Hybrid argon plasma coagulation after endoscopic mucosal resection—some caveats in the comparison with snare tip soft coagulation

Abstract

We read with great interest the study by Motchum et al,1Motchum L. Levenick J.M. Djinbachian R. et al.Endoscopic mucosal resection combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps.Gastrointest Endosc. 2022; 96: 840-848.e2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar who analyzed the performance of hybrid argon-plasma coagulation (APC), a technique whereby APC is preceded by submucosal injection of saline through a high-pressure water jet2Kolb J.M. Shah S. Chahine A. et al.Hybrid argon plasma coagulation for Barrett’s esophagus.VideoGIE. 2021; 6: 339-341Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar after EMR of large colonic lesions. The reduction of post-EMR recurrence rates through the use of APC or snare-tip soft coagulation (STSC) on the normal-appearing scar margins is well documented.3Dhillon A.S. Ravindran S. Thomas-Gibson S. Recurrence after endoscopic mucosal resection: there’s more to it than meets the eye.Gastrointest Endosc. 2021; 94: 376-378Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,4Klein A. Tate D.J. Jayasekeran V. et al.Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection.Gastroenterology. 2019; 156: 604-613.e3Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Prior studies had also suggested that STSC may be preferable to APC.5Meulen L.W.T. Bogie R. Winkens B. et al.Thermal ablation of mucosal defect margins to prevent local recurrence after endoscopic mucosal resection of large nonpedunculated colorectal polyps: a systematic review and meta-analysis.Gastrointest Endosc. 2022; 95: AB187-AB188Abstract Full Text Full Text PDF Google Scholar In this study, Motchum and et al1Motchum L. Levenick J.M. Djinbachian R. et al.Endoscopic mucosal resection combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps.Gastrointest Endosc. 2022; 96: 840-848.e2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar found lower recurrence in the first surveillance colonoscopy after hybrid APC (2.2%) than that reported for STSC (6.0%, in a recent analysis), as well as a lower percentage of serious side effects (3.6% versus 8.5%6Chandan S. Facciorusso A. Ramai D. et al.Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (>20 mm) no pedunculated colorectal polyps: a systematic review and meta-analysis.Endosc Int Open. 2022; 10: E74-E81Crossref PubMed Scopus (0) Google Scholar).6Chandan S. Facciorusso A. Ramai D. et al.Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (>20 mm) no pedunculated colorectal polyps: a systematic review and meta-analysis.Endosc Int Open. 2022; 10: E74-E81Crossref PubMed Scopus (0) Google Scholar These results are excellent and allow hypothesizing that hybrid APC may be the method of choice, potentially because of the safer ablation of deeper tissue.7Maselli R. Belletrutti P.J. Spadaccini M. et al.Fluid cushion protects against thermal damage during argon plasma coagulation.Ann Gastroenterol. 2021; 34: 845-851PubMed Google Scholar Notwithstanding, some caveats arise, including the small sample size, the single-arm design, and the lack of standardization of the hybrid APC technique, given that most patients (72.0%) underwent ablation of both scar surface and margins, hampering comparison with prior STSC studies. No recurrence at 6 months was observed in another recent pilot study8Motz V.L. Lester C. Moyer M.T. et al.Hybrid argon plasma coagulation-assisted endoscopic mucosal resection for large sessile colon polyps to reduce local recurrence: a prospective pilot study.Endoscopy. 2022; 54: 580-584Crossref PubMed Scopus (1) Google Scholar of hybrid APC for colonic large lesions where scar surface ablation was performed in all patients, being plausible that such ablation may justify the lower recurrence rate. Another drawback is the lack of cost effectiveness analysis. In fact, although STSC does not involve additional costs, hybrid APC carries an incremental cost effectiveness ratio of $158.7/1.0% (or $603.0 per procedure for a 3.8% decrease in recurrence), and fixed costs of around $50,000 for Erbejet2 and APC3 modules (prices for Portugal). Additional studies are needed to compare head-to-head standardized STSC, APC, and hybrid APC, to evaluate characteristics of the lesions that may lead to selecting 1 technique over another, and to evaluate cost effectiveness. Both authors disclosed no financial relationships.