Cap-assisted Endoscopic Mucosal Resection is Highly Effective for Nonpedunculated Colorectal Lesions

Outcome of Endoscopic Resection of Rectal Neuroendocrine Tumors ≤ 10 mm

BACKGROUND AND AIM

Guidelines suggest endoscopic resection for rectal neuroendocrine tumors (rNETs) < 10 mm, but the most appropriate resection technique is unclear. In real-life clinical practice, the endoscopic removal of unrecognized rNETs can take place with "simple" techniques and without preliminary staging. The aim of the current study is to report our own experience at a referral center for both neuroendocrine neoplasms and endoscopy.

METHODS

Retrospective analyses of polypectomies were performed at the Humanitas Research Hospital for rNETs (already diagnosed or previously unrecognized).

RESULTS

A total of 19 patients were included, with a median lesion size of 5 mm (range 3-10 mm). Only five lesions were suspected as NETs before removal and underwent endoscopic ultrasound (EUS) before resection, being removed with advanced endoscopic techniques. Unsuspected rNETs were removed by cold polypectomy in eleven cases, EMR in two, and biopsy forceps in one. When described, the margins were negative in four cases, positive in four (R1), and indeterminate in one. The median follow-up was 40 months. A 10 mm polypoid lesion removed with cold snare polypectomy (G2 R1) needed subsequent surgery. Eighteen patients underwent EUS after a median time of 6.5 months from resection. The EUS identified local recurrence after 14 months in a 7 mm polypoid lesion removed with cold snare polypectomy (G1 R1); the lesion was treated with cap-assisted EMR. For all the other lesions, the follow-up was negative.

CONCLUSIONS

When rNETs are improperly removed without prior staging, caution must be exercised. The data from our cohort suggest that even if inappropriate resection had happened, patients may be safely managed with early EUS evaluation.

Improved Adenoma Detection Rate Using a Novel Colonoscopic Distal Attachment: A Multicenter Randomized Controlled Trial

INTRODUCTION

To evaluate the effect of Embrella, a novel-designed colonoscopic distal attachment, on adenoma detection rate (ADR) and adenoma per colonoscopy (APC), compared with standard colonoscopy in routine practice.

METHODS

All consecutive participants who underwent routine colonoscopic examinations at 3 endoscopy centers in China were enrolled. Participants were randomly assigned in a 1:1 ratio to the Embrella-assisted colonoscopy (EAC) or standard colonoscopy (SC) groups. ADR, APC, inspection time, pain scores, and adverse events were recorded.

RESULTS

Overall, 1,179 participants were randomized into the EAC (n = 593) and SC groups (n = 586). EAC increased the overall ADR from 24.6% to 34.2% ( P < 0.001) and improved APC from 0.44 to 0.64 ( P = 0.002). Subgroup analyses indicated that EAC significantly improved ADR for adenomas < 10 mm (13.8% vs 8.5%, P = 0.004 for 5-9 mm and 27.0% vs 17.2%, P < 0.001 for < 5 mm), nonpedunculated adenomas (26.6% vs 18.8%, P < 0.001), and adenomas in the transverse (10.8% vs 6.1%, P = 0.004) and left colon (21.6% vs 13.7%, P < 0.001). APC in the subgroup analyses was consistent with ADR. The mean inspection time was shorter with EAC (6.52 vs 6.68 minutes, P = 0.046), with no significant impact on participants' pain scores ( P = 0.377). Moreover, no EAC-related adverse events occurred.

DISCUSSION

EAC significantly increased ADR and APC compared with SC, particularly for adenomas <10 mm, nonpedunculated adenomas, and adenomas in the transverse and left colon.

Cap-assisted endoscopic mucosal resection as a salvage technique for challenging colorectal laterally spreading tumors

BACKGROUND

Cap-assisted endoscopic mucosal resection (EMR-c) has emerged as a potential alternative to standard piecemeal wide-field EMR (WF-EMR) for the resection of laterally spreading tumors (LSTs). However, clear indications for this technique are still lacking. Our objective was to investigate the performance of salvage EMR-c after WF-EMR failure in the resection of large colorectal LSTs.

METHODS

The data of consecutive patients undergoing WF-EMR for large colorectal LSTs (2015-2021) were analyzed in this single-center, retrospective, observational study. In the event of a WF-EMR failure, the procedure was switched to EMR-c in the same session. The efficacy of the two techniques was evaluated in terms of complete endoscopic resection, R0 resection, and recurrence rate. Safety was also assessed.

