1
|
Niu C, Zhang J, Joshi U, Elkhapery A, Boppana HK, Okolo PI. Efficacy and Safety of Cold Versus Hot Snare Endoscopic Mucosal Resection in Colorectal Polyp Removal: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2024:00004836-990000000-00338. [PMID: 39145841 DOI: 10.1097/mcg.0000000000002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND Cold snare endoscopic mucosal resection (C-EMR) is hypothesized to offer a safety advantage over hot snare endoscopic mucosal resection (H-EMR). The primary objective of this meta-analysis is to evaluate the effectiveness and safety of C-EMR versus H-EMR for the management of colorectal lesions. METHODS A meta-analysis was performed to determine pooled odds ratios (ORs) for comparing outcomes between the C-EMR and H-EMR groups. RESULTS The pooled OR for complete resection rates were estimated at 0.70 (95% CI: 0.36-1.36, P =0.29) and en bloc rates were 0.24 (95% CI: 0.05-1.08, P=0.06) between C-EMR group and H-EMR group. The overall complete resection rate for C-EMR was 84%, and the en bloc resection rate was 57. Notably, C-EMR was associated with a significantly lower incidence of delayed bleeding. The recurrence rate of polyps was very low (2%) when treating sessile serrated polyp (SSP) lesions, but higher (23%) for non-SSP lesions. Subgroup analysis revealed minimal recurrence of polyps after using C-EMR for lesions between 10 to 20 mm and ≥20 mm. CONCLUSIONS This meta-analysis suggests that C-EMR could be a safer and equally effective alternative to H-EMR for resecting colorectal lesions. We recommend C-EMR as the preferred method for excising large colorectal lesions.
Collapse
Affiliation(s)
- Chengu Niu
- Internal Medicine Residency Program, Rochester General Hospital
| | - Jing Zhang
- Rainier Springs Behavioral Health Hospital, Vancouver, WA
| | - Utsav Joshi
- Internal Medicine Residency Program, Rochester General Hospital
| | - Ahmed Elkhapery
- Internal Medicine Residency Program, Rochester General Hospital
| | | | - Patrick I Okolo
- Division of Gastroenterology, Rochester General Hospital, Rochester, NY
| |
Collapse
|
2
|
Bragança S, Garcia AC, Alexandrino G, Oliveira AM, Horta D, Lourenço LC, Costa MN. Validation of a novel BCM model for recurrence risk prediction after mucosectomy of colorectal lateral spreading tumors in a European cohort. Clin Res Hepatol Gastroenterol 2024; 48:102414. [PMID: 38972543 DOI: 10.1016/j.clinre.2024.102414] [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: 05/04/2024] [Revised: 06/15/2024] [Accepted: 07/05/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND AND AIM Piecemeal endoscopic mucosal resection (pEMR) is the best approach to resect large lateral spreading tumors (LST, > 20 mm width). However, it is associated with early recurrence (ER) and late recurrence (LR). This study aims to assess the risk factors associated with ER and LR and to validate different predictive scores (SMSA, SERT, and BCM) in identifying the risk of ER and LR after LST resected by pEMR in a European cohort. METHODS Retrospective observational cohort study, based on a prospectively collected database, of large LST submitted to pEMR. RESULTS A total of 108 patients were included in the study and the incidence rates of ER and LR were 22 % and 8 %, respectively. The lesion's size, SERT, and BCM scores were independent predictor factors of ER (p-value < 0.05), while the lesion's site and BCM score were independent predictor factors of LR (p-value < 0.05). For the prediction of ER, the SERT score (cut-off > 1) presented the highest AUROC (0.758 vs 0.697 from BCM and 0.647 from SMSA). Regarding LR, the BCM model (cut-off > 2) presented the highest AUROC (0.817 vs 0.708 from SERT and 0.691 from SMSA). CONCLUSIONS We present the first external validation of the three scores mentioned in an European cohort. SERT and BCM scores had an acceptable performance in predicting ER and LR. However, the BCM model was the only score that proved to be an independent predictor of both ER and LR, proving to be valuable for both applications.
Collapse
Affiliation(s)
- Sofia Bragança
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal.
| | - Ana Catarina Garcia
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal
| | - Gonçalo Alexandrino
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal
| | - Ana Maria Oliveira
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal
| | - David Horta
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal
| | - Luís Carvalho Lourenço
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal
| | - Mariana Nuno Costa
- Gastroenterology department, Hospital Professor Doutor Fernando Fonseca, IC 19, 2720-276, Amadora, Portugal
| |
Collapse
|
3
|
Ramai D, Clement B, Maida M, Previtera M, Brooks OW, Wang Y, Chandan S, Dhindsa B, Deliwala S, Facciorusso A, Khashab M, Ofosu A. Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:661-667. [PMID: 38227846 DOI: 10.1097/mcg.0000000000001958] [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: 10/18/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
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.
Collapse
Affiliation(s)
- Daryl Ramai
- Gastroenterology and Endoscopy Unit, S. Elia Hospital, Caltanissetta, Italy
| | | | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta
| | - Melissa Previtera
- University of Cincinnati Libraries, Donald C. Harrison Health Sciences Library, Cincinnati, OH
| | - Olivia W Brooks
- Internal Medicine Residency, University of Connecticut, Farmington, CT
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, MA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, NE
| | - Smit Deliwala
- Gastroenterology & Hepatology, Emory University Hospital, Atlanta, GA, USA
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Andrew Ofosu
- Faculty of Medicine, "Kore" University of Enna, Enna, Italy
| |
Collapse
|
4
|
O’Sullivan T, Bourke MJ. Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm. Visc Med 2024; 40:217-227. [PMID: 39157731 PMCID: PMC11326768 DOI: 10.1159/000539219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/03/2024] [Indexed: 08/20/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Timothy O’Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
| |
Collapse
|
5
|
Paspatis G, Fragaki M, Arna DE, Velegraki M, Psistakis A, Nicolaou P, Psaroudakis I, Tribonias G, Voudoukis E, Karmiris K, Theodoropoulou A, Chlouverakis G, Vardas E. Long-term adenoma recurrence and development of colorectal cancer following endoscopic mucosal resection in large non-pedunculated colonic polyps ≥4 cm. Dig Liver Dis 2024:S1590-8658(24)00839-9. [PMID: 39013709 DOI: 10.1016/j.dld.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/21/2024] [Accepted: 06/26/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES Data of long-term follow up for large non pedunculated colorectal polyps (LNPCPs) ≥4 cm removed with piecemeal wide field endoscopic mucosal resection (PWF-EMR) are limited. We primarily evaluated the recurrence rates and secondarily the rates of post colonoscopic polypectomy colorectal cancer (PCPCRC) on a long-term basis. METHODS We retrospectively reviewed a prospectively-stored electronic database of all patients who underwent PWF-EMR for LNPCPs at the Venizeleion General Hospital, between 2009 and 2020. Eligible patients were those with LNPCPs ≥4 cm, deemed completely removed by endoscopic means and followed-up for a minimum of 36 months with at least two surveillance colonoscopies, the first one (SC1) (4-6) months after the initial PWF-EMR procedure and the second one (SC2) after (12-18) months. In 2023, all cases were checked for PCPCRC development. RESULTS Residual/early recurrent tissue was detected in 44 (31 %) cases among the 142 (82 males, 60 females) assessed during SC1. Late recurrent tissue was detected in 9 (6.6 %) cases among the 137 surveyed during SC2. Investigation did not reveal any case of PCPCRC . CONCLUSIONS This historical cohort shows that the PWF-EMR for LNPCPs ≥4 cm is a safe and definitive removal method while it is not associated with the appearance of PCPCRC.
Collapse
Affiliation(s)
- Gregorios Paspatis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece.
| | - Maria Fragaki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Despoina-Eleni Arna
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Magdalini Velegraki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Andreas Psistakis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Pinelopi Nicolaou
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Ioannis Psaroudakis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - George Tribonias
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Evangelos Voudoukis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | - Konstantinos Karmiris
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| | | | - Gregorios Chlouverakis
- Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Greece
| | - Emmanouil Vardas
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete, Greece
| |
Collapse
|
6
|
Jiang SX, Shahidi N. Large non-pedunculated colorectal polyp management: The elephant in the room. World J Gastroenterol 2024; 30:3126-3131. [PMID: 39006383 PMCID: PMC11238671 DOI: 10.3748/wjg.v30.i25.3126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/19/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024] Open
Abstract
Minimally invasive innovations have transformed coloproctology. Specific to colorectal cancer (CRC), there has been a shift towards less invasive surgical techniques and use of endoscopic resection as an alternative for low risk T1 CRC. The role of endoscopic resection is however much more extensive: It is now considered the first line management strategy for most large (≥ 20 mm) non-pedunculated colorectal polyps, the majority of which are benign. This is due to the well-established efficacy, safety, and cost-effectiveness of endoscopic techniques compared to surgery. Multiple endoscopic modalities now exist with distinct risk-benefit profiles and their outcomes are further improved by site-specific technical modifications, auxiliary techniques, and adverse event mitigation strategies. Endoscopic capacity continues to evolve with emerging endoscopic techniques and expanding applications, particularly in the confines of a multi-disciplinary setting.
Collapse
Affiliation(s)
- Shirley X Jiang
- Department of Medicine, University of British Columbia, Vancouver V6Z 2K5, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 2K5, BC, Canada
| |
Collapse
|
7
|
O'Sullivan T, Cronin O, van Hattem WA, Mandarino FV, Gauci JL, Kerrison C, Whitfield A, Gupta S, Lee E, Williams SJ, Burgess N, Bourke MJ. Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial. Gut 2024:gutjnl-2024-332807. [PMID: 38964854 DOI: 10.1136/gutjnl-2024-332807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 05/31/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND AND AIMS Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR. METHODS Flat, 15-50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success. RESULTS 177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034). CONCLUSION Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique. TRIAL REGISTRATION NUMBER NCT04138030.
