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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.
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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
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Shi K, Yang Z, Leng K. Treatment for T1 colorectal cancers substratified by site and size: "horses for courses". Front Med (Lausanne) 2023; 10:1230844. [PMID: 37901402 PMCID: PMC10602675 DOI: 10.3389/fmed.2023.1230844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Owing to advances in diagnostic technology, the diagnosis of T1 colorectal cancers (CRCs) continues to increase. However, the optimal management of T1 CRCs in the Western Hemisphere remains unclear due to limited population-based data directly comparing the efficacy of endoscopic therapy (ET) and surgical resection (SR). The purpose of this study was to report outcome data from a large Western cohort of patients who underwent ET or SR for early CRCs. Methods The SEER-18 database was used to identify patients with T1 CRCs diagnosed from 2004 to 2018 treated with ET or SR. Multivariable logistic regression models were employed to identify variables related to lymph node metastasis (LNM). Rates of ET and 1-year relative survival were calculated for each year. Effect of ET or SR on overall survival and cancer-specific survival was compared using Kaplan-Meier method stratified by tumor size and site. Results A total of 28,430 T1 CRCs patients were identified from 2004 to 2018 in US, with 22.7% undergoing ET and 77.3% undergoing SR. The incidence of T1 CRCs was 6.15 per 100,000 person-years, with male patients having a higher incidence. Left-sided colon was the most frequent location of tumors. The utilization of ET increased significantly from 2004 to 2018, with no significant change in 1-year relative survival rate. Predictors of LNM were age at diagnosis, sex, race, tumor size, histology, grade, and location. The 5-year relative survival rates were 91.4 and 95.4% for ET and SR, respectively. Subgroup analysis showed that OS and CSS were similar between ET and SR in T1N0M0 left-sided colon cancers with tumors 2 cm or less and in rectal cancers with tumors 1 cm or less. Conclusion Our study showed that ET was feasible and safe for patients with left-sided T1N0M0 colon cancers and tumors of 2 cm or less, as well as T1N0M0 rectal cancers and tumors of 1 cm or less. Therefore, the over- and under-use of ET should be avoided by carefully selecting patients based on tumor size and site.
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Affiliation(s)
- Kexin Shi
- The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Zhen Yang
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
| | - Kaiming Leng
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
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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.).
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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
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Nomura H, Tsuji S, Utsunomiya M, Kawasaki A, Tsuji K, Yoshida N, Takemura K, Katayanagi K, Minato H, Doyama H. Resection depth and layer of underwater versus conventional endoscopic mucosal resection of intermediate-sized colorectal polyps: A pilot study. Endosc Int Open 2022; 10:E1037-E1044. [PMID: 35979030 PMCID: PMC9377830 DOI: 10.1055/a-1864-6452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 05/30/2022] [Indexed: 12/24/2022] Open
Abstract
Background and study aims Curability of colorectal tumors is associated with resection depth and layer in endoscopic resection. Underwater endoscopic mucosal resection (UEMR) has not undergone sufficient histopathological evaluation. We conducted a pilot study to compare the effectiveness, including resection depth and layer, of UEMR and conventional endoscopic mucosal resection (CEMR). Patients and methods This study was a single-center, retrospective study. Patients with colorectal lesions were treated by UEMR or CEMR between January 2018 and March 2020. Eligible patients were selected from included patients in a 1:1 ratio using propensity score matching. We compared the resection depth and layer and treatment results between the UEMR and CEMR groups. Results We evaluated 55 patients undergoing UEMR and 291 patients undergoing CEMR. Using propensity score matching, we analyzed 54 lesions in each group. The proportion of specimens containing submucosal tissue was 100 % in both groups. The median thickness of the submucosal tissue was significantly greater in the CEMR group than in the UEMR group [1235 µm (95 % confidence interval [CI], 1020-1530 µm) vs. 950 µm (95 % CI, 830-1090 µm), respectively]. However, vertical margins were negative in all lesions in both groups. Conclusions Our findings suggest that the median thickness of submucosal tissue in the UEMR group was about 1,000 μm. Even though the resection depth achieved with UEMR was more superficial than that achieved with CEMR, UEMR may be a treatment option, especially for colorectal lesions ≤ 20 mm in diameter without suspicious findings of submucosal deeply invasive cancer.