RESULTS

Overall, the data from 81 WF-EMRs were collected. Eighteen cases of WF-EMR failure were switched to EMR-c in the same session and complete endoscopic resection was achieved in 17/18 patients (94.4%). No statistically significant difference was observed between WF-EMR and salvage EMR-c in terms of macroscopic radicality (P = 0.40) and R0 resection (P = 0.12). However, recurrence was more common with EMR-c (44.4% vs. 23.5%; P = 0.05), as were adverse events, particularly intraprocedural bleeding (27.8% vs. 7.9%; P = 0.04).

CONCLUSION

EMR-c is an effective salvage technique for challenging colorectal LSTs following WF-EMR failure. Due to the elevated risk of adverse events associated with this procedure, careful patient selection, endoscopic expertise, and close follow-up are strongly recommended.

Novel through-the-scope suture closure of colonic EMR defects (with video)

BACKGROUND AND AIMS

Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS.

METHODS

A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding.

RESULTS

A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate).

CONCLUSION

TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.

Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos)

BACKGROUND AND AIMS

Piecemeal EMR of colorectal laterally spreading tumors (LSTs) >20 mm is effective. Experience is limited in the use of cap-assisted EMR (EMR-C) for resection of colonic lesions. We compared the efficacy and the safety of EMR-C for the removal of colonic LSTs ≥30 mm with "inject-and-cut" standard EMR (EMR-S).

METHODS

In this randomized trial from 4 Italian centers, 138 patients were treated with EMR-C and 102 with EMR-S. The rates of residual lesions, percentage of recurrence after 12 months, and adverse events were evaluated.

RESULTS

One hundred forty-three lesions were resected with EMR-C and 102 with EMR-S. Argon plasma coagulation (APC) was used as adjunctive treatment in 2.9% of EMR-Cs and in 22.5% of EMR-Ss (P < .001). The median time required was 20 minutes for EMR-C and 30 minutes for EMR-S (P < .001). Adverse events (AEs) occurred in 14 EMR-Cs (10.1%; 2 perforations, 11 bleeding events, and 1 stenosis) and in 22 EMR-Ss (21.6%; 1 perforation and 21 bleeding events) (P = .017). Intraprocedural AEs occurred in 3.6% of EMR-Cs and 16.7% of EMR-Ss (P = .001). Overall, residual lesions within 12 months were found to be significantly higher with EMR-S (32 patients, 31.4%) than with EMR-C (8 patients, 5.8%) (P < .001). Recurrence at follow-up colonoscopy in 12 months occurred in 7 EMR-Cs (5.1%) and 17 EMR-Ss (16.7%; P < .001).

CONCLUSIONS

The study demonstrated the feasibility and safety of EMR-C for removing large colorectal LSTs, with higher eradication rates, shorter resection time, and less use of APC when compared with EMR-S. (Clinical trial registration number: NCT03498664.).

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

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

Efficacy and safety of cap-assisted endoscopic mucosal resection for treatment of nonlifting colorectal polyps

BACKGROUND : Suboptimal lifting increases complexity of endoscopic mucosal resection (EMR) for benign colorectal polyps. Cap-assisted EMR (EMR-C) may allow fibrotic polyp tissue to be captured in the snare. This study evaluated the efficacy and safety of EMR-C for benign nonlifting colorectal polyps. METHODS : This was a multicenter study, which prospectively registered all EMR-C procedures (2016-2018) for presumed benign nonlifting colorectal polyps. RESULTS : 70 nonlifting polyps with a median size of 25 mm (interquartile range [IQR] 15-40) were treated with EMR-C. Complete polyp removal was achieved in 68 (97.1 %), including 47 (67.1 %) with EMR-C alone. Overall, 66 polyps showed benign histology, and endoscopic follow-up after a median of 6 months (IQR 6-10) showed recurrence in 19.7 %. First (n = 10) and second (n = 2) benign recurrences were all treated endoscopically. Deep mural injury type III-V occurred in 7.4 % and was treated successfully with clips. CONCLUSION : EMR-C may be an alternative therapeutic option for removal of benign nonlifting polyp tissue. Although recurrence still occurs, repeat endoscopic therapy usually leads to complete polyp clearance.

Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions

Endoscopic mucosal resection (EMR) is a technique allowing efficacious and minimally invasive resection of precancerous lesions across the entire gastrointestinal tract. However, conventional EMR, involving injection of fluid into the submucosal space, is imperfect, given the high rate of recurrence of post-endoscopic resection adenoma, especially after piecemeal resection. In light of these observations, modifications of the technique have been proposed to overcome the weakness of conventional EMR. Some of them were designed to maximize the chance of en bloc resection—cap-assisted EMR, underwater EMR, tip-in EMR, precutting, assisted by ligation device—while others were designed to minimize the complications (cold EMR). In this review, we present their modes of action and summarize the evidence regarding their efficacy and safety.