Collapse
Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julia L Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Clarence Kerrison
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, Paspatis GA, Moss A, Libânio D, Lorenzo-Zúñiga V, Voiosu AM, Rutter MD, Pellisé M, Moons LMG, Probst A, Awadie H, Amato A, Takeuchi Y, Repici A, Rahmi G, Koecklin HU, Albéniz E, Rockenbauer LM, Waldmann E, Messmann H, Triantafyllou K, Jover R, Gralnek IM, Dekker E, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024; 56:516-545. [PMID: 38670139 DOI: 10.1055/a-2304-3219] [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] [Indexed: 04/28/2024]
Abstract
1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
Collapse
Affiliation(s)
- Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Gastroenterology, Evangelical Hospital, Vienna, Austria
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Mauro Risio
- Department of Pathology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy
| | - Gregorios A Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Vincente Lorenzo-Zúñiga
- Endoscopy Unit, La Fe University and Polytechnic Hospital / IISLaFe, Valencia, Spain
- Department of Medicine, Catholic University of Valencia, Valencia, Spain
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthew D Rutter
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
- Department of Gastroenterology, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Leon M G Moons
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, Ospedale A. Manzoni, Lecco, Italy
| | - Yoji Takeuchi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Gabriel Rahmi
- Hepatogastroenterology and Endoscopy Department, Hôpital européen Georges Pompidou, Paris, France
- Laboratoire de Recherches Biochirurgicales, APHP-Centre Université de Paris, Paris, France
| | - Hugo U Koecklin
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Teknon Medical Center, Barcelona, Spain
| | - Eduardo Albéniz
- Gastroenterology Department, Hospital Universitario de Navarra (HUN); Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lisa-Maria Rockenbauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Helmut Messmann
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| |
Collapse
|
9
|
Mandarino FV, Danese S, Uraoka T, Parra-Blanco A, Maeda Y, Saito Y, Kudo SE, Bourke MJ, Iacucci M. Precision endoscopy in colorectal polyps' characterization and planning of endoscopic therapy. Dig Endosc 2024; 36:761-777. [PMID: 37988279 DOI: 10.1111/den.14727] [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: 08/25/2023] [Accepted: 11/19/2023] [Indexed: 11/23/2023]
Abstract
Precision endoscopy in the management of colorectal polyps and early colorectal cancer has emerged as the standard of care. It includes optical characterization of polyps and estimation of submucosal invasion depth of large nonpedunculated colorectal polyps to select the appropriate endoscopic resection modality. Over time, several imaging modalities have been implemented in endoscopic practice to improve optical performance. Among these, image-enhanced endoscopy systems and magnification endoscopy represent now well-established tools. New advanced technologies, such as endocytoscopy and confocal laser endomicroscopy, have recently shown promising results in predicting the histology of colorectal polyps. In recent years, artificial intelligence has continued to enhance endoscopic performance in the characterization of colorectal polyps, overcoming the limitations of other imaging modes. In this review we retrace the path of precision endoscopy, analyzing the yield of various endoscopic imaging techniques in personalizing management of colorectal polyps and early colorectal cancer.
Collapse
Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Hospital IRCSS, Milan, Italy
- Department of Gastrointestinal Endoscopy, Westmead Hospital, Sydney, NSW, Australia
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Hospital IRCSS, Milan, Italy
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gumma, Japan
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Yasuharu Maeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Michael J Bourke
- Department of Gastrointestinal Endoscopy, Westmead Hospital, Sydney, NSW, Australia
| | - Marietta Iacucci
- Department of Gastroenterology, University College Cork, Cork, Ireland
| |
Collapse
|
10
|
Djinbachian R, Rex DK, Chiu HM, Fukami N, Aihara H, Bastiaansen BAJ, Bechara R, Bhandari P, Bhatt A, Bourke MJ, Byeon JS, Cardoso D, Chino A, Chiu PWY, Dekker E, Draganov PV, Elkholy S, Emura F, Goldblum J, Haji A, Ho SH, Jung Y, Kawachi H, Khashab M, Khomvilai S, Kim ER, Maselli R, Messmann H, Moons L, Mori Y, Nakanishi Y, Ngamruengphong S, Parra-Blanco A, Pellisé M, Pinto RC, Pioche M, Pohl H, Rastogi A, Repici A, Sethi A, Singh R, Suzuki N, Tanaka S, Vieth M, Yamamoto H, Yang DH, Yokoi C, Saito Y, von Renteln D. International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study. Dig Endosc 2024. [PMID: 38934243 DOI: 10.1111/den.14826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
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.
Collapse
Affiliation(s)
- Roupen Djinbachian
- Montreal University Hospital Research Center, Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert Bechara
- Division of Gastroenterology, Kingston Health Sciences Centre, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | | | - Amit Bhatt
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniela Cardoso
- Institute of Digestive Apparatus, Oncological Surgery, Goiâsnia, Brazil
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Philip W Y Chiu
- Division of Upper GI Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, USA
| | - Shaimaa Elkholy
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Fabian Emura
- Gastroenterology Division, de La Sabana University, Chia, Colombia
- Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá, Colombia
| | - John Goldblum
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, USA
| | - Amyn Haji
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Shiaw-Hooi Ho
- Department of Medicine, Malaya University, Kuala Lumpur, Malaysia
| | - Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hiroshi Kawachi
- Department of Pathology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, USA
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Leon Moons
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | | | - Adolfo Parra-Blanco
- NHR Nottingham Biomedical Research Centre, Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Gastroenterology, University of Nottingham, Nottingham, UK
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Hospital Clinic of Barcelona, Biomedical Research Center in Hepatic and Digestive Diseases (CIBERehd), University of Barcelona, Barcelona, Spain
| | | | - Mathieu Pioche
- Endoscopic Division, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Heiko Pohl
- Department of Gastroenterology, VA Medical Center, White River Junction, USA
- Dartmouth-Hitchcock Medical Center, White River Junction, USA
| | - Amit Rastogi
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, USA
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York City, USA
| | - Rajvinder Singh
- Gastroenterology Unit, Division of Surgery, Northern Adelaide Local Health Area Network, Adelaide, Australia
- Department of Gastroenterology, University of Adelaide, Adelaide, Australia
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St. Mark's Hospital, London, UK
| | - Shinji Tanaka
- Gastroenterology Division, JA Onomichi General Hospital, Hiroshima, Japan
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chizu Yokoi
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Daniel von Renteln
- Montreal University Hospital Research Center, Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| |
Collapse
|
11
|
Yang D, Hasan MK, Jawaid S, Singh G, Xiao Y, Khalaf M, Tomizawa Y, Sharma NS, Draganov PV, Othman MO. Hybrid Versus Conventional Colorectal Endoscopic Submucosal Dissection: A Multicenter Randomized Controlled Trial (Short-Endoscopic Submucosal Dissection). Am J Gastroenterol 2024:00000434-990000000-01197. [PMID: 38912697 DOI: 10.14309/ajg.0000000000002897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 06/12/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Hybrid endoscopic submucosal dissection (H-ESD), which utilizes ESD knife along with snare-based resection, has been developed to overcome the technical complexity of conventional ESD (C-ESD). The aim of this study was to compare the therapeutic outcomes of H-ESD vs C-ESD for nonpedunculated colorectal lesions ≥20 mm in size. METHODS We conducted a multicenter randomized controlled trial to compare H-ESD and C-ESD (Short-ESD trial). Patients with colorectal lesions between 20 and 50 mm in size were randomly assigned (1:1) to H-ESD or C-ESD. Primary outcome was procedure time/speed. Secondary outcomes were en bloc and complete (R0) resection rates and adverse event rates. RESULTS A total of 89 patients (median age 63 years; 49.3% women) with the median polyp size of 30 mm underwent H-ESD (n = 40) and C-ESD (n = 49). The mean procedure time of H-ESD was significantly shorter than that of C-ESD (41.1 ± 16.3 vs 54.3 ± 28.2 minutes; P = 0.007). The en bloc and R0 resection rates trended lower in the H-ESD vs C-ESD groups (77.5% vs 87.8%; P = 0.26% and 72.5% vs 79.6%; P = 0.46) without reaching statistical significance. Adverse event rate was similar between H-ESD and C-ESD (10% vs 8.2%; P = 1.00). DISCUSSION Both H-ESD and C-ESD were safe and effective for resection of large colorectal lesions. H-ESD was associated with a shorter procedure time. H-ESD may represent a viable alternative to C-ESD, with the main advantage being easy applicability of a snare-based technique for colorectal lesions. Future studies are needed to further define the most suitable lesions for H-ESD, as to optimize efficiency and safety without compromising resection outcomes. ClinicaTrials.gov NCT NCT05347446.
Collapse
Affiliation(s)
- Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Salmaan Jawaid
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Gurdeep Singh
- Internal Medicine, AdventHealth Medical Group, Orlando, Florida, USA
| | - Yasi Xiao
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Mai Khalaf
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Yutaka Tomizawa
- Division of Gastroenterology, University of Washington Harborview Medical Center, Seattle, Washington, USA
| | - Neil S Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, Indiana, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Mohamed O Othman
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
12
|
Masgnaux LJ, Grimaldi J, Jacques J, Rivory J, Pioche M. Technical Advances in Endoscopic Resection Techniques for Lower GI Malignancies. Visc Med 2024; 40:128-143. [PMID: 38873630 PMCID: PMC11166901 DOI: 10.1159/000538041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/25/2024] [Indexed: 06/15/2024] Open
Abstract
Background The management of bulky neoplastic lesions in the digestive tract has historically been a surgical pursuit. With advancements in endoscopic techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a paradigm shift toward organ preservation has been initiated. These endoscopic methods, developed incrementally since the 1980s, have progressively enabled curative management of lesions with minimal morbidity, challenging the previously unchallenged domain of surgery. Summary This review traces the evolution of endoscopic resection from snare polypectomy and EMR to sophisticated ESD, highlighting the technological innovations that have expanded the scope of endoscopic resection. It discusses the intricacies of various EMR techniques like underwater EMR, anchoring EMR, and hybrid EMR, alongside traction-assisted methods and the use of viscous solutions for submucosal injection. Additionally, the manuscript delves into the advancements in ESD, emphasizing traction strategies, knife technology, and the optimization of endoscopes. The benefits of these advancements are weighed against the challenges in anatomopathological interpretation posed by piecemeal resections. Key Messages The continuous amelioration of endoscopic resection techniques has significantly improved the outcomes of digestive tract lesion management, particularly in achieving R0 resections and reducing recurrence rates. These advancements represent a monumental step toward minimizing the invasiveness of lesion management. However, despite the progress, the necessity for early follow-up post-EMR remains due to the non-negligible recurrence rates, underscoring the need for a rigorous postoperative surveillance regimen. Furthermore, our review suggests that while ESD has transformed the therapeutic landscape, its widespread adoption hinges on further simplification, safety enhancement, and acceleration of the procedure, possibly through innovations like adaptive traction devices.
