Cap-assisted Endoscopic Mucosal Resection Research Articles

Short and long term effect of anti-reflux mucosectomy with cap-assisted endoscopic mucosal resection for refractory gastroesophageal disease.

Anti-reflux mucosectomy with cap-assisted endoscopic mucosal resection (ARMS-C) is a safe and effective treatment for managing refractory gastroesophageal reflux disease (GERD). This study aimed to investigate the short and long-term outcomes of ARMS-C. This study was conducted from 2018 to 2022, during which 115 eligible patients underwent ARMS-C. The primary endpoints of this study were to evaluate the GERD-Q questionnaire score and determine the number of patients who reduced their proton pump inhibitor (PPI) dosage or discontinued PPI usage. The secondary endpoints included the evaluation of the DeMeester score, acid exposure time (AET), gastroesophageal flap valve grade (GEFV), lower esophageal sphincter pressure, the rate of successful esophageal peristalsis, and GERD-Q questionnaires. Additionally, we analyzed the long-term efficacy of ARMS-C. Out of the 120 patients, 115 underwent ARMS-C, 96 were followed up for at least six months after the procedure, and 22 were followed up for at least two years. The primary outcome showed a significant improvement in GERD-Q scores, decreasing from 10.67 to 7.55 (p < 0.001). Out of the 96 patients, 36 were able to reduce or completely stop using PPIs. The DeMeester score, GEFV, AET, and the proportion of intact peristalsis also demonstrated improvement. As for the long-term efficacy of ARMS-C, 86% of patients showed improvement in symptoms, and no serious adverse effects were reported after the procedure. ARMS-C is a safe and effective endoscopic technique to treat refractory GERD patients.

Endoscopic Mucosal Incision to Remove a Chain of Magnets Completely Embedded under the Gastric Mucosa: A Case Report

AbstractThe rising use of electronic toys containing magnets has led to an increased incidence of magnet ingestion in children. While endoscopic extraction is the preferred approach in these cases, challenges arise when multiple magnets get swallowed, which can erode through the mucosal surface and become embedded in fibrous tissue. Extraction using simple endoscopic techniques and instruments is not possible in such cases and many times, surgical intervention becomes necessary.This case showcases the application of cap-assisted endoscopic mucosal resection and endoscopic submucous dissection principles and the use of magnetic forceps, enabling the safe and complete removal of the embedded magnet pieces and highlighting the remarkable effectiveness of advanced endoscopic techniques in managing this unique challenge. The multidisciplinary approach and tailored interventions demonstrated in this case underscore the importance of prompt and comprehensive evaluation in cases of ingested foreign bodies, particularly those involving multiple magnets

Efficacy and safety of cap-assisted endoscopic mucosal resection for superficial duodenal epithelial neoplasia ≤ 10 mm.

Background and study aims Endoscopic treatment strategies for small superficial duodenal epithelial neoplasia (SDET) have not been established, and the R0 resection rates of all previously reported endoscopic techniques are somewhat low. Furthermore, no reports of cap-assisted endoscopic mucosal resection (EMRC), which is reportedly associated with a relatively high R0 resection rate, have been evaluated in sufficient numbers of patients. Therefore, we assessed the efficacy and safety of EMRC for SDETs ≤ 10 mm in a retrospective cohort study. Patients and methods We examined a prospectively maintained database and identified 248 consecutive patients (248 lesions) who had undergone endoscopic resection for SDETs ≤ 10 mm between January 2017 and June 2022. Our treatment strategy was consistent, with EMRC indicated for all SDETs ≤ 10 mm without non-lifting signs. The primary endpoint was the R0 resection rate. Results Overall, 20 lesions had non-lifting signs and were selected for endoscopic submucosal dissection, while the remaining 228 lesions were treated with EMRC. As a result of EMRC, the median tumor size was 5 mm, and the mean procedure time was 5 minutes. Most of the lesions (89.2%) were located in the descending part. The R0 resection rate was 97.4% (222/228 cases), and the en bloc resection rate was 99.6%. Only seven patients(3.1%) experienced adverse events (6 patients, delayed bleeding; 1 patient, acute pancreatitis), which were successfully managed without surgical intervention. Furthermore, no recurrences were observed. Conclusions We have demonstrated that EMRC is an effective and safe treatment for SDETs ≤ 10 mm that do not have non-lifting signs.