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Affiliation(s)
- Hiroki Nomura
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Manami Utsunomiya
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Azusa Kawasaki
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kunihiro Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Naohiro Yoshida
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kenichi Takemura
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kazuyoshi Katayanagi
- Department of Diagnostic Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroshi Minato
- Department of Diagnostic Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
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Tan DJH, Ng CH, Lim XC, Lim WH, Yuen LZH, Koh JH, Nistala KRY, Ho KY, Chong CS, Muthiah MD. Is underwater endoscopic mucosal resection of colon polyps superior to conventional techniques? A network analysis of endoscopic mucosal resection and submucosal dissection. Endosc Int Open 2022; 10:E154-E162. [PMID: 35047346 PMCID: PMC8759939 DOI: 10.1055/a-1633-3230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Background and study aims Evidence from recent trials comparing conventional endoscopic mucosal resection (EMR) to underwater EMR (UEMR) have matured. However, studies comparing UEMR to endoscopic submucosal dissection (ESD) are lacking. Hence, we sought to conduct a comprehensive network meta-analysis to compare the efficacy of UEMR, ESD, and EMR. Methods Embase and Medline databases were searched from inception to December 2020 for articles comparing UEMR with EMR and ESD. Outcomes of interest included rates of en bloc and complete polyp resection, risk of perforation and bleeding, and local recurrence. A network meta-analysis comparing all three approaches was conducted. In addition, a conventional comparative meta-analysis comparing UEMR to EMR was performed. Analysis was stratified according to polyp sizes (< 10 mm, ≥ 10 mm, and ≥ 20 mm). Results Twenty-two articles were included in this study. For polyps ≥ 10 mm, UEMR was inferior to ESD in achieving en bloc resection ( P = 0.02). However, UEMR had shorter operating time for polyps ≥ 10 mm ( P < 0.001), and ≥20 mm ( P = 0.019) with reduced perforation risk for polyps ≥ 10 mm ( P = 0.05) compared to ESD. In addition, en bloc resection rates were similar between UEMR and EMR, although UEMR had reduced recurrence for polyps ≥ 10 mm ( P = 0.013) and ≥ 20 mm ( P = 0.014). UEMR also had shorter mean operating than EMR for polyps ≥ 10 mm ( P < 0.001) and ≥ 20 mm ( P < 0.001). Risk of bleeding and perforation with UEMR and EMR were similar for polyp of all sizes. Conclusions UEMR has demonstrated technical and oncological outcomes comparable to ESD and EMR, along with a desirable safety profile. UEMR appears to be a safe and effective alternative to conventional methods for resection of polyps ≥ 10 mm.
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Affiliation(s)
- Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Xiong Chang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Linus Zhen Han Yuen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jin Hean Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Khek-Yu Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Choon Seng Chong
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Mark D. Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
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Nagl S, Ebigbo A, Goelder SK, Roemmele C, Neuhaus L, Weber T, Braun G, Probst A, Schnoy E, Kafel AJ, Muzalyova A, Messmann H. Underwater vs Conventional Endoscopic Mucosal Resection of Large Sessile or Flat Colorectal Polyps: A Prospective Randomized Controlled Trial. Gastroenterology 2021; 161:1460-1474.e1. [PMID: 34371000 DOI: 10.1053/j.gastro.2021.07.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/26/2021] [Accepted: 07/29/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Conventional endoscopic mucosal resection (CEMR) with submucosal injection is the current standard for the resection of large, nonmalignant colorectal polyps. We investigated whether underwater endoscopic mucosal resection (UEMR) is superior to CEMR for large (20-40mm) sessile or flat colorectal polyps. METHODS In this prospective randomized controlled study, patients with sessile or flat colorectal polyps between 20 and 40 mm in size were randomly assigned to UEMR or CEMR. The primary outcome was the recurrence rate after 6 months. Secondary outcomes included en bloc and R0 resection rates, number of resected pieces, procedure time, and adverse events. RESULTS En bloc resection rates were 33.3% in the UEMR group and 18.4% in the CEMR group (P = .045); R0 resection rates were 32.1% and 15.8% for UEMR vs CEMR, respectively (P = .025). UEMR was performed with significantly fewer pieces compared to CEMR (2 pieces: 45.5% UEMR vs 17.7% CEMR; P = .001). The overall recurrence rate did not differ between both groups (P = .253); however, subgroup analysis showed a significant difference in favor of UEMR for lesions of >30 mm to ≤40 mm in size (P = .031). The resection time was significantly shorter in the UEMR group (8 vs 14 minutes; P < .001). Adverse events did not differ between both groups (P = .611). CONCLUSIONS UEMR is superior to CEMR regarding en bloc resection, R0 resection, and procedure time for large colorectal lesions and shows significantly lower recurrence rates for lesions >30 mm to ≤40 mm in size. UEMR should be considered for the endoscopic resection of large colorectal polyps.