Collapse
Affiliation(s)
- Louis Jean Masgnaux
- Endoscopy Unit, Gastroenterology Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Jean Grimaldi
- Endoscopy Unit, Gastroenterology Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Jérémie Jacques
- Endoscopy Unit, Gastroenterology, Limoges University Hospital, Limoges, France
| | - Jérôme Rivory
- Endoscopy Unit, Gastroenterology Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Endoscopy Unit, Gastroenterology Pavillon L, Edouard Herriot Hospital, Lyon, France
| |
Collapse
|
13
|
Pasam RT, Chandan S, Mohan BP. Endoscopic techniques to reduce recurrence after EMR of large nonpedunculated colorectal polyps. Gastrointest Endosc 2024; 99:863-864. [PMID: 38649228 DOI: 10.1016/j.gie.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 04/25/2024]
Affiliation(s)
- Ravi Teja Pasam
- Department of Medicine, Wentworth-Douglass Hospital, Dover, New Hampshire, USA
| | - Saurabh Chandan
- Department of Gastroenterology, Creighton University Medical Center, Omaha, Nebraska, USA
| | | |
Collapse
|
14
|
Meulen LWT, Bogie RMM, Siersema PD, Winkens B, Vlug MS, Wolfhagen FHJ, Baven-Pronk M, van der Voorn M, Schwartz MP, Vogelaar L, de Vos Tot Nederveen Cappel WH, Seerden TCJ, Hazen WL, Schrauwen RWM, Alvarez Herrero L, Schreuder RMM, van Nunen AB, Stoop E, de Bruin GJ, Bos P, Marsman WA, Kuiper E, de Bièvre M, Alderlieste YA, Roomer R, Groen J, Bargeman M, van Leerdam ME, Roberts-Bos L, Boersma F, Thurnau K, de Vries RS, Ramaker JM, Vleggaar FP, de Ridder RJ, Pellisé M, Bourke MJ, Masclee AAM, Moons LMG. Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicentre cluster randomised trial. Gut 2024; 73:741-750. [PMID: 38216328 DOI: 10.1136/gutjnl-2023-330020] [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: 04/05/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024]
Abstract
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.
Collapse
Affiliation(s)
- Lonne W T Meulen
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Roel M M Bogie
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marije S Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Martine Baven-Pronk
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Michael van der Voorn
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Lauran Vogelaar
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, The Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Annick B van Nunen
- Department of Gastroenterology and Hepatology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Esther Stoop
- Department of Gastroenterology and Hepatology, Haaglanden Medical Centre, Den Haag, The Netherlands
| | - Gijs J de Bruin
- Department of Gastroenterology and Hepatology, Tergooi Hospital, Hilversum, The Netherlands
| | - Philip Bos
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Willem A Marsman
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Edith Kuiper
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Marc de Bièvre
- Department of Gastroenterology and Hepatology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Yasser A Alderlieste
- Department of Gastroenterology and Hepatology, Rivas Zorggroep, Gorinchem, The Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - John Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | - Marloes Bargeman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Monique E van Leerdam
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Linda Roberts-Bos
- Department of Gastroenterology and Hepatology, Laurentius Hospital, Roermond, The Netherlands
| | - Femke Boersma
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Karsten Thurnau
- Department of Gastroenterology and Hepatology, Hospital group Twente, Almelo, The Netherlands
| | - Roland S de Vries
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Jos M Ramaker
- Department of Gastroenterology and Hepatology, Elkerliek Hospital, Helmond, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Ad A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| |
Collapse
|
15
|
Cronin O, Kirszenblat D, Forbes N, Gupta S, Whitfield A, O'Sullivan T, Gauci J, Abuarisha M, Wang H, Burgess NG, Lee EYT, Williams SJ, Bourke MJ. Geometry of cold snare polypectomy and risk of incomplete resection. Endoscopy 2024; 56:214-219. [PMID: 37774737 DOI: 10.1055/a-2184-1609] [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] [Indexed: 10/01/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is safer than and equally efficacious as hot snare polypectomy (HSP) for the removal of small (<10mm) colorectal polyps. The maximum polyp size that can be effectively managed by piecemeal CSP (p-CSP) without an excessive burden of recurrence is unknown. METHODS Resection error risks (RERs), defined as the estimated likelihood of incomplete removal of adenomatous tissue for a single snare resection pass, for CSP and HSP were calculated, based on an incomplete resection rate. Polyp area, snare size, estimated number of resections, and optimal resection defect area were modeled. Overall risk of incomplete resection (RIR) was defined as RIR=1 - (1 - p)n, where p is the RER and n the number of resections. RESULTS A 40-mm polyp has a four times greater area than a 20-mm polyp (314.16mm2 vs. 1256.64mm2), and requires three times more resections (11 vs. 33, respectively, assuming 8-mm piecemeal resection pieces for p-CSP). RIRs for a 40-mm polyp by HSP and p-CSP were 15.1%-23% and 40.74%-60.60% respectively. CONCLUSION RER is more important with p-CSP than with HSP. The number of resections, n, and consequently RIR increases with increasing polyp size. Given the overwhelming safety of CSP, specific techniques to minimize the RER should be studied and developed.
Collapse
Affiliation(s)
- Oliver Cronin
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - David Kirszenblat
- Department of Mathematics and Statistics, University of Melbourne, Parkville, Australia
| | | | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Timothy O'Sullivan
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Julia Gauci
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Muhammad Abuarisha
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Hunter Wang
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Nicholas G Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Eric Y T Lee
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Stephen J Williams
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Medicine, University of Sydney Westmead Clinical School, Sydney, Australia
| |
Collapse
|
16
|
Rex DK, Haber GB, Khashab M, Rastogi A, Hasan MK, DiMaio CJ, Kumta NA, Nagula S, Gordon S, Al-Kawas F, Waye JD, Razjouyan H, Dye CE, Moyer MT, Shultz J, Lahr RE, Yuen PYS, Dixon R, Boyd L, Pohl H. Snare Tip Soft Coagulation vs Argon Plasma Coagulation vs No Margin Treatment After Large Nonpedunculated Colorectal Polyp Resection: a Randomized Trial. Clin Gastroenterol Hepatol 2024; 22:552-561.e4. [PMID: 37871841 DOI: 10.1016/j.cgh.2023.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/23/2023] [Accepted: 09/29/2023] [Indexed: 10/25/2023]
Abstract
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.).
Collapse
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Gregory B Haber
- Division of Gastroenterology and Hepatology, NYU Langone Medical Center, New York, New York
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Amit Rastogi
- Department of Gastroenterology, The University of Kansas Medical Center, Kansas City, Kansas
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Christopher J DiMaio
- Center for Advanced Colonoscopy and Therapeutic Endoscopy at Sinai (CACTES), Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Nikhil A Kumta
- Center for Advanced Colonoscopy and Therapeutic Endoscopy at Sinai (CACTES), Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Satish Nagula
- Center for Advanced Colonoscopy and Therapeutic Endoscopy at Sinai (CACTES), Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Stuart Gordon
- Section of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Firas Al-Kawas
- Division of Gastroenterology, Sibley Memorial Hospital, Washington, DC
| | - Jerome D Waye
- Center for Advanced Colonoscopy and Therapeutic Endoscopy at Sinai (CACTES), Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Hadie Razjouyan
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Charles E Dye
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Jeremiah Shultz
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Poi Yu Sofia Yuen
- Division of Gastroenterology and Hepatology, NYU Langone Medical Center, New York, New York
| | - Rebekah Dixon
- Center for Advanced Colonoscopy and Therapeutic Endoscopy at Sinai (CACTES), Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
| | - LaKeisha Boyd
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine and Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Heiko Pohl
- Section of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Gastroenterology, VA White River Junction, White River Junction, Vermont
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Haghbin H, Zakirkhodjaev N, Fatima R, Kamal F, Aziz M. Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis. J Clin Med 2024; 13:1298. [PMID: 38592137 PMCID: PMC10932371 DOI: 10.3390/jcm13051298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(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.