Cap-assisted endoscopic mucosal resection as a salvage technique for challenging colorectal laterally spreading tumors.

Cap-assisted endoscopic mucosal resection (EMR-c) has emerged as a potential alternative to standard piecemeal wide-field EMR (WF-EMR) for the resection of laterally spreading tumors (LSTs). However, clear indications for this technique are still lacking. Our objective was to investigate the performance of salvage EMR-c after WF-EMR failure in the resection of large colorectal LSTs. The data of consecutive patients undergoing WF-EMR for large colorectal LSTs (2015-2021) were analyzed in this single-center, retrospective, observational study. In the event of a WF-EMR failure, the procedure was switched to EMR-c in the same session. The efficacy of the two techniques was evaluated in terms of complete endoscopic resection, R0 resection, and recurrence rate. Safety was also assessed. Overall,the data from 81 WF-EMRs were collected. Eighteen cases of WF-EMR failure were switched to EMR-c in the same session and complete endoscopic resection was achieved in 17/18 patients (94.4%). No statistically significant difference was observed between WF-EMR and salvage EMR-c in terms of macroscopic radicality (P = 0.40) and R0 resection (P = 0.12). However, recurrence was more common with EMR-c (44.4% vs. 23.5%; P = 0.05), as were adverse events, particularly intraprocedural bleeding (27.8% vs. 7.9%; P = 0.04). EMR-c is an effective salvage technique for challenging colorectal LSTs following WF-EMR failure. Due to the elevated risk of adverse events associated with this procedure, careful patient selection, endoscopic expertise, and close follow-up are strongly recommended.

Linked color imaging aids in identification of multiple rectal neuroendocrine tumors.

A 63-year-old man with a history of three synchronous primary cancers (colon, lung, and thyroid) underwent surveillance colonoscopy after his curative left hemicolectomy. A new 8 mm rectal lesion was identified and removed with hot snare polypectomy. Histology showed a grade 1 rectal neuroendocrine tumor (NET). Repeat colonoscopy 6 months later showed five new sub-centimeter rectal NETs, which were removed with cap-assisted endoscopic mucosal resection (EMR).

Comparison of Modified Cap-Assisted Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in Treating Intraluminal Gastric Gastrointestinal Stromal Tumor (≤20 mm).

A modified cap-assisted endoscopic mucosal resection (mEMR-C), introduced in this study, was a novel variation of the standard EMR. We aimed to compare the outcomes of mEMR-C and endoscopic submucosal dissection (ESD) for the treatment of small (≤20 mm) intraluminal gastric gastrointestinal stromal tumors (gGISTs). This retrospective study included 43 patients who underwent mEMR-C and 156 patients who received ESD at Nanjing Drum Tower Hospital. Baseline characteristics, adverse events, and clinical outcomes were compared between the 2 groups. Univariate and multivariable analyses were conducted to adjust for confounders. After propensity score matching using sex, year, location, and tumor size, outcomes were compared with 41 patients in each group. A total of 199 patients underwent endoscopic resection and the en bloc resection rate was 100%. The complete resection rate was comparable in both groups ( P = 1.000). Approximately 9.5% of all patients had a positive margin. There was no significant difference in positive margin for patients undergoing mEMR-C or ESD (9.3% vs 9.6%, P = 1.000). No difference in adverse events in both groups ( P = 0.724). The mEMR-C was associated with shorter operation time and lower cost than the ESD. Recurrence was reported in 2 patients at 1 and 5 years after ESD during a median follow-up of 62 months. No metastasis and disease-related death were identified in both groups. Propensity score matching analysis revealed similar results. The mEMR-C was found to be the preferable technique for small (≤20 mm) intraluminal gGISTs with shorter operation time and lower cost as compared with ESD.

