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Okimoto K, Matsumura T, Matsusaka K, Inaba Y, Ishikawa T, Akizue N, Kaneko T, Ota M, Ohta Y, Taida T, Saito K, Ogasawara S, Maruoka D, Kato J, Ikeda JI, Kato N. Outcomes for Underwater Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection of 21-30-mm Colorectal Polyps: A Feasible Study. Dig Dis Sci 2023; 68:3963-3973. [PMID: 37658209 DOI: 10.1007/s10620-023-08093-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/22/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND AND AIMS This randomized controlled trial (RCT) was designed to evaluate the short-term outcomes of underwater endoscopic mucosal resection (UEMR) and endoscopic submucosal dissection (ESD) of 21-30 mm colonic polyps. METHOD We conducted a single-center RCT. Patients diagnosed with suspected colorectal intramucosal carcinoma (21-30 mm and adaptable for both UEMR and ESD) were randomly assigned to the UEMR and ESD groups at a 1:1 ratio. The primary endpoint was the R0 resection rate. We independently performed one-sample tests against the set threshold for each treatment. The significance level was set at p = 0.224. RESULT Eleven polyps each in the UEMR and ESD groups, respectively, were analyzed. The R0 resection rate (%) was 36 (95% confidence interval 11-69) and 100 (72-100) for UEMR and ESD, respectively, with a significant difference between the two groups (p = 0.002). The p-value against the set threshold for UEMR was 0.743, whereas that for ESD was < 0.001 (one-sample binomial test). The en bloc resection rates (%) were 82 (48-97) and 100 (72-100) for UEMR and ESD, respectively; however, no significant difference was observed (p = 0.167). The mean treatment time (min) was significantly shorter in the UEMR group (8 ± 6) than in the ESD group (48 ± 29) (p = 0.001). CONCLUSION ESD could achieve a high R0 resection rate, while the en bloc resection rate was comparable between the two treatment techniques with less burden on patients undergoing UEMR for 21-30-mm colorectal polyps. CLINICAL TRIAL REGISTRATION The study was registered at the Japan Registry of Clinical Trial as jRCT1030210015 and jRCT1030210177.
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Affiliation(s)
- Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | | | - Yosuke Inaba
- Biostatistics Section, Chiba University Hospital Clinical Research Center, Chiba, Japan
| | - Tsubasa Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Tatsuya Kaneko
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Masayuki Ota
- Department of Diagnostic Pathology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
- Kameido Endoscopy and Gastroenterology Clinic, Tokyo, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Jun-Ichiro Ikeda
- Department of Pathology, Chiba University Hospital, Chiba, Japan
- Department of Diagnostic Pathology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
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Abstract
Although an established standard, conventional endoscopic mucosal resection (EMR) has disseminated despite an absence of studies demonstrating the value of submucosal injection. Several consequences of poorly executed submucosal injection may increase the difficulty and risk of EMR. Underwater EMR (UEMR), an alternative resection method for colonic neoplasms, avoids the need for submucosal injections. In comparison with reported outcomes of EMR, UEMR achieves similar rates of complete resection with comparable safety, with lower rates of recurrence and fewer repeat procedures. UEMR also compares favorably with endoscopic submucosal dissection in terms of procedure time and rates of complete resection, recurrence, and complications.
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Affiliation(s)
- Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, 1101 Van Ness Ave. Floor 3, San Francisco, CA 94109, USA.
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, 1101 Van Ness Ave. Floor 3, San Francisco, CA 94109, USA
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Amato A, Radaelli F, Spinzi G. Underwater endoscopic mucosal resection: The third way for en bloc resection of colonic lesions? United European Gastroenterol J 2015; 4:595-8. [PMID: 27536370 DOI: 10.1177/2050640615617635] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/24/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection without submucosal injection has been described for removing large flat colorectal lesions. OBJECTIVE We aim to evaluate the reproducibility of this technique in terms of ease of implementation, safety and efficacy. METHODS A prospective observational study of consecutive underwater endoscopic mucosal resection in a community hospital was performed. RESULTS From September 2014 to April 2015, 25 flat or sessile colorectal lesions (median size 22.8 mm, range 10-50 mm; 18 placed in the right colon) were removed in 25 patients. Two of the lesions were adenomatous recurrences on scar of prior resection and one was a recurrence on a surgical anastomosis. The resection was performed en bloc in 76% of the cases. At the pathological examination, 14 lesions (56%) had advanced histology and seven (28%) were sessile serrated adenomas (two with high-grade dysplasia). Complete resection was observed in all the lesions removed en bloc. Intra-procedural bleeding was observed in two cases; both were managed endoscopically and were uneventful. No major adverse events occurred. CONCLUSION Underwater endoscopic mucosal resection appears to be an easy, safe and effective technique in a community setting. Further studies evaluating the efficacy of the technique (early and late recurrence), as well as comparing it with traditional mucosal resection, are warranted.
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Affiliation(s)
- Arnaldo Amato
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
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Binmoeller KF, Shah JN, Bhat YM, Kane SD. "Underwater" EMR of sporadic laterally spreading nonampullary duodenal adenomas (with video). Gastrointest Endosc 2013; 78:496-502. [PMID: 23642790 DOI: 10.1016/j.gie.2013.03.1330] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 03/13/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND EMR for the treatment of duodenal adenomas is challenging due to a thin wall and rich vascularity. OBJECTIVE To evaluate a novel technique of "underwater" EMR without prior submucosal injection for the removal of large (≥2 cm) laterally spreading nonampullary duodenal adenomas. DESIGN Prospective, observational study. SETTING Tertiary academic referral center. PATIENTS Twelve patients (median age, 60 years) meeting the inclusion criteria. INTERVENTIONS Piecemeal EMR technique after sterile water submersion when using a double-channel endoscope. MAIN OUTCOME MEASUREMENTS Technical success, adverse events, completeness of resection on follow-up endoscopy. RESULTS Median adenoma size was 35 mm (25% greater than one-half circumference, 50% equal to one-third to one-half circumference, and 25% less than one-third circumference). Median procedure time was 65 minutes (range, 32-151). Final histology was tubular adenoma (7), tubulovillous adenoma (1), villous adenoma (3), and high-grade dysplasia (1). Eleven patients (92%) met the primary endpoint (technical success) and all patients met the secondary endpoint (completeness of resection). Median interval until follow-up endoscopy was 16 weeks (range, 11-56). Adverse events were as follows: delayed bleeding (3 patients, of whom 2 required transfusions), water intoxication syndrome manifested by altered mental status and hyponatremia (1), and stricture formation (1) that responded to balloon dilation. No perforation or postresection abdominal pain was found. LIMITATIONS Single operator, single center, small sample size, limited follow-up. CONCLUSION Underwater EMR for large sessile duodenal adenomas has high success rates for complete removal. The risk of delayed bleeding is significant, and precautions are needed when infusing a large volume of fluid into the GI tract.
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Affiliation(s)
- Kenneth F Binmoeller
- Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California 94115, USA
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