Collapse
Affiliation(s)
- Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Hospital, Southfield, MI 48075, USA
| | - Nuruddinkhodja Zakirkhodjaev
- Division of Occupational and Environmental Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77021, USA;
| | - Rawish Fatima
- Division of Rheumatology, University of Toledo, Toledo, OH 43606, USA;
| | - Faisal Kamal
- Division of Gastroenterology, Thomas Jefferson University, Philadelphia, PA 19144, USA;
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, OH 43608, USA;
| |
Collapse
|
19
|
Kemper G, Gerges C, Schoon EJ, Schreuder RM, Schrauwen RRW, Epping LSM, Beyna T, Drenth JPH, Gündug U, Siersema PD, van Geenen EJM. 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. Trials 2024; 25:132. [PMID: 38368409 PMCID: PMC10874049 DOI: 10.1186/s13063-024-07915-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/09/2024] [Indexed: 02/19/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Gijs Kemper
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands.
| | - Christian Gerges
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ruud R W Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, The Netherlands
| | - Ludger S M Epping
- Department of Gastroenterology and Hepatology, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands
| | - Ufuk Gündug
- Department of Internal Medicine and Gastroenterology, Katholisches Karl Leisner Klinikum - St.-Antonius-Hospital Kleve, Kleve, Germany
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands
| |
Collapse
|
20
|
Jacques J, Schaefer M, Wallenhorst T, Rösch T, Lépilliez V, Chaussade S, Rivory J, Legros R, Chevaux JB, Leblanc S, Rostain F, Barret M, Albouys J, Belle A, Labrunie A, Preux PM, Lepetit H, Dahan M, Ponchon T, Crépin S, Marais L, Magne J, Pioche M. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial. Ann Intern Med 2024; 177:29-38. [PMID: 38079634 DOI: 10.7326/m23-1812] [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] [Indexed: 01/17/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Jérémie Jacques
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Marion Schaefer
- Hépato-Gastro-Entérologie, CHRU de Nancy, Nancy, France (M.S., J.-B.C.)
| | | | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital, Hamburg-Eppendorf, Hamburg, Germany (T.R.)
| | - Vincent Lépilliez
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | | | - Jérôme Rivory
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Romain Legros
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | | | - Sarah Leblanc
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | - Florian Rostain
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Maximilien Barret
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Jérémie Albouys
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Arthur Belle
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Anaïs Labrunie
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Pierre-Marie Preux
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Hugo Lepetit
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Martin Dahan
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Thierry Ponchon
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Sabrina Crépin
- Service de Pharmacologie-Toxicologie et Pharmacovigilfance-Unité de Vigilance des Essais Cliniques, CHU de Limoges, Limoges, France (S.C.)
| | - Loïc Marais
- Direction de la Recherche et de l'Innovation, CHU de Limoges, Limoges, France (L.M.)
| | - Julien Magne
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Mathieu Pioche
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| |
Collapse
|
21
|
Gupta S, Kurup R, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Lee EY, Williams SJ, Burgess NG, Bourke MJ. Safety and efficacy of physician-administered balanced-sedation for the endoscopic mucosal resection of large non-pedunculated colorectal polyps. Endosc Int Open 2024; 12:E1-E10. [PMID: 38188923 PMCID: PMC10769574 DOI: 10.1055/a-2180-8880] [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: 12/24/2022] [Accepted: 08/17/2023] [Indexed: 01/09/2024] Open
Abstract
Background and study aims Because of concerns about peri-procedural adverse events (AEs), guidelines recommend anesthetist-managed sedation (AMS) for long and complex endoscopic procedures. The safety and efficacy of physician-administered balanced sedation (PA-BS) for endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) ≥20 mm is unknown. Patients and methods We compared PA-BS with AMS in a retrospective study of prospectively collected data from consecutive patients referred for management of LNPCPs (NCT01368289; NCT02000141). A per-patient propensity analysis was performed following a 1:2 nearest-neighbor (Greedy-type) match, based on age, gender, Charlson comorbidity index, and lesion size. The primary outcome was any peri-procedural AE, which included hypotension, hypertension, tachycardia, bradycardia, hypoxia, and new arrhythmia. Secondary outcomes were unplanned admissions, 28-day re-presentation, technical success, and recurrence. Results Between January 2016 and June 2020, 700 patients underwent EMR for LNPCPs, of whom 638 received PA-BS. Among them, the median age was 70 years (interquartile range [IQR] 62-76 years), size 35 mm (IQR 25-45 mm), and duration 35 minutes (IQR 25-60 minutes). Peri-procedural AEs occurred in 149 (23.4%), most commonly bradycardia (116; 18.2%). Only five (0.8%) required an unplanned sedation-related admission due to AEs (2 hypotension, 1 arrhythmia, 1 bradycardia, 1 hypoxia), with a median inpatient stay of 1 day (IQR 1-3 days). After propensity-score matching, there were no differences between PA-BS and AMS in peri-procedural AEs, unplanned admissions, 28-day re-presentation rates, technical success or recurrence. Conclusions Physician-administered balanced sedation for the EMR of LNPCPs is safe. Peri-procedural AEs are infrequent, transient, rarely require admission (<1%), and are experienced in similar frequencies to those receiving anesthetist-managed sedation.
Collapse
Affiliation(s)
- Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Rajiv Kurup
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Neal Shahidi
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
- Gastroenterology and Hepatology, The University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Sergei Vosko
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Owen McKay
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Simmi Zahid
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Eric Y. Lee
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | | | - Nicholas Graeme Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Michael J. Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| |
Collapse
|
22
|
Saklani A, Kazi M, Desouza A, Sharma A, Engineer R, Krishnatry R, Gudi S, Ostwal V, Ramaswamy A, Dhanwat A, Bhargava P, Mehta S, Sundaram S, Kale A, Goel M, Patkar S, Vartey G, Kulkarni S, Baheti A, Ankathi S, Haria P, Katdare A, Choudhari A, Ramadwar M, Menon M, Patil P. Tata Memorial Centre Evidence Based Management of Colorectal cancer. Indian J Cancer 2024; 61:S29-S51. [PMID: 38424681 DOI: 10.4103/ijc.ijc_66_24] [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: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.
Collapse
Affiliation(s)
- Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ankit Sharma
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Reena Engineer
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Rahul Krishnatry
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shivkumar Gudi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Aditya Dhanwat
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Prabhat Bhargava
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shaesta Mehta
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Sridhar Sundaram
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Gurudutt Vartey
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Suyash Kulkarni
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Akshay Baheti
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Suman Ankathi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Purvi Haria
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Aparna Katdare
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Amit Choudhari
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Mukta Ramadwar
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Munita Menon
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Prachi Patil
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| |
Collapse
|
23
|
Maselli R, de Sire R, Massimi D, Franchellucci G, Busacca A, Castiglione F, Rispo A, Hassan C, Armuzzi A, Repici A. Advancements in Endoscopic Resection for Colitis-Associated Colorectal Neoplasia in Inflammatory Bowel Disease: Turning Visible into Resectable. Diagnostics (Basel) 2023; 14:9. [PMID: 38201318 PMCID: PMC10795709 DOI: 10.3390/diagnostics14010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Patients suffering from inflammatory bowel disease (IBD) face a two to three-fold higher risk of developing colorectal cancer (CRC) compared to the general population. In recent years, significant progress has been made in comprehending the natural history of IBD-associated CRC (IBD-CRC) and refining its treatment strategies. The decreased incidence of IBD-CRC can be attributed to improved therapeutic management of inflammation, advancements in endoscopy, and early detection of precancerous lesions via surveillance programs. Advanced imaging technologies have made previously undetectable dysplasia visible in most cases, allowing for a much more precise and detailed examination of the mucosa. Additionally, new tools have facilitated the endoscopic resection (ER) of visible lesions in IBD. Particularly, the key to effectively manage colitis-associated colorectal neoplasia (CAN) is to first identify it and subsequently guarantee a complete ER in order to avoid surgery and opt for continuing surveillance. Advanced ER techniques for CAN include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and hybrid ESD-EMR (h-ESD). This narrative review aims to consolidate the current literature on IBD-CRC, providing an overview of advanced techniques for ER of CAN in IBD, with a particular emphasis on the impact of ESD on the long-term outcomes of IBD patients.
Collapse
Affiliation(s)
- Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (D.M.); (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (G.F.); (A.A.)
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (D.M.); (C.H.); (A.R.)
- IBD Unit, Department of Clinical Medicine and Surgery, University Federico II, 80126 Naples, Italy; (F.C.); (A.R.)
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (D.M.); (C.H.); (A.R.)
| | - Gianluca Franchellucci
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (G.F.); (A.A.)
| | - Anita Busacca
- Gastroenterology, IBD Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy;
| | - Fabiana Castiglione
- IBD Unit, Department of Clinical Medicine and Surgery, University Federico II, 80126 Naples, Italy; (F.C.); (A.R.)
| | - Antonio Rispo
- IBD Unit, Department of Clinical Medicine and Surgery, University Federico II, 80126 Naples, Italy; (F.C.); (A.R.)
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (D.M.); (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (G.F.); (A.A.)
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (G.F.); (A.A.)
- Gastroenterology, IBD Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy;
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (D.M.); (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (G.F.); (A.A.)
| |
Collapse
|
24
|
Mandarino FV, Medas R, Gauci JL, Kerrison C, Whitfield A, Gupta S, Williams SJ, Lee EY, Burgess NG, Bourke MJ. Endoscopic mucosal resection for large non-pedunculated colorectal polyps: staying on track with a safe, effective and cost-efficient technique. Gut 2023:gutjnl-2023-331402. [PMID: 38071534 DOI: 10.1136/gutjnl-2023-331402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/25/2023] [Indexed: 12/22/2023]
Affiliation(s)
| | - Renato Medas
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Julia L Gauci
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Clarence Kerrison
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Eric Y Lee
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
25
|
O'Sullivan T, Sidhu M, Gupta S, Byth K, Elhindi J, Tate D, Cronin O, Whitfield A, Wang H, Lee E, Williams S, Burgess NG, Bourke MJ. A novel tool for case selection in endoscopic mucosal resection training. Endoscopy 2023; 55:1095-1102. [PMID: 37391184 DOI: 10.1055/a-2121-1148] [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] [Indexed: 07/02/2023]
Abstract
BACKGROUND As endoscopic mucosal resection (EMR) of large (≥ 20 mm) adenomatous nonpedunculated colonic polyps (LNPCPs) becomes widely practiced outside expert centers, appropriate training is necessary to avoid failed resection and inappropriate surgical referral. No EMR-specific tool guides case selection for endoscopists learning EMR. This study aimed to develop an EMR case selection score (EMR-CSS) to identify potentially challenging lesions for "EMR-naïve" endoscopists developing competency. METHODS Consecutive EMRs were recruited from a single center over 130 months. Lesion characteristics, intraprocedural data, and adverse events were recorded. Challenging lesions with intraprocedural bleeding (IPB), intraprocedural perforation (IPP), or unsuccessful resection were identified and predictive variables identified. Significant variables were used to form a numerical score and receiver operating characteristic curves were used to generate cutoff values. RESULTS Of 1993 LNPCPs, 286 (14.4 %) were in challenging locations (anorectal junction, ileocecal valve, or appendiceal orifice), 368 (18.5 %) procedures were complicated by IPB and 77 (3.9 %) by IPP; 110 (5.5 %) procedures were unsuccessful. The composite end point of IPB, IPP, or unsuccessful EMR was present in 526 cases (26.4 %). Lesion size, challenging location, and sessile morphology were predictive of the composite outcome. A six-point score was generated with a cutoff value of 2 demonstrating 81 % sensitivity across the training and validation cohorts. CONCLUSIONS The EMR-CSS is a novel case selection tool for conventional EMR training, which identifies a subset of adenomatous LNPCPs that can be successfully and safely attempted in early EMR training.