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Affiliation(s)
- Sandra Nagl
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany.
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Karl Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Christoph Roemmele
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Lukas Neuhaus
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Tobias Weber
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Georg Braun
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Elisabeth Schnoy
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | | | - Anna Muzalyova
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
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Chandan S, Khan SR, Kumar A, Mohan BP, Ramai D, Kassab LL, Draganov PV, Othman MO, Kochhar GS. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021; 94:471-482.e9. [PMID: 33385463 DOI: 10.1016/j.gie.2020.12.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Major limitations with conventional EMR (C-EMR) include high rates of polyp recurrence and low en-bloc resection rates, especially for lesions >20 mm in size. Underwater EMR (U-EMR) has emerged as an alternate technique for en-bloc resection of larger lesions. We conducted a systematic review and meta-analysis comparing the efficacy and safety of the 2 techniques. METHODS Multiple databases were searched through June 2020 for studies that compared outcomes of U-EMR and C-EMR for colorectal lesions. Meta-analysis was performed to determine pooled odds ratios (ORs) of successful R0, en-bloc, and piecemeal resection of colorectal lesions. We compared the rates of polyp recurrence at follow-up, diagnostic accuracy for colorectal cancer, and adverse events with the 2 techniques. RESULTS Eleven studies, including 4 randomized controlled trials (RCTs) with 1851 patients were included in the final analysis. A total of 1071 lesions were removed using U-EMR, and 1049 lesions were removed using C-EMR. Although U-EMR had an overall superior en-bloc resection rate compared with C-EMR (OR, 1.9; 95% confidence interval [CI], 1-3.5; P = .04), both techniques were comparable in terms of polyps >20 mm in size (OR, 0.8; 95% CI, 0.3-2.1; P = .75), R0 resection (OR, 3.1; 95% CI, 0.74-12.6; P = .14), piecemeal resection (OR, 3.1; 95% CI, 0.74-12.6; P = .13), and diagnostic accuracy for colorectal cancer (OR, 1.1; 95% CI, 0.6-1.8; P = .82). There were lower rates of polyp recurrence (OR, 0.3; 95% CI, 0.1-0.8; P = .01) and incomplete resection (OR, 0.4; 95% CI, 0.2-0.5; P = .001) with U-EMR. Both techniques have comparable resection times and safety profiles. CONCLUSIONS Our results support the use of U-EMR over C-EMR for successful resection of colorectal lesions. Further randomized controlled trials are needed to evaluate the efficacy of U-EMR for resecting polyps >20 mm in size.
