Can underwater endoscopic mucosal resection be an alternative to conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumors?

Objectives

Underwater endoscopic mucosal resection (UEMR) is a simpler procedure for superficial non-ampullary duodenal epithelial tumors (SNADET) than conventional endoscopic mucosal resection (cEMR). This study aimed to evaluate whether cEMR can be substituted by UEMR for SNADET in terms of effectiveness, safety, and learning curve.

Methods

A total of 157 consecutive patients with 203 SNADETs ≤20 mm in diameter, including 107 lesions resected by cEMR and 96 lesions resected by UEMR, between January 2019 and May 2023, were retrospectively recruited. The treatment outcomes were compared between the cEMR and UEMR groups. The risk factors for incomplete resection by UEMR were analyzed using univariate and multivariate analyses. Lesions in the UEMR group were divided chronologically into five periods; thereafter, the en bloc resection rate and procedure time were compared.

Results

No significant differences existed between the cEMR and UEMR groups in the mean procedure time (3.9 min vs. 3.6 min, p = 0.1380) or en bloc resection rate (91% vs. 94%, p = 0.4138). No perforation was observed in either group. Tumor size was an independent risk factor for incomplete resection using UEMR (p < 0.01). The history of biopsy was not associated with incomplete resection using UEMR. The en bloc resection rate of UEMR was 100% (20/20) in the first period and ranged from 90% to 100% over all periods.

Conclusion

UEMR is safe and effective for SNADET ≤20 mm, regardless of a history of biopsy, and is easy to learn. Thus, UEMR can serve as an alternative to cEMR.

Conventional versus underwater endoscopic resection for superficial non-ampullary duodenal epithelial tumours

BACKGROUND AND OBJECTIVE

Several endoscopic resection methods have been developed as less invasive treatments for superficial non-ampullary duodenal epithelial tumours. This study aimed to compare outcomes of conventional endoscopic mucosal resection and underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours, including resection depth and rate of the muscularis mucosa contained under the lesion.

METHODS

This single-centre retrospective cohort study conducted from January 2009 to December 2021 enrolled patients who underwent conventional endoscopic mucosal resection and underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours and investigated their clinicopathological outcomes using propensity score matching.

RESULTS

Of the 285 superficial non-ampullary duodenal epithelial tumours, 98 conventional endoscopic mucosal resections and 187 underwater endoscopic mucosal resections were included. After propensity score matching, 64 conventional endoscopic mucosal resections and 64 underwater endoscopic mucosal resections were analysed. The R0 resection rate was significantly higher in underwater endoscopic mucosal resection cases than in conventional endoscopic mucosal resection cases (70.3% vs. 50.0%; P = 0.030). In the multivariate analysis, a lesion diameter > 10 mm (odds ratio 7.246; P = 0.001), being in the 1st-50th treatment period (odds ratio 3.405; P = 0.008), and undergoing conventional endoscopic mucosal resection (odds ratio 3.617; P = 0.016) were associated with RX/R1 resection. Furthermore, in underwater endoscopic mucosal resection cases, the R0 rate was significantly higher for lesions diameter ≤10 mm than >10 mm, and was significantly higher in the 51st-treatment period than in the 1st-50th period. Conventional endoscopic mucosal resection and underwater endoscopic mucosal resection cases showed no significant difference in resection depth and muscularis mucosa containing rate.

CONCLUSIONS

Underwater endoscopic mucosal resection may be more acceptable than conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours ≤ 10 mm. A steep early learning curve may be acquired for underwater endoscopic mucosal resection. Large multicentre prospective studies need to be conducted to confirm the effectiveness of underwater endoscopic mucosal resection.

'Underwater endoscopic mucosal resection with submucosal injection and marking' for superficial non-ampullary duodenal epithelial tumors to achieve R0 resection: a single-center case series

OBJECTIVES

To describe an endoscopic technique named 'underwater endoscopic mucosal resection (UEMR) with submucosal injection and marking (UEMR-SIM)' and to evaluate the therapeutic characteristics of superficial non-ampullary duodenal epithelial tumors (SNADETs) < 20 mm vis-a-vis classical EMR (CEMR) and UEMR techniques.

MATERIALS AND METHODS

This retrospective study included 103 consecutive SNADET patients (103 lesions) who underwent CEMR, UEMR, or UEMR-SIM. The UEMR-SIM procedure included (1) marking and submucosal injection, (2) filling of the duodenal lumen with 0.9% saline, (3) snaring of the lesion, and (4) electrosurgical removal. The procedural outcomes were compared between the UEMR-SIM and other-procedure groups.

RESULTS

The en bloc resection rate was significantly higher in the UEMR-SIM group (100%) than in the CEMR group (76.8%) (p = 0.015) but was not statistically different between the UEMR-SIM and UEMR groups (88.0%) (p = 0.236). The R0 resection rate was significantly higher in the UEMR-SIM group (90.9%) than in the UEMR group (48.0%) (p = 0.001) but was not statistically different between the UEMR-SIM and CEMR groups (76.8%) (p = 0.209).