A155 OUTCOMES FOLLOWING ENDOSCOPIC RESECTION OF DUODENAL NEUROENDOCRINE TUMOURS FROM A TERTIARY-CARE ACADEMIC CENTRE

Abstract Background Duodenal neuroendocrine tumours (D-NET) are rare cancers derived from neuroendocrine cells of the duodenum. A steady increase in the incidence of these tumours has been observed. Current treatment and surveillance strategies are guided by various tumour characteristics including size, grade, and depth of invasion. There exists conflicting evidence, however, on the rates of recurrence after positive resection margins following endoscopic resection. Thus, it remains uncertain whether complete endoscopic resection (R0) of these indolent tumours is clinically significant and whether follow-up endoscopic or surgical intervention is justified. Purpose Our aim is to characterize endoscopic management and clinical outcomes in patients undergoing endoscopic resection of D-NETs. Method We conducted a retrospective, single-centre cohort study at The Centre for Advanced Therapeutic Endoscopy and Endoscopic Oncology at St. Michael’s Hospital, Toronto, Ontario. Consecutive patients over the age of 18 who underwent endoscopic resection of histologically proven D-NETs between 2011 and 2020 were included. Data on patient, endoscopic, and tumour characteristics were collected through electronic chart review. Descriptive statistics were conducted for data analysis. Result(s) A total of 155 foregut neuroendocrine tumours (NET) were endoscopically resected amongst 96 patients during the study period. 47 of these were histologically identified as D-NETs. Mean tumour size was 9.88 ± 6.86 mm. Conventional endoscopic mucosal resection (EMR) was performed most frequently (55%, n=26/47), followed by cap-assisted EMR (30%, n=14/47). Hybrid endoscopic submucosal dissection (ESD)/EMR was performed in one case. A total of two intra-procedural perforations occurred, both of which were successfully closed endoscopically. One patient with a peri-ampullary D-NET experienced significant intra-procedural bleeding requiring Hemospray® and subsequent endotracheal intubation resulting in a brief hospitalization. 57% of all resected D-NETs were followed at surveillance endoscopy 1 (SE1) at a median interval of 199 days (range, 84 to 830). Positive resection margins (R1) were found in 26 cases (55%), of which 16 were assessed at SE1 while nine were lost to follow-up. One patient with R1 margins was electively treated with APC at SE1. Tumour recurrence at SE1 occurred in only two patients. Image Conclusion(s) D-NET recurrence is found in less than 5% of patients at surveillance endoscopy following endoscopic resection in spite of a high R1 resection rate. Given this indolent nature of these tumours, our study suggests that patients with positive resection margins can be followed conservatively with surveillance endoscopy. Further investigation is warranted to determine the optimal duration and surveillance strategy for these patients. Please acknowledge all funding agencies by checking the applicable boxes below CAG Disclosure of Interest None Declared

A novel cap-assisted endoscopic resection device for resection of a rectal lesion in an in vitro pig model.

In a previous study, we proved that modified cap-assisted endoscopic mucosal resection (mEMR-C) is non-inferior to endoscopic submucosal dissection (ESD) for rectal neuroendocrine tumors smaller than 10 mm with a similar complete resection rate. In addition, mEMR-C had a shorter procedure duration time and lower hospitalization costs [1]. However, a snare needs to be precisely placed into the inner groove of the cap during the mEMR-C procedure, which is time-consuming and difficult for an inexperienced doctor. To solve this problem, we proposed a novel cap-assisted endoscopic resection device for resecting of a rectal lesion that might make the procedure much simpler and easier. In the current study, we initially explored the feasibility of this device for endoscopic resection in an in vitro pig model.

Conventional endoscopic mucosal resection versus modified endoscopic mucosal resection for duodenal neuroendocrine tumor.

As the incidence of duodenal neuroendocrine tumors (DNET) is steadily increasing, the role of endoscopic treatment for appropriate lesions is becoming more significant. We aimed to compare the outcomes according to lesion size and endoscopic mucosal resection (EMR) techniques for DNET treatment. Patients who underwent endoscopic treatment for DNET between June 2000 and December 2019 were included. The clinicopathologic features and treatment outcomes were investigated by reviewing medical records. Overall, 104 cases underwent endoscopic resection for nonampullary DNET, including conventional EMR (n = 57), cap-assisted EMR (EMR-C, n = 19), and precut EMR (EMR-P, n = 28). The en bloc resection rates (100% vs. 94.7% vs. 96.4%) and histologic complete resection rates (45.6% vs. 52.6% vs. 57.1%) were not significantly different between the EMR, EMR-C, and EMR-P groups. The histologic complete resection rates were significantly higher in lesions < 10mm than in lesions ≥ 10mm (69.8% vs. 38.9%, P = 0.013). In lesions < 10mm, perforation occurred more frequently in the modified EMR group than in the conventional EMR group (13.2% vs. 0.0%, P = 0.007). During the median follow-up period of 88.0months, the recurrence-free survival (92.2% vs. 94.4% vs. 92.1%) and overall survival (98.0% vs. 88.1% vs. 100.0%) rates did not show significant differences between the EMR, EMR-C, and EMR-P groups. Conventional EMR and modified EMR are feasible and effective for the treatment of nonampullary DNET sized < 10mm and limited to mucosal and submucosal layer. Additionally, endoscopists should be aware of the high risk of perforation in modified EMR.