Collapse
Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- The NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - James Elhindi
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Ghent, Ghent, Belgium
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
26
|
Yzet C, Le Baleur Y, Albouys J, Jacques J, Doumbe-Mandengue P, Barret M, Abou Ali E, Schaefer M, Chevaux JB, Leblanc S, Lepillez V, Privat J, Degand T, Wallenhorst T, Rivory J, Chaput U, Berger A, Aziz K, Rahmi G, Coron E, Kull E, Caillo L, Vanbiervliet G, Koch S, Subtil F, Pioche M. Use of endoscopic submucosal dissection or full-thickness resection device to treat residual colorectal neoplasia after endoscopic resection: a multicenter historical cohort study. Endoscopy 2023; 55:1002-1009. [PMID: 37500072 DOI: 10.1055/a-2116-9930] [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] [Indexed: 07/29/2023]
Abstract
INTRODUCTION : Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different management techniques are feasible including endoscopic full-thickness resection using the full-thickness resection device (FTRD) system and endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of these two techniques for the treatment of such lesions. METHODS : All consecutive patients with RCN treated either using the FTRD or by ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate, defined as an en bloc resection with histologically tumor-free lateral and deep margins. RESULTS : 275 patients (median age 70 years; 160 men) who underwent 177 ESD and 98 FTRD procedures for RCN were included. R0 resection was achieved in 83.3 % and 77.6 % for ESD and FTRD, respectively (P = 0.25). Lesions treated by ESD were however larger than those treated by FTRD (P < 0.001). The R0 rates for lesions of 20-30 mm were 83.9 % and 57.1 % in the ESD and FTRD groups, respectively, and for lesions of 30-40 mm were 93.6 % and 33.3 %, respectively. On multivariable analysis, ESD procedures were associated with statistically higher en bloc and R0 resection rates after adjustment for lesion size (P = 0.02 and P < 0.001, respectively). The adverse event rate was higher in the ESD group (16.3 % vs. 5.1 %), mostly owing to intraoperative perforations. CONCLUSION: ESD is effective in achieving R0 resection for RCN whatever the size and location of the lesions. When residual lesions are smaller than 20 mm, the FTRD is an effective alternative.
Collapse
Affiliation(s)
- Clara Yzet
- Endoscopy and Gastroenterology Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Yann Le Baleur
- Endoscopy and Gastroenterology Unit, Hospital Saint Joseph, Paris, France
| | - Jérémie Albouys
- Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
| | - Jérémie Jacques
- Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
| | - Paul Doumbe-Mandengue
- Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
| | - Maximilien Barret
- Endoscopy and Gastroenterology Unit, Cochin University Hospital, Paris, France
| | - Einas Abou Ali
- Endoscopy and Gastroenterology Unit, Cochin University Hospital, Paris, France
| | - Marion Schaefer
- Endoscopy and Gastroenterology Unit, Nancy University Hospital, Nancy, France
| | | | - Sarah Leblanc
- Department of Endoscopy and Gastroenterology, Hôpital Privé Jean Mermoz, Lyon, France
| | - Vincent Lepillez
- Department of Endoscopy and Gastroenterology, Hôpital Privé Jean Mermoz, Lyon, France
| | - Jocelyn Privat
- Endoscopy and Gastroenterology Unit, Vichy Hospital, Vichy, France
| | - Thibault Degand
- Endoscopy and Gastroenterology Unit, Dijon University Hospital, Dijon, France
| | - Timothée Wallenhorst
- Endoscopy and Gastroenterology Unit, Pontchaillou University Hospital, Rennes, France
| | - Jérôme Rivory
- Endoscopy and Gastroenterology Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Ulriikka Chaput
- Endoscopy and Gastroenterology Unit, Saint-Antoine University Hospital, Paris, France
| | - Arthur Berger
- Endoscopy and Gastroenterology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Karim Aziz
- Endoscopy and Gastroenterology Unit, Saint Brieuc Hospital, Saint Brieuc, France
| | - Gabriel Rahmi
- Endoscopy and Gastroenterology Unit, Georges Pompidou European Hospital, Paris, France
| | - Emmanuel Coron
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
- Digestive Diseases Institute, University Hospital Nantes, Nantes, France
| | - Eric Kull
- Endoscopy and Gastroenterology Unit, Metz Hospital, Metz, France
| | - Ludovic Caillo
- Endoscopy and Gastroenterology Unit, Nîmes University Hospital, Nîmes, France
| | | | - Stéphane Koch
- Endoscopy and Gastroenterology Unit, Besançon University Hospital, Besançon, France
| | - Fabien Subtil
- Biostatistics Unit, Hospices Civils de Lyon, Université de Lyon, Université Claude Bernard Lyon 1, CNRS, and Laboratoire de Biométrie et Biologie Évolutive, Lyon, France
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
27
|
Tate DJ, Desomer L, Argenziano ME, Mahajan N, Sidhu M, Vosko S, Shahidi N, Lee E, Williams SJ, Burgess NG, Bourke MJ. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72:1875-1886. [PMID: 37414440 DOI: 10.1136/gutjnl-2023-330300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort. DESIGN Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two. RESULTS 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up. CONCLUSIONS RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases. TRIAL REGISTRATION NUMBERS NCT01368289 and NCT02000141.
Collapse
Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Maria Eva Argenziano
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
| | - Neha Mahajan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
28
|
von Renteln D, Djinbachian R, Benard F, Barkun AN, Bouin M, Bouchard S, Deslandres É, Panzini B, Sidani S, Leduc R, Jobse BC, Pohl H. Incomplete resection of colorectal polyps of 4-20 mm in size when using a cold snare, and its associated factors. Endoscopy 2023; 55:929-937. [PMID: 36377124 DOI: 10.1055/a-1978-3277] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND : Cold snare polypectomy (CSP) is increasingly used for polypectomy and is recommended as the first-line modality for small (< 10 mm) polyps. This study aimed to evaluate incomplete resection rates (IRRs) when using CSP for colorectal polyps of 4-20 mm. METHODS : Adults (45-80 years) undergoing screening, surveillance, or diagnostic colonoscopy and CSP by one of nine endoscopists were included. The primary outcome was the IRR for colorectal polyps of 4-20 mm, defined as the presence of polyp tissue in marginal biopsies after resection of serrated polyps or adenomas. Secondary outcomes included the IRR for serrated polyps, ease of resection, and complications. RESULTS: 413 patients were included (mean age 63; 48 % women) and 182 polyps sized 4-20 mm were detected and removed by CSP. CSP required conversion to hot snare resection in < 1 % of polyps of < 10 mm and 44 % of polyps sized 10-20 mm. The IRRs for polyps < 10 mm and ≥ 10 mm were 18 % and 21 %. The IRR was higher for serrated polyps (26 %) compared with adenomas (16 %). The IRR was higher for flat (IIa) polyps (odds ratio [OR] 2.9, 95 %CI 1.1-7.4); and when resection was judged as difficult (OR 4.2, 95 %CI 1.5-12.1), piecemeal resection was performed (OR 6.6, 95 %CI 2.0-22.0), or visible residual polyp was present after the initial resection (OR 5.4, 95 %CI 2.0-14.9). Polyp location, use of a dedicated cold snare, and submucosal injection were not associated with incomplete resection. Intraprocedural bleeding requiring endoscopic intervention occurred in 4.7 %. CONCLUSIONS : CSP for polyps of 4-9 mm is safe and feasible; however, for lesions ≥ 10 mm, CSP failure occurs frequently, and the IRR remains high even after technical success. Incomplete resection was associated with flat polyps, visual residual polyp, piecemeal resection, and difficult polypectomies.
Collapse
Affiliation(s)
- Daniel von Renteln
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Roupen Djinbachian
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Florence Benard
- Division of General Surgery, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Mickael Bouin
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Simon Bouchard
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Érik Deslandres
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Benoit Panzini
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Sacha Sidani
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Raymond Leduc
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Bruce C Jobse
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| |
Collapse
|
29
|
Cronin O, Bourke MJ. Endoscopic Management of Large Non-Pedunculated Colorectal Polyps. Cancers (Basel) 2023; 15:3805. [PMID: 37568621 PMCID: PMC10417738 DOI: 10.3390/cancers15153805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Large non-pedunculated colorectal polyps ≥20 mm (LNPCPs) comprise approximately 1% of all colorectal polyps. LNPCPs more commonly contain high-grade dysplasia, covert and overt cancer. These lesions can be resected using several means, including conventional endoscopic mucosal resection (EMR), cold-snare EMR (C-EMR) and endoscopic submucosal dissection (ESD). This review aimed to provide a comprehensive, critical and objective analysis of ER techniques. Evidence-based, selective resection algorithms should be used when choosing the most appropriate technique to ensure the safe and effective removal of LNPCPs. Due to its enhanced safety and comparable efficacy, there has been a paradigm shift towards cold-snare polypectomy (CSP) for the removal of small polyps (<10 mm). This technique is now being applied to the management of LNPCPs; however, further research is required to define the optimal LNPCP subtypes to target and the viable upper size limit. Adjuvant techniques, such as thermal ablation of the resection margin, significantly reduce recurrence risk. Bleeding risk can be mitigated using through-the-scope clips to close defects in the right colon. Endoscopic surveillance is important to detect recurrence and synchronous lesions. Recurrence can be readily managed using an endoscopic approach.