CONCLUSIONS

Our study indicates that the proposed method, UEMR-SIM for SNADETs, is feasible to achieve a high R0 resection rate and a potentially low local recurrence rate.

Efficacy and safety of underwater endoscopic mucosal resection for ≤20 mm superficial non-ampullary duodenal epithelial tumors: Systematic review and meta-analysis

Background and aims

Superficial non-ampullary duodenal epithelial tumors (SNADETs) as a rare disease have gradually increased in recent years. Underwater endoscopic mucosal resection (UEMR) has emerged as a newly available option for the endoscopic resection of SNADETs. This study aimed to evaluate the efficacy and safety of UEMR for ≤20 mm SNADETs.

Methods

A literature search was performed across multiple databases, including PubMed, Embase, Scopus, and Clinical trials for studies containing tumors ≤20 mm published from January 1, 2012, to August 8, 2022. Outcomes examined were the pooled rates of en bloc resection, R0 resection, adverse events, and recurrence. Subgroup analyses of the resection rate were conducted stratified by sample size and polyp size.

Results

A total of 10 studies with UEMR performed in a total of 648 tumors were included for analysis. The pooled rate of en bloc resection and R0 resection was 88.2% (95% confidence interval (CI): 82.1-93.2) and 69.1% (95% CI: 62.2-76.1), respectively. The results showed pooled rate of intraoperative bleeding rate was 2.9% (95% CI: 0-9.0), delayed bleeding rate was 0.9% (95% CI: 0.1-2), recurrence rate was 1.5% (95% CI: 0-4.9). In the subgroup analysis, R0 and en-bloc resection rates were significantly higher in <10 mm than 10-20 mm SNADETs subgroups (R0 resection rate 83.1 vs. 48.6%; en bloc resection rate 100.0 vs. 84.0%, P < 0.05).

Conclusion

Underwater endoscopic mucosal resection was an effective and safe technique for the optional treatment for ≤20 mm SNADETs, especially of <10 mm.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022340578.

Issues and Prospects of Current Endoscopic Treatment Strategy for Superficial Non-Ampullary Duodenal Epithelial Tumors

An increasing number of duodenal tumors are being diagnosed over the years, leading to increased confusion regarding the choice of treatment options. Small-to-large tumors and histological types vary from adenoma to carcinoma, and treatment methods may need to be selected according to lesion characteristics. Because of its anatomic characteristics, complications are more likely to occur in the duodenum than in other gastrointestinal organs. Several reports have described the outcomes of conventional endoscopic mucosal resection, endoscopic submucosal dissection, cold snare polypectomy, underwater endoscopic mucosal resection, endoscopic full-thickness resection, and laparoscopic and endoscopic cooperative surgery for duodenal tumors. However, even in the guidelines set out by various countries, only the treatment methods are listed, and no clear treatment strategies are provided. Although there are few reports with a sufficiently high level of evidence, considering the currently available treatment options is essential. In this report, we reviewed previous reports on each treatment strategy, discussed the current issues and prospects, and proposed the best possible treatment strategy.

Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20-30 mm colorectal polyps

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) for large polyps provides a high en bloc resection rate, accurate pathological diagnosis, and low recurrence rate. However, ESD requires advanced techniques, and underwater endoscopic mucosal resection (UEMR) is an alternative. We investigated the efficacy and safety of UEMR for 20-30 mm colorectal lesions compared with ESD.

METHODS

We retrospectively evaluated systematically collected data of patients who underwent UEMR or ESD for 20-30 mm sessile colorectal lesions. Outcome measures were the incidence of local recurrence, procedure time, en bloc resection rate, and incidence of adverse events. We performed propensity score matching and inverse probability weighting adjustment to control for possible confounders.

RESULTS

We evaluated 125 patients undergoing UEMR and 306 patients undergoing ESD. Using propensity score matching, we analyzed 74 lesions in each group. UEMR had a shorter procedure time than ESD [6.7 min (95% confidence interval (CI), 5.3-8.1 min) vs 64.8 min (95% CI, 57.4-72.2 min), respectively]. Although the en bloc resection rate with UEMR was inferior to ESD [61% (95% CI, 49-72%) vs 99% (95% CI, 93-100%), respectively], there was no significant difference in the local recurrence rate between the procedures [0% (95% CI, 0-4.0%) in each group]. Inverse probability weighting adjustment revealed that neither ESD nor UEMR had a significant association with local recurrence.

CONCLUSIONS

Underwater endoscopic mucosal resection for 20-30  mm colorectal lesions was comparable with ESD regarding long-term outcomes, with a shorter procedure time, despite the lower en bloc resection rate.

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

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.

Efficacy and safety of underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumors: a systematic review and meta-analysis

Background:

Superficial non-ampullary duodenal epithelial tumors (SNADET) are increasingly found during upper endoscopy. Underwater endoscopic mucosal resection (UEMR) is an emerging technique for the endoscopic resection of SNADET. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of this technique.

