Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (> 20 mm) non pedunculated colorectal polyps: a systematic review and meta-analysis

Abstract

Background and study aims Endoscopic mucosal resection (EMR) of laterally spreading tumors (LSTs) > 20 mm in size can be challenging. Piecemeal EMR of these lesions results in high rates of adenoma recurrence at first surveillance colonoscopy (SC1). Snare tip soft coagulation (STSC) of post resection margins is a safe and effective technique to prevent adenoma recurrence. We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of this technique. Patients and methods Multiple databases were searched through April 2021 for studies that reported on outcomes of post EMR STSC for LSTs > 20 mm in size. Meta-analysis was performed to determine pooled odds of adenoma recurrence as well as pooled proportion of adverse events including intraprocedural and delayed bleeding as well as intraprocedural perforation events. Results Six studies including two randomized controlled trials (RCT) and four cohort studies with 2122 patients were included in the final analysis. Overall pooled odds of adenoma recurrence at SC1 with post EMR STSC compared to no STSC was 0.27 (95 % 0.18–0.42; I2 = 0 %), P < 0.001. Pooled rate of adenoma recurrence at SC1 in post EMR STSC cohort was 6 %. Rates of intraprocedural bleeding, delayed bleeding and intraprocedural perforation were 10.3 %, 6.5 % and 2 % respectively. Conclusions Our results show that thermal ablation of resection margins with STSC in LSTs > 20 mm is a safe and effective technique in reducing the incidence of adenoma recurrence.

Hybrid Argon Plasma Coagulation for Barrett’s Esophagus and for Colonic Mucosal Resection—A Systematic Review and Meta-Analysis

“…Intraprocedural bleeding occurred in 13% of patients included in the single study that quantified this parameter [ 10 ]. These values are identical to those reported for STSC-assisted EMR, where intraprocedural and delayed bleeding are estimated to occur in 10% and 6.5%, respectively [ 13 ]. However, no studies compared directly hAPC with the currently preconized margins’ ablation methods (standard APC and STSC).…”

“…Five studies evaluated the recurrence of intestinal metaplasia [ 4 , 9 , 10 , 13 , 15 ]. Knabe et al [ 9 ] found a histologic recurrence rate of 29.2% ( Table 1 ; Figure 3 ) after 24 months of follow-up.…”

“…Another field where hAPC has been generating interest is in the adjuvant management of large (>20 mm) non-pedunculated colorectal lesions [ 10 , 11 , 12 ] which carry a significant risk of submucosal invasive cancer [ 13 ]. The mainstay for these polyps’ resection is endoscopic mucosal resection (EMR), mostly in a piecemeal fashion.…”

Recurrence rates after piecemeal endoscopic mucosal resection of large colorectal laterally spreading tumors

“…Irrespective of the EMR technique used, the endoscopist decided to attempt the closure of the mucosal defect with clips and the thermal ablation of its margins with snare tip coagulation, as recommended in the literature [ 17 ]. It should be noted that margin thermal treatment of the margins had not been employed in the initial years of our retrospective analysis.…”

Minimally Invasive Endoscopic and Surgical Management of Rectal Neoplasia

“…Due to the differences in techniques compared to hot EMR, it is suggested that cold snare resection be performed by using a dedicated cold snare while aiming for smaller pieces with attention to overlapping and obtaining wide healthy margins. Thermal ablation of the defect margin after EMR of large nonpedunculated colorectal polyps has been shown to significantly reduce residual or recurrent adenoma at first surveillance colonoscopy and is therefore recommended as adjunct therapy [ 35 , 36 , 37 ]. Another variant of cold EMR can also be performed underwater, known as underwater EMR (uEMR), which has the benefit of not requiring submucosal injection.…”