Collapse
Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
| |
Collapse
|
30
|
Hollenbach M, Vu Trung K, Hoffmeister A. [Interventional endoscopy in gastroenterology]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023:10.1007/s00108-023-01565-3. [PMID: 37405423 DOI: 10.1007/s00108-023-01565-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
Essential innovations in interventional endoscopy have significantly broadened the treatment armamentarium in gastroenterology. The treatment and complication management of intraepithelial neoplasms and early forms of cancer are increasingly being primarily addressed endoscopically. In cases of endoluminal lesions with no risk of lymph node or distant metastases, endoscopic mucosal resection and endoscopic submucosal dissection have become established as standards. For broad-based adenomas, coagulation of the resection margins should be performed in the case of a piecemeal resection. Submucosal lesions can be reached and resected by tunneling techniques. Peroral endoscopic myotomy in cases of achalasia is a new treatment option for hypertensive and hypercontractile motility disorders. In addition, endoscopic myotomy for gastroparesis has shown very promising results. In this article, new resection techniques and so-called third space endoscopy are presented and critically discussed.
Collapse
Affiliation(s)
- Marcus Hollenbach
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Kien Vu Trung
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| |
Collapse
|
31
|
Masunaga T, Kato M, Sasaki M, Iwata K, Miyazaki K, Kubosawa Y, Mizutani M, Takatori Y, Matsuura N, Nakayama A, Takabayashi K, Yahagi N. Effectiveness of water pressure method in colorectal endoscopic submucosal dissection by novice endoscopists. Endosc Int Open 2023; 11:E641-E648. [PMID: 37502676 PMCID: PMC10370489 DOI: 10.1055/a-2102-7578] [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: 05/25/2023] [Indexed: 07/29/2023] Open
Abstract
Background and study aims Colorectal endoscopic submucosal dissection (ESD) remains challenging for novice endoscopists. Not only the underwater conditions but also active use of water pressure with the water pressure method (WPM) can help widen the submucosal layer. This study aimed to clarify the usefulness of WPM in colorectal ESD, especially for novice endoscopists. Methods This study was ex vivo and enrolled three novices. Each endoscopist performed conventional ESD (C-ESD) and ESD with WPM (WPM-ESD) 10 times on an excised bovine rectum. The treatment outcomes were compared between the two groups. Results Median procedure time was significantly shorter in the WPM-ESD group than in the C-ESD group (54 minutes, interquartile range [IQR] 42-67 vs. 45 minutes, IQR 34-55, P = 0.035). Although no significant difference in the activation time of electrical surgical unit (ESU) during the procedure was noted, the interval time during the procedure at which the ESU was not activated was significantly shorter in the WPM-ESD group (52 minutes, IQR 40-65 vs. 42 minutes, IQR 32-52, P = 0.030) than in the C-ESD group. Moreover, the time required for the endoscope to enter the submucosa was significantly shorter in the WPM-ESD group than in the C-ESD group (8.0 minutes, IQR 6.0-10 vs. 5.0 minutes, IQR 3.0-6.0, P < 0.001). Conclusions The present study reveals that the WPM method significantly shortens the procedure times for novices in colorectal ESD, especially the interval time, which refers to the time spent creating the field of view, and the time required for the endoscope to enter the submucosa.
Collapse
Affiliation(s)
- Teppei Masunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Kentaro Iwata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Kurato Miyazaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Yoko Kubosawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
32
|
Tate DJ, Argenziano ME, Anderson J, Bhandari P, Boškoski I, Bugajski M, Desomer L, Heitman SJ, Kashida H, Kriazhov V, Lee RRT, Lyutakov I, Pimentel-Nunes P, Rivero-Sánchez L, Thomas-Gibson S, Thorlacius H, Bourke MJ, Tham TC, Bisschops R. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023. [PMID: 37285908 DOI: 10.1055/a-2077-0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.
Collapse
Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
- Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
| | - John Anderson
- Cheltenham General Hospital, Gloucestershire Hospitals Foundation Trust, Cheltenham, UK
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marek Bugajski
- Department of Gastroenterology, Luxmed Oncology, Warsaw, Poland
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Vladimir Kriazhov
- Endoscopy Department, Nizhny Novgorod Regional Clinical Oncology Center, Nizhny Novgorod, Russia Federation
| | - Ralph R T Lee
- The Ottawa Hospital - Civic Campus, University of Ottawa, Ottawa, Canada
| | - Ivan Lyutakov
- University Hospital Tsaritsa Yoanna-ISUL, Medical University Sofia, Sofia, Bulgaria
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| |
Collapse
|
33
|
Burgess NG, Bourke MJ. Can we stop routine biopsy of post-endoscopic mucosal resection scars? Endoscopy 2023. [PMID: 37263279 DOI: 10.1055/a-2085-5660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
34
|
Keating E, Leyden J, O'Connor DB, Lahiff C. Unlocking quality in endoscopic mucosal resection. World J Gastrointest Endosc 2023; 15:338-353. [PMID: 37274555 PMCID: PMC10236981 DOI: 10.4253/wjge.v15.i5.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Eoin Keating
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Jan Leyden
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Donal B O'Connor
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Conor Lahiff
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| |
Collapse
|
35
|
Sundaram S, Seth V, Jearth V, Giri S. Underwater versus conventional endoscopic mucosal resection for sessile colorectal polyps: an updated systematic review and meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:225-233. [PMID: 36148677 DOI: 10.17235/reed.2022.8956/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND underwater endoscopic mucosal resection (uEMR) without submucosal injection for sessile colorectal polyps was introduced as a new replacement for conventional EMR (cEMR). However, the optimal resection strategy remains a topic of debate. Hence, this meta-analysis was performed to compare the efficacy and safety of uEMR and cEMR in patients with sessile colorectal polyps. METHODS a comprehensive search of the literature from 2000 till January 2022 was performed from Medline, CENTRAL and Embase for randomized controlled trials (RCTs) comparing cEMR vs uEMR for colorectal polyps. The evaluated outcomes included en bloc resection, R0 resection, procedure time, overall bleeding and recurrence. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a random effect model. RESULTS six studies were included, out of which four were full-text articles and two were conference abstracts. En bloc resection (RR 1.26, 95 % CI: 1.00-1.60), R0 resection (RR 1.10, 95 % CI: 0.96-1.26), overall bleeding (RR 0.85, 95 % CI: 0.54-1.34) and recurrence rate (RR 0.75, 95 % CI: 0.45-1.27) were comparable between uEMR and cEMR. However, uEMR was associated with a shorter procedure time (mean difference [MD] -1.55 minutes, 95 % CI: -2.71 to -0.39). According to the subgroup analysis, uEMR led to a higher rate of en bloc resection (RR 1.41, 95 % CI: 1.07-1.86) and R0 resection (RR 1.19, 95 % CI: 1.01-1.41) for polyps ≥ 10 mm in size. CONCLUSION both uEMR and cEMR have a comparable safety and efficacy. For polyps larger than 10 mm, uEMR may have an advantage over cEMR and should be the topic for future studies.
Collapse
Affiliation(s)
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research
| | - Suprabhat Giri
- Gastroenterology, Nizam's Institute of Medical Sciences, India
| |
Collapse
|
36
|
Gomez Cifuentes JD, Berger S, Caskey K, Jove A, Sealock RJ, Hair C, Velez M, Jarbrink-Sehgal M, Thrift AP, da Costa W, Gyanprakash K. Evolution of endoscopic mucosal resection (EMR) technique and the reduced recurrence of large colonic polyps from 2012 to 2020. Scand J Gastroenterol 2023; 58:435-440. [PMID: 36254785 DOI: 10.1080/00365521.2022.2134734] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is an effective method for removing non-pedunculated polyps ≥ 20 mm. We aimed to examine changes in EMR techniques over a 9-year period and evaluate frequency of histologic-confirmed recurrence. METHODS We identified patients who underwent EMR of non-pedunculated polyps ≥ 20 mm at a safety net and the Veteran's Affairs (VA) hospital in Houston, Texas between 2012 and 2020. Odds ratios (ORs) and 95% confidence intervals (CI) for associations with recurrence risk were estimated using multivariable logistic regression. RESULTS 461 unique patients were included. The histologic-confirmed recurrence was 29.0% at 15.6 months median follow up (IQR 12.3 - 17.4). Polyps removed between 2018 and 2020 had a 0.43 decreased odds of recurrence vs. polyps removed between 2012 and 2014. The use of viscous lifting agents increased over time (from 0 to 54%), and the use of saline was associated with increased risk of recurrence (OR 2.28 [CI 1.33 - 3.31]). CONCLUSIONS Histologic-confirmed recurrence after EMR for non-pedunculated polyps ≥ 20 mm decreased over the seven year-period. Saline was associated with a higher risk of recurrence and the use of more viscous agents increased over time.