Safety and efficacy of band ligation and auto-amputation as adjunct to EMR of colonic large laterally spreading tumors, and polyps not amenable to routine polypectomy

Introduction:

The safety and efficacy of colonic band ligation and auto-amputation (1) as adjunct to endoscopic mucosal resection of large laterally spreading tumors and (2) for polyps not amenable to routine polypectomy due to polyp burden or difficult location remain unknown.

Methods:

An institutional review board–approved retrospective single-institution study was undertaken of patients undergoing colonic band ligation and auto-amputation from 2014 to date. Patients with indications of ‘endoscopic mucosal resection for laterally spreading tumors’ and ‘polyp not amenable to snare polypectomy’ were included in the study. Data were collected on patient demographics, colonoscopy details (laterally spreading tumors/polyp characteristics, therapies applied, complications), pathology results, and follow-up (polyp eradication based on endoscopic appearance and biopsy results).

Results:

Patients undergoing endoscopic mucosal resection for laterally spreading tumors: Thirty-two patients (31 males, aged 68 ± 9.17 years) underwent endoscopic mucosal resection-band ligation and auto-amputation of 34 laterally spreading tumors (40 ± 10.9 mm). A median of 2 ± 1.09 bands were placed. Follow-up colonoscopy and biopsy results confirmed complete eradication in 21 laterally spreading tumors (70%). Nine (30%) laterally spreading tumors required additional endoscopic therapy to achieve complete eradication. Four (13%) patients underwent surgery for cancer, and two of them had resection specimens negative for cancer or residual adenoma. One patient suffered post-polypectomy syndrome. Patients undergoing band ligation and auto-amputation for polyps not amenable to snare polypectomy: Seven patients underwent band ligation and auto-amputation due to serrated polyposis syndrome (one patient) and innumerable polyps, or polyps in difficult locations (extension into diverticula: two patients; terminal ileum: two patients; appendiceal orifice: one patient; anal canal: one patient). The patient with serrated polyposis syndrome achieved dramatic decrease in polyp burden, but not eradication. Follow-up in five of the six remaining patients documented polyp eradication. The patient with serrated polyposis syndrome suffered from rectal pain and tenesmus following placement of 18 bands.

Conclusions:

Band ligation and auto-amputation in the colon may be a safe and effective adjunct to current endoscopic mucosal resection and polypectomy methods and warrants further study.

Plain Language Summary

Colonoscopy with rubber band placement to aid in complete removal of large polyps and polyps in technically challenging locations

Colonoscopy is a commonly performed procedure for the early detection of colon and rectal cancer, and prevention through polyp removal.During colonoscopy, sometimes situations are encountered making polyp removal difficult. These can include the presence of larger polyps or the location of a polyp in an area that makes removal technically challenging or high risk.A particularly challenging situation arises when after extensive effort there is still polyp tissue remaining that cannot be removed using routine techniques. We are interested in exploring a technique which involves the placement of a rubber band after sucking a small area of the colon lining into a cap loaded onto the tip of the colonoscope. With time the rubber band strangulates the tissue and falls off along with captured tissue and passes out of the colon naturally.To assess the effectives of this technique we studied patients that have undergone this procedure at our GI unit. We identified 32 patients with 34 large polyps between 4cm to 6cm that we placed rubber bands on polyp tissue after we were unable to completely remove the polyp. On their follow up colonoscopy, complete polyp removal was successful in 21 polyps. We were also able to achieve complete polyp removal in 9 of the remaining large polyps after additional treatment. Four patients underwent surgery because cancer was found in analysis of polyp tissue.In 5 of 6 patients with polyps in difficult locations (e.g. partly within the lumen of the appendix), placement of a rubber band led to complete removal of polyp tissue.Two patients in our study population had mild adverse events that were managed with simple measures.We believe our results show promise for our described technique and this technique should be tested in larger studies.