Effective, safe and efficient porcine model of Forrest Ib bleeding gastric and colonic ulcers.

Developing effective gastrointestinal (GI) bleeding animal models is necessary to advance endoscopic hemostasis methods and train endoscopists on their use. Our aim, therefore, was to develop an effective and safe porcine GI bleeding model in the stomach and colon of large and small-sized oozing-type ulcers. Gastric and colonic bleeding ulcers were created using either a hybrid endoscopic submucosal dissection (ESD) technique or a cap-assisted endoscopic mucosal resection (EMR-C) technique in 14 pigs. Prior to ulcer creation, animals were treated with either oral apixaban or intravenous (IV) unfractionated heparin anticoagulation in combination with clopidogrel and aspirin. The primary outcome was the technical success of inducing oozing-type Forrest Ib bleeding ulcers. Secondary outcomes included ulcer diameter, number, creation time and the number of complications associated with each technique. Using hybrid ESD and IV heparin anticoagulation, bleeding was observed in 21/23 (91.3%) gastric ulcers and 6/7 (85.7%) colonic ulcers created. The mean diameter and ulcer creation time were 2.3 ± 0.3cm and 5.3 ± 0.5min, respectively, for gastric ulcers and 2.2 ± 0.4cm and 4.06 ± 0.6min, respectively, for colonic ulcers. Using EMR-C and IV heparin anticoagulation, bleeding was observed in 14/15 (93.3%) gastric ulcers and 6/6 (100%) colonic ulcers created. The mean diameter and ulcer creation time were 0.8 ± 0.2cm and 2.1 ± 0.5min, respectively, for gastric ulcers and 0.7 ± 0.2cm and 1.7 ± 0.3min, respectively, for colonic ulcers. None of the ulcers created in animals anticoagulated with apixaban developed bleeding. None of the 14 pigs developed any complications. We have demonstrated the effectiveness and safety of a porcine GI bleeding model utilizing IV heparin anticoagulation and either hybrid ESD or EMR-C techniques to create oozing-type bleeding ulcers in the stomach and colon with customizable size.

Distal Cap-assisted Endoscopic Mucosal Resection for Non-lifting Colorectal Polyps: An International, Multicenter Study

Background and AimsSubmucosal fibrosis is a commonly encountered problem associated with complex polyps referred for endoscopic mucosal resection (EMR). Previous biopsies, submucosal tattoo injection, and previous unsuccessful attempts at polyp resection have all been shown to induce submucosal fibrosis, which makes subsequent EMR more difficult and increases the risk of recurrence. MethodsWe conducted a multicenter, international, retrospective study of 61 distal cap-assisted endoscopic mucosal resection (EMR-DC) cases done for the indication of a non-lifting colorectal lesion occurring after a previous biopsy, tattoo, or attempted resection at 3 tertiary referral centers. ResultsEMR-DC was preceded by attempted polypectomy or EMR in 88.5% of cases, submucosal tattoo injection in 2%, previous biopsy in 5%, and both biopsy and tattoo in 5%. Complete macroscopic resection was achieved in 100% of EMR-DC procedures in an average procedure time of 49.5 minutes. The adenoma recurrence rate for these adherent lesions at surveillance (average 6.6 months) was only 9.8%. Two serious adverse events occurred (3.3%) within 30 days of the procedure: one instance of postprocedural bleeding and one episode of post-polypectomy syndrome. ConclusionThis large, multicenter series demonstrates EMR-DC to be a safe, effective, and efficient approach to a difficult and common clinical problem: adherent and non-lifting polyps. It may offer several advantages over more expensive or invasive endoscopic techniques used for this indication. The use of EMR-DC for larger adherent polyps with adjuvant techniques such as hot avulsion or cold forceps avulsion with adjuvant snare tip soft coagulation for smaller adherent sections may represent an ideal approach.