Methods:

We conducted a comprehensive search of several databases from inception to August 2019, which included Ovid Cochrane Database of Systematic Reviews, Ovid Embase, Scopus, Ovid Cochrane Central Register of Controlled trials, Ovid MEDLINE^®, and In-Process and other non-indexed citations. The primary outcome assessed was the pooled clinical success rate of UEMR. Secondary outcomes included rate of en bloc resection, pooled rate of high-grade dysplasia or intramucosal carcinoma (HGIC), and pooled rate of adverse events. Meta-regression analysis was performed based on tumor size.

Results:

A total of 8 study arms were included for analysis with UEMR performed in a total of 258 lesions. The pooled clinical success rate was 89.9% (95% confidence interval [CI] 83.4-94.1). En-bloc removal was achieved in 84.6% of treated lesions (95%CI 75.5-90.7). The pooled rate of HGIC was 24.7% (95%CI 10.3-48.3). The pooled rate of adverse events was 6.9% (95%CI 2.5-17.9). This included 10 total adverse events, with the majority being self-limited delayed bleeding. There were no duodenal perforations.

Conclusions:

UEMR for endoscopic resection of SNADET has a high efficacy. In addition, this technique has a high rate of en bloc resection and an acceptable adverse event profile. Given these data, UEMR should be considered as a method for endoscopic resection of SNADET.

Feasibility study comparing underwater endoscopic mucosal resection and conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumor < 20 mm

BACKGROUND AND AIM

Underwater endoscopic mucosal resection (UEMR) has been reported as an alternative to conventional EMR for superficial non-ampullary duodenal epithelial tumors (SNADET). However, the detailed outcomes are unclear. This study aimed to compare the clinical outcomes between UEMR and EMR for SNADET <20 mm.

PATIENTS AND METHODS

This is a retrospective observational study using a prospective maintained database. From November 2017 to December 2018, 104 consecutive cases of attempted UEMR for SNADET <20 mm were prospectively allocated. A total of 240 cases of attempted EMR were chosen as historical controls. We compared technical success rate, defined as the resection rate without conversion to ESD; en bloc resection rate; R0 resection rate; and adverse event rate. Next, multivariate analyses were constructed to identify predictors of conversion to ESD, piecemeal resection, and RX or R1 (RX/R1) resection.

RESULTS

Technical success rate of UEMR was significantly higher than that of EMR (87% and 70%, P < 0.01). En bloc resection and R0 resection rates of UEMR were significantly lower than those of EMR (en bloc resection: 87% vs 96%, P < 0.01; R0 resection: 67% vs 80%, P = 0.05). Concerning adverse events, there were no significant differences. In multivariate analyses, attempted EMR, lesion size and depressed type were independent predictors of conversion to ESD. Attempted UEMR was an independent predictor of piecemeal resection and RX/R1 resection.

CONCLUSION

The present study indicated that UEMR could be a feasible endoscopic resection method for SNADET (UMIN000025442).

Underwater endoscopic colorectal polyp resection: Feasibility in everyday clinical practice

BACKGROUND

Endoscopic mucosal resection is well-established for resecting flat or sessile benign colon polyps. The novel underwater endoscopic mucosal resection eschews submucosal injection prior to endoscopic mucosal resection. Reports about underwater endoscopic mucosal resection were limited to small series of single and/or tertiary-care referral centers, with single or supervised operators.

OBJECTIVE

The purpose of this study was to determine feasibility and efficacy of underwater resection of polyps of any morphology (underwater polypectomy, here includes underwater endoscopic mucosal resection) in routine clinical practice.

METHODS

This study involved a comparison of colonoscopy records of two community hospitals (January 2015-December 2016) for underwater polypectomy (n = 195) and gas insufflation polypectomy (n = 186).

RESULTS

Comparable demographics, procedural data, overall distribution, morphology and size of resected lesions, number of en bloc and R0 resections (any polyp morphology and size); exception: overall, underwater polypectomy pedunculated polyps were significantly larger than those in the gas insufflation polypectomy group, p = 0.030. Underwater polypectomy (median, min) resection time was significantly shorter than gas insufflation polypectomy: sessile and flat polyps 6-9 mm, 0.8 vs 2.7 (p = 0.040); 10-19 mm, 2.0 vs 3.3 (p = 0.025), respectively; pedunculated polyps 6-19 mm, 0.8 vs 3.3 (p < 0.001). Underwater polypectomy resection of pedunculated polyps 6-19 mm showed significantly less immediate bleeding: 11.1% vs 1.5%, respectively (p = 0.031).

CONCLUSIONS

Underwater polypectomy can be efficaciously used in routine clinical practice for the complete resection of colon polyps, with several advantages over gas insufflation polypectomy.

Underwater endoscopic mucosal resection: The third way for en bloc resection of colonic lesions?

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.