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Affiliation(s)
- Saurabh Chandan
- Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Shahab R Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anand Kumar
- Gastroenterology & Hepatology, Lenox Hill Hospital, New York, New York, USA
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daryl Ramai
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, New York, USA
| | - Lena L Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter V Draganov
- Gastroenterology, University of Florida Health, Gainesville, Florida, USA
| | - Mohamed O Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Li DF, Lai MG, Yang MF, Zou ZY, Xu J, Peng RM, Xiong F, Wei C, Zhang DG, Xu ZL, Wang LS, Yao J. The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: systematic review and meta-analysis. Endoscopy 2021; 53:636-646. [PMID: 32767283 DOI: 10.1055/a-1234-8918] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a promising strategy for nonpedunculated colorectal polyp removal. However, the efficacy and safety of the technique for the treatment of ≥ 10-mm colorectal polyps remain unclear. We aimed to comprehensively assess the efficacy and safety of UEMR for polyps sized 10-19 mm and ≥ 20 mm. METHODS PubMed, EMBASE, and the Cochrane Library databases were searched for relevant articles from January 2012 to November 2019. Primary outcomes were the rates of adverse events and residual polyps. Secondary outcomes were the complete resection, en bloc resection, and R0 resection rates. RESULTS 18 articles including 1142 polyps from 1093 patients met our inclusion criteria. The overall adverse event and residual polyp rates were slightly lower for UEMR when removing colorectal polyps of 10-19 mm vs. ≥ 20 mm (3.5 % vs. 4.3 % and 1.2 % vs. 2.6 %, respectively). The UEMR-related complete resection rate was slightly higher for colorectal polyps of 10-19 mm vs. ≥ 20 mm (97.9 % vs. 92.0 %). However, the en bloc and R0 resection rates were dramatically higher for UEMR removal of polyps of 10-19 mm vs. ≥ 20 mm (83.4 % vs. 36.1 % and 73.0 % vs. 40.0 %, respectively). In addition, univariate meta-regression revealed that polyp size was an independent predictor for complete resection rate (P = 0.03) and en bloc resection (P = 0.01). CONCLUSIONS UEMR was an effective and safe technique for the removal of ≥ 10-mm nonpedunculated colorectal polyps. However, UEMR exhibited low en bloc and R0 resection rates for the treatment of ≥ 20-mm polyps.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ming-Guang Lai
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Mei-Feng Yang
- Department of Hematology, Yantian District People's Hospital, Shenzhen, Guangdong, China
| | - Zhi-Yuan Zou
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jing Xu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Ru-Mei Peng
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, Hunan, China
| | - Feng Xiong
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Cheng Wei
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
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9
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Garg R, Singh A, Aggarwal M, Bhalla J, Mohan BP, Burke C, Rustagi T, Chahal P. Underwater Endoscopic Mucosal Resection for 10 mm or Larger Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis. Clin Endosc 2021; 54:379-389. [PMID: 33910271 PMCID: PMC8182235 DOI: 10.5946/ce.2020.276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Recent studies have reported the favorable outcomes of underwater endoscopic mucosal resection (UEMR) for colorectal polyps. We performed a systematic review and meta-analysis evaluating the efficacy and safety of UEMR for nonpedunculated polyps ≥10 mm.
Methods We performed a comprehensive search of multiple databases (through May 2020) to identify studies reporting the outcomes of UEMR for ≥10 mm nonpedunculated colorectal polyps. The assessed outcomes were recurrence rate on the first follow-up, en bloc resection, incomplete resection, and adverse events after UEMR.
Results A total of 1276 polyps from 16 articles were included in our study. The recurrence rate was 7.3% (95% confidence interval [CI], 4.3–12) and 5.9% (95% CI, 3.6–9.4) for nonpedunculated polyps ≥10 and ≥20 mm, respectively. For nonpedunculated polyps ≥10 mm, the en bloc resection, R0 resection, and incomplete resection rates were 57.7% (95% CI, 42.4–71.6), 58.9% (95% CI, 42.4–73.6), and 1.5% (95% CI, 0.8–2.6), respectively. The rates of pooled adverse events, intraprocedural bleeding, and delayed bleeding were 7.0%, 5.4%, and 2.9%, respectively. The rate of perforation and postpolypectomy syndrome was 0.8%.
Conclusions Our systematic review and meta-analysis demonstrates that UEMR for nonpedunculated colorectal polyps ≥10 mm is safe and effective with a low rate of recurrence.