Efficacy and safety of cap-assisted endoscopic mucosal resection of ileocecal valve polyps

Background and study aims  Standard endoscopic mucosal resection (EMR) of ileocecal valve (ICV) polyps is challenging. Cap-assisted endoscopic mucosal resection (C-EMR) can be performed when polyps are not easily amenable to standard EMR. Current literature is limited regarding its efficacy and safety for ICV polyps. The objectives of this study were to assess the efficacy and safety of C-EMR for ICV polyps. Patients and methods  A retrospective review was conducted from September 2008 to November 2018 at a tertiary care center. Patients included in the study underwent C-EMR for ICV polyps by a single gastroenterologist (LHJ). Polyps were successfully eradicated if they were removed en-bloc as confirmed by pathology, or had a negative biopsy on follow-up colonoscopy. Outcomes of the procedures were evaluated, including complete adenoma clearance and adverse events. Results  Twenty-one ICV polyps were removed with C-EMR. Median polyp size was 15 mm (range, 5-45). The rate of complete adenoma clearance was 100 %. Procedure-related complications occurred in five patients (24 %): delayed GI bleeding (4.8 %) and deep mucosal resection/visible vessel (14.3 %). Three patients had subsequent surveillance colonoscopies at 8, 56, and 67 months, respectively. The third patient was found to have a 6-mm flat polyp at the edge of the previous polypectomy site. This was treated with C-EMR and repeat colonoscopy 6 months later did not show residual. Conclusion  C-EMR is highly effective in treating ICV polyps with a low complication rate. It is our suggested method in approaching ICV polyps that are difficult to remove via standard freehand snare EMR technique.

Safety and efficacy of cap-assisted EMR for sporadic nonampullary duodenal adenomas

BACKGROUND AND AIMS

Eradication of sporadic nonampullary duodenal adenomas (SNADAs) is essential because of their high rate of malignant transformation. EMR techniques are the alternative to the traditional surgical treatments of SNADAs. There are very limited data on the safety and efficacy of cap-assisted EMR (C-EMR) in the treatment of SNADA.

METHODS

The medical records of patients who underwent C-EMR for SNADAs between July 2002 and April 2013 were retrospectively reviewed. Eradication was defined as no residual adenoma on follow-up or en bloc resection on pathology. Recurrence was defined as finding adenoma after a negative follow-up.

RESULTS

Fifty-nine C-EMR sessions were performed on 49 SNADAs (flat, 46; sessile, 3); 39 polyps were treated in piecemeal fashion and 10 polyps with en bloc resection. The polyp histology was tubular adenoma (63.3%) and tubulovillous adenoma (36.7%), with 16.3% of lesions showing high-grade dysplasia. Initial eradication rate was 90.5%; residual adenomas were successfully treated with repeat C-EMR/snare, resulting in 100% ultimate eradication rate without any recurrences (median follow-up of 17 months). The overall adverse events rate was 16.9%: intraprocedural bleeding (10.2%), delayed GI bleeding (5.1%), and perforation (1.7%). Among large polyps (≥15 mm), the initial and ultimate eradication rates were 87.9% and 100%, respectively, and the adverse event rate was 17%. Initial eradication rate for small polyps was higher than in large polyps (100% vs 87.9%, respectively; P = .02).

CONCLUSION

C-EMR is a highly efficient and safe method for the treatment of SNADAs. We recommend that endoscopists should learn C-EMR on esophageal, gastric, rectal, or left-sided colonic lesions before attempting C-EMR in the duodenum.

Colorectal endoscopic mucosal resection (EMR)

Colonoscopy has the benefit of detecting and treating precancerous adenomatous polyps and thus reduces mortality associated with CRC. Screening colonoscopy is the keystone for prevention of colorectal cancer. Over the last 20 years there has been increased in the management of large colorectal polyps from surgery to endoscopic removal techniques which is less invasive. Traditionally surgical resection was the treatment of choice for many years for larger polyps but colectomy poses significant morbidity of 14-46% and mortality of up to 7%. There are several advantages of endoscopic resection technique over surgery; it is less invasive, less expensive, has rapid recovery, and preserves the normal gut functions. In addition patient satisfaction and efficacy of EMR is higher with minor complications. Thus, this has facilitated the development of advanced resection technique for the treatment of large colorectal polyps called as endoscopic mucosal resection (EMR).

Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection

Endoscopic mucosal resection (EMR) has been used in western countries to remove colonic polyps for at least the last two decades. Significant experience has been accumulated and the efficacy of the method has recently been evaluated in a large meta-analysis. A number of variations to modify the technique, including knife-assisted, cap-assisted, ligation devices, and underwater EMR, have been developed in an attempt to improve outcomes. However, to date there are only limited data comparing these techniques or demonstrating the superiority of any one of them. This article reviews the current evidence on the efficacy of each of these modified techniques.