (1), 16 after polypectomy, two for hemostasis of active bleeding, and one each for fistula closure, per-oral endoscopic myotomy mucosal closure, or anchoring a feeding tube. Complete defect closure was achieved in 32 of 33 colon EMR defects and 21 of 22 other defects. All clips were placed per labeled directions for use. In 41 patients (82.0%), prophylaxis of delayed bleeding was reported as an indication for endoscopic clipping. There were three instances of delayed bleeding. There were no device-related SAEs. The only technical difficulty was one instance of premature clip deployment. Conclusions A novel TTSC with anchor prongs showed success in a range of defect closures, an acceptable safety profile, and low incidence of technical difficulties.

Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicentre cluster randomised trial

OBJECTIVE

Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. We evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals.

DESIGN

In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months.

RESULTS

A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs 30 mm, 45% vs 52% size, morphology, site and access (SMSA) score IV, 64% vs 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs 25%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 1.36; p=0.720). Recurrences were more often unifocal in the intervention group (92% vs 76%; p=0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20-40 mm LNPCPs (5% vs 20% in 20-29 mm, p=0.001; 10% vs 21% in 30-39 mm, p=0.013) but less evident in ≥40 mm LNPCPs (24% vs 31%; p=0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high.

CONCLUSION

A compact standardised EMR training for LNPCPs significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥40 mm.

TRIAL REGISTRATION NUMBER

NTR7477.

Endoscopic resection of large non-pedunculated colorectal polyps: current standards of treatment

Colorectal cancer is a significant public health concern, and large non-pedunculated colorectal polyps pose a substantial risk for malignancy and incomplete resection, which may lead to interval cancer. The choice of resection technique is influenced by various factors, including polyp size, morphology, location, submucosal invasion depth and endoscopist expertise. For non-cancerous superficial large non-pedunculated polyps, conventional hot or cold snare polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection are common techniques for non-surgical therapeutic endoscopic resection of these polyps. This manuscript provides a comprehensive review of literature on current endoscopic resection techniques for large non-pedunculated colorectal polyps, emphasising indications, advantages, limitations and outcomes.

Snare Tip Soft Coagulation vs Argon Plasma Coagulation vs No Margin Treatment After Large Nonpedunculated Colorectal Polyp Resection: a Randomized Trial

BACKGROUND & AIMS

Thermal treatment of the defect margin after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions reduces the recurrence rate. Both snare tip soft coagulation (STSC) and argon plasma coagulation (APC) have been used for thermal margin treatment, but there are few data directly comparing STSC with APC for this indication.

METHODS

We performed a randomized 3-arm trial in 9 US centers comparing STSC with APC with no margin treatment (control) of defects after EMR of colorectal nonpedunculated lesions ≥15 mm. The primary end point was the presence of residual lesion at first follow-up.

RESULTS

There were 384 patients and 414 lesions randomized, and 308 patients (80.2%) with 328 lesions completed ≥1 follow-up. The proportion of lesions with residual polyp at first follow-up was 4.6% with STSC, 9.3% with APC, and 21.4% with control subjects (no margin treatment). The odds of residual polyp at first follow-up were lower for STSC and APC when compared with control subjects (P = .001 and P = .01, respectively). The difference in odds was not significant between STSC and APC. STSC took less time to apply than APC (median, 3.35 vs 4.08 minutes; P = .019). Adverse event rates were low, with no difference between arms.

CONCLUSIONS

In a randomized trial STSC and APC were each superior to no thermal margin treatment after EMR. STSC was faster to apply than APC. Because STSC also results in lower cost and plastic waste than APC (APC requires an additional device), our study supports STSC as the preferred thermal margin treatment after colorectal EMR. (Clinicaltrials.gov, Number NCT03654209.).

Local recurrence rates after resection of large colorectal serrated lesions with or without margin thermal ablation

INTRODUCTION

Serrated lesions (SLs) including traditional serrated adenomas (TSA), large hyperplastic polyps (HP) and sessile serrated lesions (SSLs) are associated with high incomplete resection rates. Margin ablation combined with EMR (EMR-T) has become routine to reduce local recurrence while cold snare polypectomy (CSP) is becoming recognized as equally effective for large SLs. Our aim was to evaluate local recurrence rates (LRR) and the use of margin ablation in preventing recurrence in a retrospective cohort study.