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Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Jaideep Bhalla
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Carol Burke
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Nogueira PB, Albuquerque W, Nascimento RC, Marianelli BS, Campos FF, Carreiro RA, Rocha RF, Pereira RM, Arantes VN. Underwater endoscopic mucosal resection of adenomas and colorectal serrated lesions: a prospective clinical study. Ann Gastroenterol 2021; 34:552-558. [PMID: 34276195 PMCID: PMC8276360 DOI: 10.20524/aog.2021.0625] [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: 02/18/2020] [Accepted: 02/18/2021] [Indexed: 12/02/2022] Open
Abstract
Background Underwater endoscopic mucosal resection (UEMR) without submucosal injection has been described as an alternative technique to the endoscopic resection of adenomas and colorectal serrated lesions. We aimed to assess the feasibility, safety, and efficacy of UEMR in a Brazilian setting. Methods This was a prospective observational study of consecutive patients who underwent UEMR between January and July 2019, in a single tertiary care center. Inclusion criteria were lesions without endoscopic stigmata of deep submucosal invasion in patients referred for endoscopic resection of colorectal adenomas, and serrated lesions detected in a previous colonoscopy. The following features were assessed: complete resection rate, en bloc resection rate, resection time, adverse events, and resection infeasibility. Results A total of 36 patients underwent UEMR for 51 colorectal lesions. The mean/median lesion size was 16.24/13 mm and the mean/median resection time was 16.97/9.19 min. Histopathology revealed the following: tubular adenoma (43.1%), tubulovillous adenoma (13.7%), serrated lesions (41.2%), and intramucosal adenocarcinoma (2%). Complete resection was achieved in 86.3% of cases; 52.9% of the lesions were removed en bloc, while 47.1% were resected in a piecemeal fashion. UEMR was feasible in 96.1% of cases and failed on 2 occasions, requiring conversion to standard endoscopic mucosal resection. Minor intraoperative bleeding occurred in 5 patients (9.8%) and only 1 presented with delayed bleeding (2%), all controlled endoscopically. Conclusion UEMR for removal of adenomas and colorectal serrated lesions was demonstrated to be feasible, safe and effective.
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Affiliation(s)
- Pedro Bothrel Nogueira
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Walton Albuquerque
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Ricardo Castejon Nascimento
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Bruna Santos Marianelli
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Frederico Fonseca Campos
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Rodrigo Albuquerque Carreiro
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Renata Figueiredo Rocha
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Roberto Motta Pereira
- Department of Digestive Endoscopy, Hospital Madre Teresa (Pedro Bothrel Nogueira, Walton Albuquerque, Ricardo Castejon Nascimento, Bruna Santos Marianelli, Frederico Fonseca Campos, Rodrigo Albuquerque Carreiro, Renata Figueiredo Rocha, Roberto Motta Pereira)
| | - Vitor Nunes Arantes
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Alfa Institute of Gastroenterolgy (Vitor Nunes Arantes), Belo Horizonte, Minas Gerais, Brazil
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11
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Choi AY, Moosvi Z, Shah S, Roccato MK, Wang AY, Hamerski CM, Samarasena JB. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc 2021; 93:378-389. [PMID: 33068608 DOI: 10.1016/j.gie.2020.10.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Underwater EMR (UEMR) has emerged as an attractive alternative to conventional EMR (CEMR) for the resection of colorectal polyps. The purpose of this systematic review and meta-analysis was to compare UEMR and CEMR for the resection of colorectal polyps with respect to efficacy and safety. METHODS A literature search was performed across multiple databases, including MEDLINE/PubMed, The Cochrane Library, CINAHL, Google Scholar, and Scopus, for studies that were published until May 2020. Only studies that compared the resection of colorectal polyps using UEMR with CEMR were included. Outcomes examined included rates of en bloc resection, recurrence, postprocedure bleeding, perforation, and resection time. RESULTS Seven studies totaling 1237 polyps were included: 614 polyps were resected with UEMR and 623 polyps with CEMR. UEMR was associated with a significant increase in the rate of overall en bloc resection (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.42-2.39; P < .001; I2 = 38%), with subgroup analysis showing a significant increase in the rates of en bloc resection in polyps ≥20 mm (OR, 1.51; 95% CI, 1.06-2.14; P = .02; I2 = 44%) but not in polyps <20 mm (OR, 1.07; 95% CI, .65-1.76; P = .80; I2 = 27%), and with a significant reduction in the rate of recurrence (OR, .30; 95% CI, .16-.57; P = .0002; I2 = 0%), again driven by improvements in polyps ≥20 mm. There was no significant difference in postprocedure bleeding (OR, 1.11; 95% CI, .57-2.17; P = .76; I2 = 0%) or perforation (OR, .72; 95% CI, .19-2.83; P = .64; I2 = 0%). CONCLUSIONS The results of this systematic review and meta-analysis demonstrate that UEMR is a safe and efficacious alternative to CEMR. With appropriate training, UEMR may be strongly considered as a first-line option for resection of colorectal polyps.
