Cap-fitted endoscopic mucosal resection of ≥ 20 mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate

Abstract

Background and study aims Endoscopic mucosal resection (EMR) is increasingly used for the treatment of large colonic polyps (≥ 20 mm). A drawback of EMR is local adenoma recurrence. Therefore, we studied the impact of argon plasma coagulation (APC) of the EMR edge on local adenoma recurrence. Patients and methods This was a retrospective study of patients with laterally spreading tumors (LST) ≥ 20 mm, who underwent EMR from January 2009 to August 2018 and follow-up endoscopic assessment. A cap-fitted endoscope was used to assess completeness of resection by systematically inspecting the EMR defect for any macroscopic disease. This was followed by forced APC of the resection edge followed by clip closure of the defect. Surveillance colonoscopy was performed at 6 months after resection to detect recurrence. Results Two hundred forty-six patients met the inclusion criteria. Most were female (53 %) and white (80 %), with a Median age of 64 years. Median polyp size was 35 mm (interquartile range, 30–45 mm). Most polyps were located in the right colon (77 %) and were removed by piecemeal EMR (70 %). Eleven patients (5 %) had residual tumor at the resection site. Conclusions We observed low adenoma recurrence after argon plasma coagulation of the EMR edge with a cap fitted colonoscope in patients with LST ≥ 20 mm of the colon, which requires further validation in a randomized controlled study.

Endoscopic techniques to reduce recurrence rates after colorectal EMR: systematic review and meta-analysis

“…In order to reduce recurrence rates, APC is applied to the entire margin of the resection site leaving a white touch indicating the coagulated tissue. In line with our findings, a large retrospective multicenter cohort study from 2019 treating 264 lesions with APC resulted in a recurrence rate of only 4.5% [22]. The two studies in our meta-analysis that compared STSC with standard EMR reported similar results.…”

“…And last, alternative strategies not targeting the resection margin were not included in this meta-analysis. These techniques are based on enhancing optical imaging during the EMR and therefore theoretically reduce adenoma recurrence rates, such as underwater EMR [ 12 , 30 ], cap-assisted EMR [ 22 , 31 ], and wide-field EMR [ 32 ].…”

Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis

“…distinction between en bloc and piecemeal resection [6,21,25], and only one of these three performed post-hoc analysis to evaluate the specific effects of EMR-T after en bloc and piecemeal resection separately [6]. In this study, there was no significant difference in recurrence rate after traditional en bloc EMR (0/23; 0%) compared to en bloc EMR-T (1/25; 4%).…”

“…For STSC, universally, the soft coagulation mode is used with a current of 80 Watts and effect mode 4 on Erbe ENDO CUT Q [6,15,[21][22][23]. Settings for APC show more variation between operators, with currents between 30-70 Watts and a gasflow of 0.8-2.0 liters per min [18,19,24,25]. A recent study in porcine models evaluating the effects of STSC and APC showed that APC applied at 1.0 L/min, 30 W, was associated islands of preserved mucosa [26].…”

Colorectal EMR outcomes in octogenarians versus younger patients referred for removal of large (≥20 mm) nonpedunculated polyps

“…Hence, our data suggest that special measures should be considered to help ensure that elderly patients undergo follow-up after EMR. Recent breakthroughs in EMR technique, [19][20][21][22] such as application of snare tip soft coagulation thermal injury to the margin of the EMR defect, should result in lower recurrence rates and reduce the implications of lower follow-up rates after EMR in elderly patients. Rates of synchronous disease were similar to younger patients with large sessile or flat colorectal lesions and high in both groups (18).…”