METHODS

Patients undergoing resection of ≥15 mm colorectal SLs from 2010-2022 were identified through a pathology database and electronic medical records search. Hereditary CRC syndromes, first follow-up > 18 months or no follow-up, surgical resection were excluded. Primary outcome was LRRs (either histologic or visual) during the first 18-month follow-up. Secondary outcomes were LRRs according to size, and resection technique.

RESULTS

191 polyps in 170 patients were resected (59.8% women; mean age, 65 years). The mean size of polyps was 22.4 mm, with 107 (56.0%) ≥20 mm. 99 polyps were resected with EMR, 39 with EMR-T, and 26 with CSP. Mean first surveillance was 8.2 mo. Overall LRR was 18.8% (36/191) (16.8% for ≥20 mm, 17.9% for ≥30 mm). LRR was significantly lower after EMR-T when compared with EMR (5.1% vs. 23.2%; p = 0.013) or CSP (5.1% vs. 23.1%; p = 0.031). There was no difference in LRR between EMR without margin ablation and CSP (p = 0.987).

CONCLUSION

The local recurrence rate for SLs ≥15 mm is high with 18.8% overall recurrence. EMR with thermal ablation of the margins is superior to both no ablation and CSP in reducing LRRs.

Comparing efficacy and factors of postoperative bleeding in endoscopic mucosal resection vs coagulation for intestinal polyps

This study aimed to assess the effectiveness of Endoscopic Mucosal Resection (EMR) and Argon Plasma Coagulation (APC) as therapeutic approaches for intestinal polyps in patients, and to examine the factors associated with postoperative bleeding. This study included 132 patients diagnosed with colorectal polyps (188 polyps) who underwent endoscopic surgery at our hospital between January 2022 and December 2022. Based on the surgical method employed, the patients were divided into 2 groups: EMR (68 cases, 97 polyps) and APC (64 cases, 91 polyps). Comparative analyses were conducted to assess the clinical efficacy, surgery-related indicators, and quality of life the 2 groups. Furthermore, an investigation was carried out to identify the factors associated with postoperative bleeding. The analysis revealed no statistically significant difference in the cure rate of flat and superficial raised polyps between the EMR group and the APC (P > .05). However, it was found that the EMR group exhibited a significantly higher cure rate for subpedunculated and raised-pedunculated polyps compared to the APC group (P < .05). The results of logistics analysis showed that patients with hypertension (OR = 2.876, 95% CI: 1.119-7.393), patients with diabetes (OR = 5.278, 95% CI: 1.388-20.064), patients with hyperlipidemia (OR = 2.594, 95% CI: 1.054-6.380), the polyps of right hemicolon (OR = 2.743, 95% CI: 1.003-7.504), rectal polyps (OR = 5.143, 95% CI: 1.728-7.504), pedunculated polyps (OR = 4.758, 95% CI: 1.322-17.129), adenomatous polyps (OR = 3.152, 95% CI: 1.018-9.757) were independent risk factors for postoperative bleeding in patients with colorectal polyps (P < .05). The findings suggest that for subpedunculated and pedunculated-raised polyps, EMR can be a suitable treatment approach. On the other hand, flat and superficial-raised polyps can be effectively managed with either EMR or APC. The presence of hypertension, diabetes, hyperlipidemia, polyps of the right hemicolon, rectal polyps, pedunculated polyps, and adenomatous polyps has been established as independent risk factors for postoperative bleeding in patients with colorectal polyps.

Endoscopic management of colorectal polyps

Colorectal polyps are premalignant lesions in the lower gastrointestinal tract. Endoscopic polypectomy is an effective strategy to prevent colorectal cancer morbidity and more invasive procedures. Techniques for the endoscopic resection of polyps keep evolving, and endoscopists are required to perform the most appropriate technique for each polyp. In this review, we outline the evaluation and classification of polyps, update the recommendations for optimal treatment, describe the polypectomy procedures and their strengths/weaknesses, and discuss the promising innovative methods or concepts.