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Affiliation(s)
- Alyssa Y Choi
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Zain Moosvi
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Sagar Shah
- University of California, Irvine School of Medicine, Irvine, California, USA
| | - Mary Kathryn Roccato
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher M Hamerski
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Jason B Samarasena
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
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12
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Garg R, Singh A, Mohan BP, Mankaney G, Regueiro M, Chahal P. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1884-E1894. [PMID: 33269325 PMCID: PMC7695518 DOI: 10.1055/a-1287-9621] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Underwater endoscopic mucosal resection (UEMR) for colorectal polyps has been reported to have good outcomes in recent studies. We conducted a systematic review and meta-analysis comparing the effectiveness and safety of UEMR to conventional EMR (CEMR). Methods A comprehensive search of multiple databases (through May 2020) was performed to identify studies that reported outcome of UEMR and CEMR for colorectal lesions. Outcomes assessed included incomplete resection, rate of recurrence, en bloc resection, adverse events (AEs) for UEMR and CEMR. Results A total of 1,651 patients with 1,704 polyps were included from nine studies. There was a significantly lower rate of incomplete resection (odds ratio [OR]: 0.19 (95 % confidence interval (CI), 0.05-0.78, P = 0.02) and polyp recurrence (OR: 0.41, 95 % CI, 0.24-0.72, P = 0.002) after UEMR. Compared to CEMR, rates overall complications (relative risk [RR]: 0.66 (95 % CI, 0.48-0.90) ( P = 0.008), and intra-procedural bleeding (RR: 0.59, 95 % CI, 0.41-0.84, P = 0.004) were significantly lower with UEMR. The recurrence rate was also lower for large non-pedunculated polyps ≥ 10 mm (OR 0.24, 95 % CI, 0.10-0.57, P = 0.001) and ≥ 20 mm (OR 0.14, 95 % CI, 0.02-0.72, P = 0.01). The rates of en bloc resection, delayed bleeding, perforation and post-polypectomy syndrome were similar in both groups ( P > 0.05). Conclusions In this systematic review and meta-analysis, we found that UEMR is more effective and safer than CEMR with lower rates of recurrence and AEs. UEMR use should be encouraged over CEMR.
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Affiliation(s)
- Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic, Ohio, United States
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Babu P. Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, United States
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
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13
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Liu Y, Shi M, Ren J, Zhou XL, Liu S. Effectiveness of underwater endoscopic mucosal resection versus conventional endoscopic mucosal resection for 10 to 20 mm colorectal polyps: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23041. [PMID: 33126395 PMCID: PMC7598875 DOI: 10.1097/md.0000000000023041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a standard method commonly for removing 10 to 20 mm colorectal polyps. While the incidence of residual or recurrent after conventional EMR is remarkably high. Underwater endoscopic mucosal resection (UEMR) as an alternative technique to conventional EMR for removing colorectal polyps has high adenoma detection and complete resection rates, improves patient comfort, decreases sedation needs, eliminates the risks associated with submucosal injection, and reduces snare and diathermy-induced mucosal injury. We will conduct a comprehensive systematic review and meta-analysis to compare the effectiveness of these two therapies in the management of 10 to 20 mm colorectal polyps. METHODS PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, China Science and Technology Journal Database and Chinese Biomedical Literature Database will be searched from inception of databases to November 2020 without language limitation. Two reviewers will independently conduct article selection, data collection, and assessment of risk of bias. Any disagreement will be resolved by discussion with the third reviewer. Review Manager Software 5.3 will be used for meta-analysis. The Cochrane risk of bias tool will be used to assess the risk of bias. RESULTS This study will provide a systematic synthesis of current published data to compare the effectiveness of UEMR and conventional EMR for 10 to 20 mm colorectal polyps. CONCLUSIONS This systematic review and meta-analysis will provide clinical evidence as to whether UEMR is more effective and safer than conventional EMR for 10 to 20 mm colorectal polyps. STUDY REGISTRATION NUMBER INPLASY2020100006.
