Mo1726 A NOVEL TRIPLE-ANCHORING TECHNIQUE FOR HYBRID ENDOSCOPIC MUCOSAL RESECTION: A PRELIMINARY STUDY

Abstract

A hybrid technique may be a reasonable compromise to make EMR more reliable for lesions ≥ 20 mm and a good way of approaching to ESD. The aim of this study was to assess the efficacy and safety of a novel hybrid EMR technique (triple-anchoring EMR, T-EMR) for colorectal lesions between 20 and 30 mm. Fifteen patients have been prospectively and consecutively enrolled to T-EMR from December 2018 to April 2019 in two Endoscopy Units: Policlinico A. Gemelli, Rome, and University Hospital of Udine, Italy. Patients eligible for the study were ≥18 years old with superficial colorectal lesions between 20 and 30 mm, morphologically liable to endoscopic treatment based on chromoendoscopy. T-EMR was randomly performed by three skilled endoscopists in the EMR procedure. Sequential steps of T-EMR were done as follows (Figure 1,2): 1. measurement of lesions through an open 6 mm biopsy forceps; 2. injection of a solution of diluted epinephrine, indigocarmine and Glycerol under, at the top and then all around the lesion; 3. creation of a mucosal hole at the top and then of a small mucosal cut on the right and left side of the lesion; 4. snare placement with the tip into the apical hole and the lateral wires into the small cuts on the right and left side of the lesion; 5. lumen inflation before cutting; 6. resection; 7. ulcer closure by clips. The procedure was performed with a 25 mm snare, an elettrosurgical source, a colonoscope, and Carbon dioxide for insufflation. The primary endpoint of this study was assessment of the “en bloc” and the free resection margins (R0) rates. The secondary endpoints were: resected specimen size, procedure time, complication rate, and recurrence rate at 6 months. Among the 15 patients enrolled, 12 were males (80%), mean age was 68.73±11.04 years. The mean size of the lesions was 24.93±2.89 mm. Mean procedure time was 22.13±4.31 min. T-EMR was performed en bloc in 14/15 patients (93.3%) with R0 in 13/15 patients (86.7%). The mean number of clips placed after procedures was 5±1.77. No major intra-/peri-procedural or delayed complications occurred. At histological analysis, 13/15 lesions (86.7%) were adenomas, while 2 were early colorectal cancer. At a 6 months follow-up colonoscopy, only one patient (6.7%) had a recurrence of adenoma. A linear correlation analysis showed a positive correlation between procedure time and size of the lesions (r=0.678; p=0.005), between procedure time and number of clips placed (r=0.851; p<0.001), and between size and number of clips placed (r=0.753; p=0.001). There was no significant difference between the mean sizes of right and left colon lesions (p=0.325) and between the mean procedure time of right and left colon lesions (p=0.625). T-EMR seems to be an effective and safe option to treat colorectal lesions between 20 and 30 mm, with a short procedure time and low costs.Endoscopic images showing: A. a large flat colonic polyp in the cecum suitable for endoscopic mucosal resection by the triple-anchoring technique; B. the polyp after submucosal injection; C. small incisions on the top and on the lateral margins of the lesion, which were made using the tip of the snare in Endocut mode; D. the 25-mm snare grasping the lesion with the triple-anchoring technique; E. the resected area following en bloc capture of the entire large polyp, consistent with macroscopic complete resection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)