Collapse
Affiliation(s)
| | - Scott Berger
- Internal Medicine Department, Baylor College of Medicine, Houston, TX, USA
| | | | - Andre Jove
- Baylor College of Medicine, Houston, TX, USA
| | - Robert J Sealock
- Gastroenterology Department, Baylor College of Medicine, Houston, TX, USA
| | - Clark Hair
- Gastroenterology Department, Baylor College of Medicine, Houston, TX, USA
| | - Maria Velez
- Gastroenterology Department, Baylor College of Medicine, Houston, TX, USA
| | | | - Aaron P Thrift
- Department of Medicine, Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Wilson da Costa
- Department of Medicine, Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX, USA
| | | |
Collapse
|
37
|
Bak MTJ, Albéniz E, East JE, Coelho-Prabhu N, Suzuki N, Saito Y, Matsumoto T, Banerjee R, Kaminski MF, Kiesslich R, Coron E, de Vries AC, van der Woude CJ, Bisschops R, Hart AL, Itzkowitz SH, Pioche M, Moons LMG, Oldenburg B. Endoscopic management of patients with high-risk colorectal colitis-associated neoplasia: a Delphi study. Gastrointest Endosc 2023; 97:767-779.e6. [PMID: 36509111 DOI: 10.1016/j.gie.2022.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Current guidelines recommend endoscopic resection of visible and endoscopically resectable colorectal colitis-associated neoplasia (CAN) in patients with inflammatory bowel disease (IBD). However, patients with high-risk CAN (HR-CAN) are often not amenable to conventional resection techniques, and a consensus approach for the endoscopic management of these lesions is presently lacking. This Delphi study aims to reach consensus among experts on the endoscopic management of these lesions. METHODS A 3-round modified Delphi process was conducted to reach consensus among worldwide IBD and/or endoscopy experts (n = 18) from 3 continents. Consensus was considered if ≥75% agreed or disagreed. Quality of evidence was assessed by the criteria of the Cochrane Collaboration group. RESULTS Consensus was reached on all statements (n = 14). Experts agreed on a definition for CAN and HR-CAN. Consensus was reached on the examination of the colon with enhanced endoscopic imaging before resection, the endoscopic resectability of an HR-CAN lesion, and endoscopic assessment and standard report of CAN lesions. In addition, experts agreed on type of resections of HR-CAN (< 20 mm, >20 mm, with or without good lifting), endoscopic success (technical success and outcomes), histologic assessment, and follow-up in HR-CAN. CONCLUSIONS This is the first step in developing international consensus-based recommendations for endoscopic management of CAN and HR-CAN. Although the quality of available evidence was considered low, consensus was reached on several aspects of the management of CAN and HR-CAN. The present work and proposed standardization might benefit future studies.
Collapse
Affiliation(s)
- Michiel T J Bak
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra Navarrabiomed, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, and Oxford NIHR Biomedical Research Centre, Oxford, UK; Division of Gastroenterology and Hepatology, Mayo Clinic Healthcare, London, UK
| | | | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, UK
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Rupa Banerjee
- Inflammatory Bowel Disease Center, Asian Institute of Gastroenterology, Hyderabad, India
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Ralf Kiesslich
- Department of Internal Medicine and Gastroenterology, Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Emmanuel Coron
- Department of Gastroenterology and Hepatology, University Hospital of Geneva, Geneva, Switzerland
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Belgium
| | - Ailsa L Hart
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, London, UK
| | - Steven H Itzkowitz
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
38
|
Ngamruengphong S, Saito Y. Commentary. Endoscopy 2023; 55:393. [PMID: 36990078 DOI: 10.1055/a-2009-1568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | |
Collapse
|
39
|
Abu Arisha M, Scapa E, Wishahi E, Korytny A, Gorelik Y, Mazzawi F, Khader M, Muaalem R, Bana S, Awadie H, Bourke MJ, Klein A. Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice. Gastrointest Endosc 2023; 97:559-567. [PMID: 36328207 DOI: 10.1016/j.gie.2022.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/14/2022] [Accepted: 10/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice. METHODS We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy. RESULTS Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P < .001; RR = .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups. CONCLUSION TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.
Collapse
Affiliation(s)
- Muhammad Abu Arisha
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Erez Scapa
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Efad Wishahi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Alexander Korytny
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yuri Gorelik
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Fares Mazzawi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Majd Khader
- Department of Gastroenterology, Barzilai Medical Center, Ashkelon, Israel
| | - Rawia Muaalem
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Suzan Bana
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Halim Awadie
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia, and Westmead Clinical School, University of Sydney, New South Wales, Australia
| | - Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.
| |
Collapse
|
40
|
Nader SM, Lahr RE, Rex DK. Impact of margin thermal treatment after EMR of giant (≥40 mm) colorectal lateral spreading lesions. Gastrointest Endosc 2023; 97:544-548. [PMID: 36306831 DOI: 10.1016/j.gie.2022.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/16/2022] [Accepted: 10/16/2022] [Indexed: 02/01/2023]
Abstract
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.
Collapse
Affiliation(s)
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
41
|
João M, Areia M, Pinto-Pais T, Gomes LC, Saraiva S, Alves S, Elvas L, Brito D, Saraiva S, Teixeira-Pinto A, Claro I, Dinis-Ribeiro M, Cadime AT. Can white-light endoscopy or narrow-band imaging avoid biopsy of colorectal endoscopic mucosal resection scars? A multicenter randomized single-blind crossover trial. Endoscopy 2023. [PMID: 36690030 DOI: 10.1055/a-2018-1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND : Current guidelines suggest that routine biopsy of post-endoscopic mucosal resection (EMR) scars can be abandoned, provided that a standardized imaging protocol with virtual chromoendoscopy is used. However, few studies have examined the accuracy of advanced endoscopic imaging, such as narrow-band imaging (NBI) vs. white-light endoscopy (WLE) for prediction of histological recurrence. We aimed to assess whether NBI accuracy is superior to that of WLE and whether one or both techniques can replace biopsies. METHODS : The study was a multicenter, randomized, pathologist-blind, crossover trial, with consecutive patients undergoing first colonoscopy after EMR of lesions ≥ 20 mm. Computer-generated randomization and opaque envelope concealed allocation. Patients were randomly assigned to scar examination with NBI followed by WLE (NBI + WLE), or WLE followed by NBI (WLE + NBI). Histology was the reference method, with biopsies being performed for all tissues. RESULTS : The study included 203 scars (103 in the NBI + WLE group, 100 in the WLE + NBI group). Recurrence was confirmed histologically in 29.6 % of the scars. The diagnostic accuracy of NBI was not statistically different from that of WLE (95 % [95 %CI 92 %-98 %] vs. 94 % [95 %CI 90 %-97 %]; P = 0.48). The negative predictive values (NPVs) were 96 % (95 %CI 93 %-99 %) for NBI and 93 % (95 %CI 89 %-97 %) for WLE (P = 0.06). CONCLUSIONS : The accuracy of NBI for the diagnosis of recurrence was not superior to that of WLE. Endoscopic assessment of EMR scars with WLE and NBI achieved an NPV that would allow routine biopsy to be avoided in cases of negative optical diagnosis.
Collapse
Affiliation(s)
- Mafalda João
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Miguel Areia
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Teresa Pinto-Pais
- RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto / Porto Comprehensive Cancer Center, Porto, Portugal
| | - Luís Correia Gomes
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Sofia Saraiva
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Susana Alves
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Luís Elvas
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Daniel Brito
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Sandra Saraiva
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | | | - Isabel Claro
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Mário Dinis-Ribeiro
- RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto / Porto Comprehensive Cancer Center, Porto, Portugal.,Department of Community Medicine, Health Information and Decision, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Teresa Cadime
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| |
Collapse
|
42
|
Ken O, Kobayashi N, Saito Y. Reply. Gastroenterology 2023; 164:1342-1343. [PMID: 36740197 DOI: 10.1053/j.gastro.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Affiliation(s)
- Ohata Ken
- Department of Gastroenterology, NTT Medical Center, Tokyo, Japan
| | - Nozomu Kobayashi
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
43
|
Estevinho MM, Pinho R. Hybrid argon plasma coagulation after endoscopic mucosal resection-some caveats in the comparison with snare tip soft coagulation. Gastrointest Endosc 2023; 97:379. [PMID: 36669824 DOI: 10.1016/j.gie.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/02/2022] [Accepted: 08/06/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Maria Manuela Estevinho
- Department of Gastroemterology, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal; Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rolando Pinho
- Department of Gastroemterology, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal
| |
Collapse
|
44
|
Schiemer M, Schmidt A. [Current endoscopic resection techniques in the colorectum: possibilities, perspectives, limitations]. Dtsch Med Wochenschr 2023; 148:84-93. [PMID: 36690004 DOI: 10.1055/a-1832-4090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Since the first endoscopic polypectomies have been performed, the resection of premalignant lesions during colonoscopy has become a success story in the field of gastroenterology: Incidence and mortality of colorectal cancer have been significantly reduced with the implementation of screening programs. Most polyps in the lower gastrointestinal tract are small and easy to remove. However, larger polyps, early carcinomas and subepithelial lesions can be removed with modern endoscopic resection techniques as well. Minimally invasive endoscopic resections offer an organ-preserving alternative to surgery in a growing number of patients. In this review, we discuss the advantages and limitations of traditional and novel endoscopic resection techniques, including endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic full thickness resection.
Collapse
|
45
|
Kim SY, Kwak MS, Yoon SM, Jung Y, Kim JW, Boo SJ, Oh EH, Jeon SR, Nam SJ, Park SY, Park SK, Chun J, Baek DH, Choi MY, Park S, Byeon JS, Kim HK, Cho JY, Lee MS, Lee OY. Korean Guidelines for Postpolypectomy Colonoscopic Surveillance: 2022 revised edition. Intest Res 2023; 21:20-42. [PMID: 36751043 PMCID: PMC9911266 DOI: 10.5217/ir.2022.00096] [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: 07/25/2022] [Accepted: 10/05/2022] [Indexed: 02/09/2023] Open
Abstract
Colonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer (CRC). Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia. Postpolypectomy surveillance is the most important method for managing advanced metachronous neoplasia. A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of the limited medical resources and concerns regarding colonoscopy complications. In these consensus guidelines, an analytic approach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy. The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows: adenoma ≥10 mm in size; 3 to 5 (or more) adenomas; tubulovillous or villous adenoma; adenoma containing high-grade dysplasia; traditional serrated adenoma; sessile serrated lesion containing any grade of dysplasia; serrated polyp of at least 10 mm in size; and 3 to 5 (or more) sessile serrated lesions. More studies are needed to fully comprehend the patients who are most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.
