Adverse events and residual lesion rate after cold endoscopic mucosal resection of serrated lesions ≥10 mm

McWhinney, Connor D.; Vemulapalli, Krishna C.; Rahyel, Ahmed El; Abdullah, Nor Azizan; Rex, Douglas K.

doi:10.1016/j.gie.2020.08.032

Cited by 31 publications

(30 citation statements)

References 25 publications

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“…Other authors have also reported low rates of adverse events with cold snare resection for large polyps, with or without submucosal injection: 1.1 % in a meta-analysis (eight studies, of which five used submucosal injection, for a total of 522 colorectal adenomas and SSP/As ≥ 10 mm) 25 , and 3.9 % of 205 patients with serrated lesions ≥ 10 mm resected by cold snaring with submucosal injection in a subsequent study (no intervention required for any adverse event) 26 . With respect to bowel perforation, only two cases have been reported following CSP and were probably due to inadequate technique (insufficient colonic distension) and the use of a snare not specifically designed for CSP 27 .…”

Section: Discussionmentioning

confidence: 99%

Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions

Barros¹,

Monteverde²,

Dumonceau

et al. 2021

Endosc Int Open

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Background and study aim Cold resection is becoming the standard of care for the resection of nonpedunculated colon lesions up to 10 mm in diameter. Sessile serrated adenomas/polyps (SSA/Ps), including those ≥ 10 mm, present various characteristics that make them ideal candidates for cold snare polypectomy (CSP). Patients and methods A prospectively maintained database was searched retrospectively for consecutive patients with lesions ≥ 10 mm resected between March 2013 and March 2018. During that period, all SSA/P-appearing lesions were resected using CSP without submucosal injection, except for lesions with endoscopic suspicion of dysplasia or submucosal invasion. Patients with a pathological diagnosis of SSA/P were included in the analysis. Adverse events were recorded up to 21 days following colonoscopy. Results 615 SSA/Ps ≥ 10 mm were resected during 452 colonoscopy procedures in 379 patients (mean age 54.1 years; standard deviation [SD] 11.9 years). Mean polyp size was 13.7 (SD 5.2) mm; 122 lesions (19.8 %) were ≥ 20 mm and 479 lesions (77.9 %) underwent piecemeal resection. Immediate adverse events included persistent abdominal pain that resolved spontaneously within 2 hours in three patients (0.8 %; 95 % confidence interval [CI] 0.2 %–2.3 %). One patient with persistent intraprocedural bleeding was successfully treated with a hemostatic clip. No late adverse events were detected. Surveillance colonoscopy was performed in 293 patients (77.3 %) at 23.4 (SD 11.6) months following index colonoscopy; residual/recurrent lesions were diagnosed in 23 patients (7.8 %; 95 %CI 5.0 %–11.6 %). Conclusion CSP without submucosal injection appeared to be safe and effective for the resection of large SSA/Ps.

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Section: Discussionmentioning

confidence: 99%

Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions

Barros¹,

Monteverde²,

Dumonceau

et al. 2021

Endosc Int Open

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confidence: 84%

“…In contrast to the results of this study, there was no difference in the incidence of esophageal acid exposure or reflux esophagitis in a previous randomized trial comparing short versus long myotomy. 2 Interestingly, the incidence of reflux esophagitis was quite low in both groups (14.6% and 8.7%). In a recent prospective study 6 and in 2 randomized trials comparing POEM with dilatation or Heller's myotomy, 7,8 the incidences of reflux esophagitis after POEM were 54%, 41%, and 44%, respectively.…”

mentioning

confidence: 85%

“…We concur with the authors that an SEM may be sufficient in certain subtypes of achalasia (types I and II) in contrast to spastic esophageal motility disorders, where a long myotomy is often required. 2 Because a noninferiority margin of 15% was used for sample size determination, caution is advised in the interpretation of the study results. SEM has been shown to be efficacious in previous studies; therefore, a wide noninferiority margin may not be justifiable.…”

mentioning

confidence: 99%

“…SEM has been shown to be efficacious in previous studies; therefore, a wide noninferiority margin may not be justifiable. [2][3][4][5] The other intriguing finding of the study is the reduced incidence of esophageal acid exposure in the SEM group (43.8% vs 23.9%, P Z .042). However, the difference just reached statistical significance, signifying the need for additional studies before SEM can be recommended to prevent GERD after POEM.…”