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Affiliation(s)
- Yi Liu
- Digestive Endoscopy Center
| | - Min Shi
- Second Ward of Gastrointestinal Surgery, Wuhan NO.1 Hospital, Wuhan, China
| | - Jun Ren
- Second Ward of Gastrointestinal Surgery, Wuhan NO.1 Hospital, Wuhan, China
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14
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Ni DQ, Lu YP, Liu XQ, Gao LY, Huang X. Underwater vs conventional endoscopic mucosal resection in treatment of colorectal polyps: A meta-analysis. World J Clin Cases 2020; 8:4826-4837. [PMID: 33195650 PMCID: PMC7642536 DOI: 10.12998/wjcc.v8.i20.4826] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/09/2020] [Accepted: 09/03/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) of colorectal lesions is emerging as an alternative method to conventional endoscopic mucosal resection (EMR); however, it is still controversial whether there is a difference in the effectiveness between UEMR and EMR.
AIM To evaluate the effectiveness and safety of UEMR in the treatment of colorectal polyps.
METHODS Clinical studies comparing the effectiveness or safety of UEMR in the treatment of colorectal polyps were searched in medical databases, including PubMed, Embase, Cochrane Library, CNKI, and Wanfang Data, monographs, theses, and papers presented at conferences. Statistical analyses were performed using Revman 5.3 software.
RESULTS Seven non-randomized controlled trials and one randomized controlled trial met the inclusion criteria. In total, 1382 patients (1511 polyps) were included in the study, including 722 who received UEMR and 789 who received EMR. In the UEMR and EMR groups, the en bloc resection rates were 85.87% and 73.89%, respectively, with a relative risk (RR) value of 1.14 (95% confidence interval [CI]: 1.01-1.30; P < 0.05). In the sub-group analysis, the en bloc resection rate showed no statistically significant difference between the EMR and UEMR groups for polyps less than 20 mm in diameter. However, a statistically significant difference was found between the EMR and UEMR groups for polyps equal to or greater than 20 mm in diameter. The post-endoscopic resection recurrence rates at 3-6 mo of the UEMR and EMR groups were 3.26% and 15.17%, respectively, with an RR value of 0.27 (95%CI: 0.09-0.83; P < 0.05). The post-endoscopic resection recurrence rates of UEMR and EMR at 12 mo were 6.25% and 14.40%, respectively, with an RR value of 0.43 (95%CI: 0.20-0.92; P < 0.05). Additionally, the incidence of adverse events was 8.17% and 6.21%, respectively, with an RR value of 1.07 (95%CI: 0.50-2.30; P > 0.05).
CONCLUSION UEMR is an effective technique for colorectal polyps and appears to have some advantages over EMR, particularly with regard to some treatment outcomes.
