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

Abstract

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.

Impact of observational training on endoscopic mucosal resection outcomes and competency for large colorectal polyps: single endoscopist experience

“…Irrespective of these differences, it is clear that further data from endoscopists across different practice settings are necessary to understand the learning curve of colorectal EMR. ▶ EMR outcomes in our study were consistent with those described in the Western literature (Supplemental Table 4) [8,9,15,[19][20][21][22][23]. These results suggest that gastroenterologists without additional formal advanced endoscopy training can acquire the necessary skill set for EMR through dedicated, comprehensive training.…”

“…Endoscopic mucosal resection (EMR) has been shown to be safe and effective for large colorectal polyps, with the additional benefits of avoidance of surgery and cost-savings [1][2][3][4][5][6][7][8][9][10][11]. As a result, it is considered standard of care over the invasive alternative of surgical resection for benign lesions, which is supported by the recommendations of the European Society of Gastrointestinal Endoscopy (ESGE) [2].…”

Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting gastrointestinal neoplasia of the colon, expanded experience and follow-up

“…Improved recognition of sessile and flat colorectal lesions has prompted an increase in tertiary care referrals for endoscopic resection [30][31][32]. However, as a result of submucosal invasion or submucosal fibrosis from previous lesion manipulation (incomplete resection attempts, extensive biopsies, or intralesional tattooing) resections even at expert centers have become more complex, given impeded lifting of those manipulated or more invasive lesions [3,32,33].…”

“…While the above techniques used to endoscopically remove scarred, non-lifting colorectal lesions are feasible strategies for resection of these historically difficult-to-resect colorectal lesions, the improved recognition of sessile and flat colorectal lesions; limitations of EMR for large, sessile colorectal lesions; complexities associated with standard ESD and EMR-ESD techniques; lack of widespread adoption of ESD or EFTR; and lack of consistent efficacy of ablative or avulsion therapies have unsurprisingly led to an increase in tertiary care referrals for endoscopic resection of colorectal lesions [3,31,32]. However, as a result of submucosal invasion or submucosal fibrosis from previous lesion manipulation (incomplete resection attempts, extensive biopsies, or intralesional tattooing) resections even at expert centers have become more complex, given impeded lifting of those manipulated or more invasive lesions [3,33,[41][42][43].…”

Patients with non-colorectal cancers may be at elevated risk of colorectal neoplasia

“…Colonoscopy allows for early detection and removal of CAP or early-stage CRC. Additionally, the advent of advanced endoscopic treatment for CAP, even large ones (>10 mm), has decreased the need for surgical intervention and lowered the morbidity and mortality associated with open intra-abdominal Ivyspring International Publisher interventions [4]. The implementation of CRC screening efforts, including colonoscopy, has recently been shown to be highly cost-effective over a patient's lifetime [5].…”