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confidence: 99%

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Rex

2021

Gastrointestinal Endoscopy

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Thanks to Tao et al 1 for their interest in our study of cold EMR for serrated lesions. 2 Tao et al 1 state that we did not discuss the incomplete resection rate for large lesions, which we interpret as incomplete by pathologic assessment. We stated in the article that "lesions were nearly all removed piecemeal." By definition, the completeness of resection cannot be assessed pathologically after piecemeal resection. We assessed completeness of resection using the clinically relevant definition of residual polyp at follow-up. Arguably, no definition of success is more relevant than the persistence of polyp tissue at follow-up.With regard to "preoperational biopsy," we did not perform biopsy before resection in any lesions. In general, actual biopsy of serrated lesions is inadvisable because it often results in submucosal fibrosis. Certainly, many of the lesions underwent biopsy by referring physicians. None of the lesions had suspected high-grade dysplasia before resection. For the 18 lesions with residual at follow-up, the only difference compared with lesions without residual was size. Lesions with residual were similar to lesions without residual with regard to flat morphology (72.2% vs 67.1%; P Z .659), location proximal to the descending colon (88.9% vs 85.5%; P Z 1.000), sessile serrated lesion as histology (88.9% vs 93.2%; P Z .373), cytologic dysplasia (0% vs 6.8%; P Z .608), and resection from serrated polyposis syndrome (SPS) patients (61.1% vs 61.4%; P Z .984).Using endoscopic submucosal dissection (ESD) to remove serrated lesions (often in the proximal colon) that appear endoscopically benign seems overly time consuming and exposes patients to excessive risk, compared with EMR. The risk of cancer in individual serrated lesions is considerably lower than the risk in conventional adenomas of comparable size. 3 Randomized controlled trials of cold versus hot EMR for serrated lesions are warranted, but ESD for endoscopically benign-appearing serrated lesions would seem like "overkill" to most American endoscopists. Certainly I acknowledge that how to best remove serrated lesions deserves considerable additional and controlled investigation.

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Cold versus hot polypectomy/endoscopic mucosal resection–A review of current evidence

et al. 2021

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Background: Colonoscopy with polypectomy substantially reduces the risk of colorectal cancer (CRC) but interval cancers still account for 9% of all CRCs, some of which are due to incomplete resection. Aim:The aim of this review is to compare the outcomes of cold and hot endoscopic resection and provide technical tips and tricks for optimizing cold snare polypectomy.Results: Cold snare polypectomy (CSP) is the standard technique for small (≤10 mm) colorectal polyps. For large colonic polyps (>10 mm), hot resection techniques with use of electrocautery (polypectomy or endoscopic mucosal resection) were recommended until recently. However, the use of electrocoagulation brings serious adverse effects in up to 9% of the patients, such as delayed bleeding, post-polypectomy syndrome and perforation. In recent years, efforts have been made to improve the polypectomy with cold snare in order to avoid these adverse effects of electrocoagulation without compromising the efficacy of the resection. Several authors have recently shown that the complication rates of CSP of polyps >10 mm is close to zero and recurrence rates varies between 5-18%. Lower recurrence rates are found in serrated lesions (<8%).

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Adverse events and residual lesion rate after cold endoscopic mucosal resection of serrated lesions ≥10 mm

Cited by 31 publications

References 25 publications

Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions

Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions

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Cold versus hot polypectomy/endoscopic mucosal resection–A review of current evidence

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