Hybrid Argon Plasma Coagulation for Barrett's Esophagus and for Colonic Mucosal Resection-A Systematic Review and Meta-Analysis

Hybrid argon plasma coagulation (hAPC) is a novel technique that combines conventional argon plasma coagulation and waterjet submucosal expansion. The aims of this metanalysis were to evaluate the efficacy and safety of hAPC in the setting of Barret's esophagus (BE) ablation and as an adjunct to colonic endoscopic mucosal resection (EMR). Four electronic databases were searched, and the results were analyzed by two independent authors. Random-effects meta-analyses of the proportions of endoscopic and histologic remission (for BE), recurrence, and post-procedure adverse events were performed using R. Studies' reporting quality was also assessed. From the 979 identified records, 13 studies were included (10 regarding BE and three colonic EMR). The pooled percentages of endoscopic and histologic remission after hAPC for BE were 95% (95% confidence interval [CI] 91-99, I² = 34) and 90% (95%CI 84-95, I² = 46), respectively, while major adverse events and recurrence were registered in 2% (95%CI 0-5, I² = 41) and 11% (95%CI 2-27, I² = 11), respectively. Concerning hAPC-assisted EMR, the pooled percentages of major adverse events and recurrence were 5% (95%CI 2-10, I² = 0) and 1% (95%CI 0-3, I² = 40). Evidence suggests that the main advantages of hAPC are the increase in safety in the setting of BE ablation and the reduction of local recurrence after colonic EMR. Trials comparing hAPC with standard strategies are required to support its use for these indications.

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.

How to avoid overtreatment of benign colorectal lesions: Rationale for an evidence-based management

Implementing population-based screening programs for colorectal cancer has led to an increase in the detection of large but benign histological lesions. Currently, endoscopic mucosal resection can be considered the standard technique for the removal of benign lesions of the colon due to its excellent safety profile and good clinical results. However, several studies from different geographic areas agree that many benign colon lesions are still referred for surgery. Moreover, the referral rate to surgery is not decreasing over the years, despite the theoretical improvement of endoscopic resection techniques. This article will review the leading causes for benign colorectal lesions to be referred for surgery and the influence of the endoscopist experience on the referral rate. It will also describe how to categorize a polyp as complex for resection and consider an endoscopist as an expert in endoscopic resection. And finally, we will propose a framework for the accurate and evidence-based treatment of complex benign colorectal lesions.

Recurrence rates after endoscopic resection of large colorectal polyps: A systematic review and meta-analysis

BACKGROUND

Complete polyp resection is the main goal of endoscopic removal of large colonic polyps. Resection techniques have evolved in recent years and endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) with margin ablation, cold snare polypectomy (CSP), cold EMR, and underwater EMR have been introduced. Yet, efficacy of these techniques with regard to local recurrence rates (LRRs) vs traditional hot snare polypectomy and standard EMR remains unclear.

AIM

To analyze LRR of large colonic polyps in a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, EBM Reviews, and CINAHL were searched for prospective studies reporting LRR or incomplete resection rate (IRR) after colonic polypectomy of polyps ≥ 10 mm, published between January 2011 and July 2021. Primary outcome was LRR for polyps ≥ 10 mm.

RESULTS

Six thousand nine hundred and twenty-eight publications were identified, of which 34 prospective studies were included. LRR for polyps ≥ 10 mm at up to 12 mo’ follow-up was 11.0% (95%CI, 7.1%-14.8%; 15 studies; 4904 polyps). ESD (1.7%; 95%CI, 0%-3.4%; 3 studies, 221 polyps) and endoscopic mucosal resection with margin ablation (3.3%; 95%CI, 2.2%-4.5%; 2 studies, 947 polyps) significantly reduced LRR vs standard EMR without (15.2%; 95%CI, 12.5%-18.0%; 4 studies, 650 polyps) or with unsystematic margin ablation (16.5%; 95%CI, 15.2%-17.8%; 6 studies, 3031 polyps).

CONCLUSION

LRR is significantly lower after ESD or EMR with routine margin ablation; thus, these techniques should be considered standard for endoscopic removal of large colorectal polyps. Other techniques, such as CSP, cold EMR, and underwater EMR require further evaluation in prospective studies before their routine implementation in clinical practice can be recommended.