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Affiliation(s)
- Dong-Qiong Ni
- Department of Gastroenterology, Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Yu-Ping Lu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xi-Qiao Liu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Li-Ying Gao
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xuan Huang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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Kamal F, Khan MA, Lee-Smith W, Khan Z, Sharma S, Tombazzi C, Ahmad D, Ismail MK, Howden CW, Binmoeller KF. Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1264-E1272. [PMID: 33015327 PMCID: PMC7508646 DOI: 10.1055/a-1214-5692] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/25/2020] [Indexed: 12/28/2022] Open
Abstract
Background Recently, underwater endoscopic mucosal resection (UEMR) has shown promising results in the management of colorectal polyps. Some studies have shown better outcomes compared to conventional endoscopic mucosal resection (EMR). We conducted this systematic review and meta-analysis to compare UEMR and EMR in the management of colorectal polyps. Methods We searched several databases from inception to November 2019 to identify studies comparing UEMR and EMR. Outcomes assessed included rates of en bloc resection, complete macroscopic resection, recurrent/residual polyps on follow-up colonoscopy, complete resection confirmed by histology and adverse events. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a fixed effect model. Heterogeneity was assessed by I 2 statistic. Funnel plots and Egger's test were used to assess publication bias. We used the Newcastle-Ottawa scale (NOS) for assessment of quality of observational studies, and the Cochrane tool for assessing risk of bias for RCTs Results Seven studies with 1291 patients were included; two were randomized controlled trials and five were observational. UEMR demonstrated statistically significantly better efficacy in rates of en bloc resection, pooled RR 1.16 (1.08, 1.26), complete macroscopic resection, pooled RR 1.28 (1.18, 1.39), recurrent/residual polyps; pooled RR 0.26 (0.12, 0.56) and complete resection confirmed by histology; pooled RR 0.75 (0.57, 0.98). There was no significant difference in adverse events (AEs); pooled RR 0.68 (0.44, 1.05). Conclusions This meta-analysis found statistically significantly better rates of en bloc resection, complete macroscopic resection, and lower risk of recurrent/residual polyps with UEMR compared to EMR. We found no significant difference in AEs between the two techniques.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Muhammad Ali Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Wade Lee-Smith
- Carlson and Mulford Libraries, University of Toledo, Ohio, United States
| | - Zubair Khan
- Division of Gastroenterology, University of Texas – Houston, Houston, Texas, United States
| | - Sachit Sharma
- Division of Internal Medicine, University of Toledo, Ohio, United States
| | - Claudio Tombazzi
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Dina Ahmad
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mohammad Kashif Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Colin W. Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Kenneth F. Binmoeller
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, United States
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Zhang Z, Xia Y, Cui H, Yuan X, Wang C, Xie J, Tong Y, Wang W, Xu L. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial : (UEMR vs. CEMR for small size non-pedunculated colorectal polyps). BMC Gastroenterol 2020; 20:311. [PMID: 32967616 PMCID: PMC7510164 DOI: 10.1186/s12876-020-01457-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a recently developed technique and can be performed during water-aided or ordinary colonoscopy for the treatment of colorectal polyps. The objective of this clinical trial was to evaluate the efficacy and safety of UEMR in comparison with conventional endoscopic mucosal resection (CEMR) of small non-pedunculated colorectal polyps. METHODS Patients with small size, non-pedunculated colorectal polyps (4-9 mm in size) who underwent colonoscopic polypectomy were enrolled in this multicenter randomized controlled clinical trial. The patients were randomly allocated to two groups, an UEMR group and a CEMR group. Efficacy and safety were compared between groups. RESULTS In the intention-to-treat (ITT) analysis, the complete resection rate was 83.1% (59/71) in the UEMR group and 87.3% (62/71) in the CEMR group. The en-bloc resection rate was 94.4% (67/71) in the UEMR group and 91.5% (65/71) in the CEMR group (difference 2.9%; 90% CI - 4.2 to 9.9%), showed noninferiority (noninferiority margin - 5.7% < - 4.2%). No significant difference in procedure time (81 s vs. 72 s, P = 0.183) was observed. Early bleeding was observed in 1.4% of patients in the CEMR group (1/71) and 1.4% of patients in the UEMR group (1/71). None of the patients in the UEMR group complained of postprocedural bloody stool, whereas two patients in the CEMR group (2/64) reported this adverse event. CONCLUSION Our results indicate that UEMR is safer and just as effective as CEMR in En-bloc resection for the treatment of small colorectal polyps as such, UEMR is recommended as an alternative approach to excising small and non-pedunculated colorectal adenomatous polyps. TRIAL REGISTRATION Clinical Trials.gov, NCT03833492 . Retrospectively registered on February 7, 2019.
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Affiliation(s)
- Zhixin Zhang
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Yonghong Xia
- Department of Gastroenterology, Ninghai Second Hospital, Ningbo, 315600, China
| | - Hongyao Cui
- Department of Gastroenterology, Haishu Second Hospital, Ningbo, 315000, China
| | - Xin Yuan
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Chunnian Wang
- Ningbo Clinical and Pathological Diagnosis Center, Ningbo, 315021, China
| | - Jiarong Xie
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Yarong Tong
- Department of Gastroenterology, Ninghai Second Hospital, Ningbo, 315600, China
| | - Weihong Wang
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China.
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China.
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