Collapse
Affiliation(s)
- Su Young Kim
- Department of Gastroenterology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Soon Man Yoon
- Department of Gastroenterology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jong Wook Kim
- Department of Gastroenterology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sun-Jin Boo
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Eun Hye Oh
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Seong Ran Jeon
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seung-Joo Nam
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seon-Young Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo-Kyung Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Mi-Young Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University College of Medicine, Seoul, Korea,Department of Applied Statistics, Chung-Ang University, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence to Jeong-Sik Byeon, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3905, Fax: +82-2-476-0824, E-mail:
| | - Hyung Kil Kim
- Department of Gastroenterology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Joo Young Cho
- Department of Gastroenterology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Moon Sung Lee
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea,Co-Correspondence to Oh Young Lee, Department of Internal Medicine, Hanyang University School of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea. Tel: +82-2-2290-8343, Fax: +82-2-2298-8314, E-mail:
| | | | | | | |
Collapse
|
46
|
A Rectum-Specific Selective Resection Algorithm Optimizes Oncologic Outcomes for Large Nonpedunculated Rectal Polyps. Clin Gastroenterol Hepatol 2023; 21:72-80.e2. [PMID: 35526795 DOI: 10.1016/j.cgh.2022.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are complementary techniques for large (≥20 mm) nonpedunculated rectal polyps (LNPRPs). A mechanism for appropriate technique selection has not been described. METHODS We evaluated the performance of a selective resection algorithm (SRA) (August 2017 to April 2021) compared with a universal EMR algorithm (UEA) (July 2008 to July 2017) for LNPRPs within a prospective observational study. In the SRA, LNPRPs with features of superficial submucosal invasive cancer (SMIC) (<1000 μm; Kudo pit pattern Vi), or with an increased risk of SMIC (Paris 0-Is or 0-IIa+Is nongranular, 0-IIa+Is granular with a dominant nodule ≥10 mm) underwent ESD. The remaining LNPRPs underwent EMR. Algorithm performance was evaluated by SMIC identified after EMR, curative oncologic resection (R0 resection, superficial SMIC, absence of negative histologic features), technical success, adverse events, and recurrence at first surveillance colonoscopy. RESULTS A total of 480 LNPRPs were evaluated (290 UEA, 190 SRA). Median lesion size was 40 (interquartile range, 30-60) mm. SMIC was identified in 56 (11.7%) LNPRPs. Significant differences in SMIC after EMR (SRA 1 [1.0%] vs UEA 35 [12.1%]; P = .001) and curative oncologic resection (SRA n = 7 [33.3%] vs UEA n = 2 [5.7%]; P = .010) were identified. No significant differences in technical success or adverse events were identified (all P > .137). Among LNPRPs with SMIC amenable to curative oncologic resection and which underwent ESD, 100% (n = 7 of 7) were cured. CONCLUSIONS A rectum-specific SRA optimizes oncologic outcomes for LNPRPs and mitigates the risk of piecemeal resection of cancers.
Collapse
|
47
|
Gibson DJ, Sidhu M, Zanati S, Tate DJ, Mangira D, Moss A, Singh R, Hourigan LF, Raftopoulos S, Pham A, Kostos P, Kumarasinghe MP, Ruszkiewicz A, McLeod D, Brown GJE, Bourke MJ. Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer. Gut 2022; 71:2481-2488. [PMID: 35256387 DOI: 10.1136/gutjnl-2020-323666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/25/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Management of covert submucosal invasive cancer (SMIC) discovered after piecemeal endoscopic mucosal resection (pEMR) of large (>20 mm) non-pedunculated colorectal polyps is challenging. The residual cancer risk is largely unknown. We sought to evaluate this in a large tertiary referral cohort. DESIGN Cases of covert SMIC following pEMR were identified and followed. Oncological outcomes after surgery were divided based on residual intramural cancer, lymph node metastases (LNM) or both. Risk factors for residual intramural cancer and LNM were analysed based on the original pEMR histological variables. Risk parameters were analysed with respect to low and high-risk variables for residual intramural cancer and LNM. RESULTS Among 3372 cases of large non-pedunculated colorectal polyps, 143 cases of covert SMIC (4.2%) were identified. 109 underwent surgical resection. Histological analysis of pEMR histology was available in 98 of 109 (90%) cases. 62 cases (63%) had no residual malignancy. 36 cases had residual malignancy (residual intramural cancer n=24; LNM n=5; both n=7). All cases of residual intramural cancer could be identified by a R1 histological deep margin. Cases with poor differentiation (PD) and/or lymphovascular invasion (LVI) had a high risk of LNM (12/33), with a very low risk without these criteria (<1%; 0/65). Cases at low risk for LNM with R0 deep margin have a low risk of residual intramural cancer (<1%; 0/35). CONCLUSION The majority of cases of large non-pedunculated colorectal polyps with covert SMIC following pEMR will have no residual malignancy. The risk of residual malignancy can be ascertained from three key variables: PD, LVI and R1 deep margin.
Collapse
Affiliation(s)
- Dave J Gibson
- Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Simon Zanati
- Gastroenterology, Western Health, Footscray, Victoria, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Dileep Mangira
- Gastroenterology, Western Health, Footscray, Victoria, Australia
| | - Alan Moss
- Department of Gastroenterology, Western Hospital, Footscray, Victoria, Australia
| | - Rajvinder Singh
- Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Luke F Hourigan
- Gastroenterology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Spiro Raftopoulos
- Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Alan Pham
- Anatomical Pathology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Phil Kostos
- Pathology, Western Health, Footscray, Victoria, Australia
| | - M Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest, QEII Medical Centre, Perth, Western Australia, Australia
| | | | - Duncan McLeod
- Institute of Clinical Pathology and Medical Research, Westmead Millennium Institute and Westmead Hospital, University of Sydney, Australia, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
48
|
Kim SY, Kwak MS, Yoon SM, Jung Y, Kim JW, Boo SJ, Oh EH, Jeon SR, Nam SJ, Park SY, Park SK, Chun J, Baek DH, Choi MY, Park S, Byeon JS, Kim HK, Cho JY, Lee MS, Lee OY. Korean guidelines for postpolypectomy colonoscopic surveillance: 2022 revised edition. Clin Endosc 2022; 55:703-725. [PMID: 36156035 PMCID: PMC9726446 DOI: 10.5946/ce.2022.136] [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: 04/26/2022] [Accepted: 06/22/2022] [Indexed: 12/15/2022] Open
Abstract
Colonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer (CRC). Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia. Postpolypectomy surveillance is the most important method for the management of advanced metachronous neoplasia. A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of limited medical resources and concerns regarding colonoscopy complications. In these consensus guidelines, an analytic approach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy. The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows: (1) adenoma ≥10 mm in size; (2) 3 to 5 (or more) adenomas; (3) tubulovillous or villous adenoma; (4) adenoma containing high-grade dysplasia; (5) traditional serrated adenoma; (6) sessile serrated lesion (SSL) containing any grade of dysplasia; (7) serrated polyp of at least 10 mm in size; and (8) 3 to 5 (or more) SSLs. More studies are needed to fully comprehend the patients most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.
Collapse
Affiliation(s)
- Su Young Kim
- Department of Gastroenterology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Soon Man Yoon
- Department of Gastroenterology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jong Wook Kim
- Department of Gastroenterology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sun-Jin Boo
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Eun Hye Oh
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Seong Ran Jeon
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seung-Joo Nam
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seon-Young Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo-Kyung Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Mi-Young Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Suyeon Park
- Department of biostatistics, Soonchunhyang University College of Medicine, Seoul, Korea,Department of Applied Statistics, Chung-Ang University, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence: Jeong-Sik Byeon Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea E-mail:
| | - Hyung Kil Kim
- Department of Gastroenterology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Joo Young Cho
- Department of Gastroenterology, CHA Gangnam Medical Center, Seoul, Korea
| | - Moon Sung Lee
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea,Correspondence: Oh Young Lee Department of Internal Medicine, Hanyang University School of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea E-mail:
| | | | | | | |
Collapse
|
49
|
Mönkemüller K, Vargo JJ. Are We Ready to Embrace Endoscopic Submucosal Dissection as the Organ-Sparing, Minimally Invasive Endoscopic Surgical Procedure of Choice for Large Colorectal Adenomas and Early Cancers? Gastroenterology 2022; 163:1168-1170. [PMID: 36067819 DOI: 10.1053/j.gastro.2022.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Klaus Mönkemüller
- Department of Gastroenterology, Helios Frankenwaldklinik, Kronach, Germany; Division of Endoscopy, Ameos Klinikum Teaching University, Halberstadt, Germany; Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clínica de Gastroenterología "Prof. Carolina Olano Gossweiler", Universidad de La República, Montevideo, Uruguay.
| | - John J Vargo
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
50
|
Motchum L, Levenick JM, Djinbachian R, Moyer MT, Bouchard S, Taghiakbari M, Repici A, Deslandres É, von Renteln D. EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos). Gastrointest Endosc 2022; 96:840-848.e2. [PMID: 35724695 DOI: 10.1016/j.gie.2022.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Abstract
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.).
Collapse
Affiliation(s)
- Leslie Motchum
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Faculty of Medicine, Montreal University Montreal, Montreal, Quebec, Canada
| | - John M Levenick
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Roupen Djinbachian
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Matthew T Moyer
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Simon Bouchard
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Mahsa Taghiakbari
- Montreal University Medical Research Center, Montreal, Quebec, Canada
| | - Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Érik Deslandres
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Daniel von Renteln
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| |
Collapse
|