EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video)

Tate, David J.; Desomer, Lobke; Awadie, Halim; Goodrick, Kathleen; Hourigan, Luke F.; Singh, Rajvinder; Williams, Stephen J.; Bourke, Michael J.

doi:10.1016/j.gie.2017.12.018

Cited by 47 publications

(47 citation statements)

References 13 publications

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“…Regarding the subgroup of patients with adenomas involving the appendiceal orifice this is considered to be a difficult anatomic location for endoscopic resection. There have been few reports of endoscopic resection of colon polyps involving the appendiceal orifice [31][32][33]. In patients with no prior history of appendectomy, when the deep margin into the appendiceal lumen is not well visualized, complete resection is not possible endoscopically.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis

et al. 2020

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Background and study aims Endoscopic full-thickness resection (EFTR) allows for treatment of epithelial and sub-epithelial lesions (SELs) unsuitable to conventional resection techniques. This meta-analysis aimed to assess the efficacy and safety of clip-assisted method for non-exposed EFTR using FTRD or over-the-scope clip of gastrointestinal tumors. Methods A comprehensive literature search was performed. The primary outcome of interest was the rate of histologic complete resection (R0). Secondary outcomes of interest were the rate of enbloc resection, FTR, adverse events, and post-EFTR surgery. Random-effects model was used to calculate pooled estimates and generate forest plots. Results Eighteen studies with 730 patients and 733 lesions were included in the analyses. Indications for EFTR were difficult/residual colorectal adenoma, adenoma at a diverticulum or appendiceal orifice and early cancer (n = 634), colorectal SELs (n = 42), and upper gastrointestinal lesions (n = 51), other colonic lesions (n = 6). Median size of lesions was 13.5 mm. There were 22 failed EFTR attempts. Pooled overall R0 resection rate was 82 % (95 % CI: 75, 89). The pooled overall FTR rate was 83 % (95 % CI: 77, 89). The pooled overall enbloc resection rate was 95 (95 % CI: 92, 96). The pooled estimates for perforation and bleeding were < 0.1 % and 2 %, respectively. Following EFTR, a total of 110 patients underwent surgery for any reason [pooled rate 7 % (95 % 2, 14). The pooled rates for post-EFTR surgery due to invasive cancer, for non-curative endoscopic resection and for adverse events were 4 %, < 0.1 % and < 0.1 %, respectively. No mortality related to EFTR was noted. Conclusions EFTR appears to be safe and effective for gastrointestinal lesions that are not amenable to conventional endoscopic resection. This technique should be considered as an alternative to surgery in selected cases.

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Section: Discussionmentioning

confidence: 99%

Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis

et al. 2020

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“…Recently successful endoscopic resection of polyps involving the AO with EMR or ESD has been described in expert tertiary endoscopy centers. However, these procedures mainly involved lesions without deep extension into the AO or when less than 50 % of the circumference of the AO was involved 14 15 16 17 . For lesions with a diameter less than 20 mm combined with a more than 50 % circumferential involvement of the AO or deep extension into the AO, eFTR could be an important alternative endoscopic strategy.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study

et al. 2018

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Background and study aims Colorectal polyps involving the appendiceal orifice (AO) are difficult to resect with conventional polypectomy techniques and therefore often require surgical intervention. These appendiceal polyps could potentially be removed with endoscopic full-thickness resection (eFTR) performed with a full-thickness resection device (FTRD). The aim of this prospective observational case study was to evaluate feasibility, technical success and safety of eFTR procedures involving the AO. Patients and methods This study was performed between November 2016 and December 2017 in a tertiary referral center by two experienced endoscopists. All patients referred for eFTR with a polyp involving the AO that could not be resected by EMR due to more than 50 % circumferential involvement of the AO or deep extension into the AO were included. The only exclusion criterion was lesion diameter > 20 mm. Results Seven patients underwent eFTR for a polyp involving the AO. All target lesions could be reached with the FTRD and retracted into the device. Technical success with an endoscopic radical en-bloc and full-thickness resection was achieved in all cases. Histopathological R0 resection was achieved in 85.7 % of patients (6/7). One patient who previously underwent an appendectomy developed a small abscess adjacent to the resection site, which was treated conservatively. Another patient developed secondary appendicitis followed by a laparoscopic appendectomy. Conclusion This small exploratory study suggests that eFTR of appendiceal polyps is feasible and can offer a minimally invasive approach for radical resection of these lesions. However, more safety and long-term follow-up data are needed to evaluate this evolving technique.

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“…After confirming its superior safety3 and cost-effectiveness4 to surgery, the technique has continued to evolve, manifesting in the ability to predict, mitigate and manage intraprocedural and postprocedural adverse outcomes 18 23–26 29–34. Alongside site-specific modifications in technique, high-quality EMR has surmounted physician-imposed boundaries by effectively treating periappendiceal,35 ileocecal,36 circumferential37 and non-lifting lesions 38. Our study highlights another major advancement: the ability of a site-specific EMR technique (online supplementary video 1) to effectively, efficiently and safely manage ARJ-LSLs in a multicentre observational cohort.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction

Shahidi¹,

Sidhu²,

Vosko

et al. 2019

Gut

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ObjectiveThe optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs.DesignEMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC).ResultsBetween July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35–60 mm). Median follow-up at SC4 was 54 months (IQR 33–83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1–SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027).ConclusionEMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.

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EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video)

Cited by 47 publications

References 13 publications

Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis

Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis

Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study

Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction

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