Improving complete EMR of colorectal neoplasia: a randomized trial comparing snares and injectate in the resection of large sessile colon polyps

Woodward, Timothy A.; Crook, Julia E.; Raimondo, Massimo; Wallace, Michael B.

doi:10.1016/j.gie.2014.10.010

Cited by 17 publications

(12 citation statements)

References 22 publications

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“…12, 27 Although piecemeal resection of colorectal tumors is reported to be associated with a higher residual/recurrence rate than is en bloc resection (20% versus 3%), 4, 28, 29 we observed a low residual colorectal tumor rate (4.4%) with EMR in the present study. This may have resulted from the use of a protocol of performing EMR in a clean colon (Boston Bowel Preparation Scale of 8 or 9) and drying up the colon segment to define the lesion better, routine use of a cap fitted colonoscope that facilitated better evaluation and resection of the entire lesion (even it extended over a fold), complete excision of the lesion to create a clean resection base and edges similar to the ones observed after endoscopic submucosal dissection, multiple photographs of the entire resection edge and base that permitted time for careful examination of the entire resection during the freeze mode before a picture was saved, and routine ablation of the edges with argon plasma coagulation.…”

Section: Discussioncontrasting

confidence: 49%

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

Raju

Lum

Ross

et al. 2016

Gastrointestinal Endoscopy

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Background and Aims Patients with complex colon polyps were traditionally referred for surgery to avoid adverse events associated with endoscopic resection. Recent advances in endoscopic imaging as well endoscopic hemostasis and clip closure allow for the use of endoscopic mucosal resection (EMR) as an alternative to surgery for such lesions. To determine the outcome of treatment of complex colon polyps with EMR as an alternative to surgery, we conducted a retrospective observational study. Methods Two hundred three patients with complex colon polyps referred to an EMR center as an alternative to surgery. Patients underwent a protocol driven EMR.. The primary endpoint was the complete resection rate. Secondary endpoints were safety, residual adenoma rate, and incidence of missed synchronous polyps. Results EMR was performed in 155 patients and was deferred in 48 patients who were referred to surgery. EMR specimens revealed benign polyps in 149 and cancer in 6 patients. EMR adverse events occurred in seven patients, requiring hospitalization in five of them. None of the patients died of their adverse events. Surveillance colonoscopy at 4-6 months after resection of a benign lesion in 137 patients revealed residual adenoma at the scar site in 6 patients and additional synchronous precancerous lesions in 117 patients that were not removed by the referring endoscopist. None underwent surgery for failure of EMR. The overall precancerous lesion burden was 2.83 per patient, the adenoma burden was 2.13 per patient, and the serrated polyp burden was 0.69 per patient. Conclusions EMR can be used instead of surgery for complex colon polyps in 75 percent of patients with few adverse events and few residual adenomas at resection sites. In addition, careful repeat examination of the entire colon for synchronous lesions overlooked by the referring endoscopist is required for the majority of patients.

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Section: Discussioncontrasting

confidence: 49%

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

Raju

Lum

Ross

et al. 2016

Gastrointestinal Endoscopy

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“…However, very stiff snares give less 'feel' to the endoscopist during the final stages of snare closure, and risk capture of the deep submucosa or muscle layer. Several snares have been purposefully designed for mucosal resection and have barbs to help catch the mucosa, or a serrated or flat tened edge for more grip 65 . A thicker snare wire results in a deeper level of cut submucosa and less margin for error.…”

Section: Emr Techniquementioning

confidence: 99%

Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps

Saunders

Tsiamoulos

2016

Nat Rev Gastroenterol Hepatol

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Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.

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“…Thus, improving the quality of EMR to increase the rate of R0 resection and to reduce the need for follow-up procedures should become a target of research. It has been reported that conventional EMR is associated with 62 – 65 % en bloc resection for lesions < 20 mm in diameter but R0 resection has never been evaluated precisely 1 3 4 .…”

Section: Introductionmentioning

confidence: 99%

Endoscopic mucosal resection with anchoring of the snare tip: multicenter retrospective evaluation of effectiveness and safety

et al. 2019

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Background Endoscopic mucosal resection (EMR) with snare is the recommended technique to resect non-invasive colorectal neoplastic lesions between 10 and 30 mm in diameter. The objective of EMR is to resect completely the neoplastic tissue en bloc and preferably with free margins (R0), avoiding recurrences. Anchoring the tip of the snare in the submucosa is a technical trick that allows snare sliding to be reduced and larger pieces to be caught. The aim of the present study was to evaluate the effectiveness and safety of anchoring-EMR (A-EMR). Methods This was a retrospective analysis of A-EMR procedures for lesions of diameter between 10 and 30 mm (endoscopic evaluation) performed consecutively in four French centers between May 2017 and January 2018. A-EMR was routinely performed for all EMR using Olympus conventional snares (10 or 25 mm). The primary outcome was evaluation of the proportion of R0 resections. Results A total of 141 A-EMR procedures were performed by 10 operators. Mean lesion size was 19.8 mm. Anchoring was feasible in 96.5 % of cases. There were 81.6 % en bloc resections and 70.2 % R0 resections, with the percentage of procedures decreasing with increasing lesion size (82.8 % < 20 mm, 55.3 % 21 – 30 mm, and 50.0 % > 30 mm, P = 0.002). Complete perforations closed endoscopically occurred in 3/141 cases (2.1 %); none occurred in lesions < 20 mm in size (0 /87). Conclusion The A-EMR technique appears to be promising with a high proportion of R0 for lesions of 10 – 20 mm in size without any perforations. It could also offer an alternative to endoscopic submucosal dissection (ESD), or to hybrid techniques to reach R0 for lesions between 20 and 30 mm in size.

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Improving complete EMR of colorectal neoplasia: a randomized trial comparing snares and injectate in the resection of large sessile colon polyps

Cited by 17 publications

References 22 publications

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps

Endoscopic mucosal resection with anchoring of the snare tip: multicenter retrospective evaluation of effectiveness and safety

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