Virtual scale endoscope-assisted wide-field resection of large sessile serrated lesions.

Large sessile serrated lesions (SSLs) are associated with a very high risk of incomplete resection. The CARE study found almost 50 % incomplete resections among 10 to 20-mm SSLs [1]. Wide-field cold snare resection with submucosal injection (cap-assisted endoscopic mucosal resection, C-EMR) has been proposed as an effective method to prevent incomplete resection since distinguishing SSL margins during resection is difficult [2] [3] [4]. In contrast to a hot snare, a more extended resection field is recommended for a cold snare [5]. However, quantification of the resection field extent in comparison to polyp size has been challenging in the past. The novel virtual scale endoscope (VSE; SCALE EYE, Fujifilm, Tokyo, Japan) can be used as dedicated technology to measure polyp size before resection and to ensure adequate post-resection defect size. The VSE allows polyp size measurement during live colonoscopies by emitting a laser beam onto the mucosa to measure distance. This permits superimposition of a linear/circular ruler that changes in size depending on distance of the endoscope to the laser point ([Fig. 1]).

S1139 Endoscopic Resection Technique Outcomes for Non-Lifting Colorectal Lesions: A Systematic Review

Introduction: Endoscopic mucosal resection (EMR) is dependent on submucosal injectate expansion to allow for effective and safe tissue capture. Non-lifting polypoid tissue can render colorectal neoplasia recalcitrant to EMR. A number of alternative resection modalities and auxiliary techniques targeting non-lifting polypoid tissue have been described. We therefore sought to perform a systematic comparative analysis of existing techniques for non-lifting colorectal neoplasia. Methods: Two authors (BZ, HJK) independently searched MEDLINE and EMBASE (Inception to April 2022) for citations evaluating endoscopic resection technique outcomes for non-lifting colorectal neoplasia. Eligible outcomes included technical success (removal of all visible polypoid tissue), R0 resection, intra-procedural perforation (IPP), clinically significant post-endoscopic resection bleeding (CSPEB), delayed perforation and recurrence. Categorical variables were expressed as frequency (%), with ranges estimated for the outcomes of interest, stratified by their respective techniques. Results: 2395 citations were identified in our search strategy, of which 18 citations provided endoscopic resection technique outcomes for non-lifting colorectal neoplasia (7 endoscopic full-thickness resection (EFTR), 3 endoscopic submucosal dissection (ESD), 3 hybrid resection techniques (2 hybrid EFTR and 1 dissection-enabled scaffold-assisted resection), 2 avulsion techniques, 2 cap-assisted EMR (C-EMR), and 1 ablative technique). Technical success ranged from 79–100% (EFTR: 80-100%, ESD: 79-91%, hybrid technique: 98-100%, avulsion: 100%, C-EMR: 97%, ablation: 96%). R0 for applicable modalities ranged from 54-100% (EFTR: 57-100%, ESD: 54-63%). IPP ranged from 0-9% (EFTR: 0-4%, ESD: 0-9%, hybrid technique: 0-2%, avulsion: 0-3%, C-EMR: 0-9%, ablation: 0%). CSPEB ranged from 0-29% (EFTR: 0-29%, ESD: 0%, hybrid technique: 0-4%, avulsion: 5-6%, C-EMR: 9%, ablation: 4%). Delayed perforation was between 0 -14% (EFTR: 0-14%, ESD: 0-9%, hybrid technique: 0%, avulsion: 0%, C-EMR: 0%, ablation: 0%). Recurrence ranged from 0-43% (EFTR: 0-43%, ESD: 0-4%, hybrid technique: 0-17%, avulsion: 15-17%, C-EMR: 19%, ablation: 26%). Conclusion: Endoscopic resection techniques are effective for non-lifting colorectal lesions. Given the frequency of technical success comparative analyses between existing techniques focusing on the frequency of low-risk T1 colorectal cancer histopathology post-resection and adverse outcomes are needed. (Table) Table 1. - Outcomes and complications of different auxiliary techniques for non-lifting colorectal neoplasia Modaility Number of Studies Number of Lesions Technical Success R0 Intra-procedure Perforation CSPEB 1 Delayed Perforation Recurrence EFTR 2 7 106 80-100% 57-100% 0-4% 0-29% 0-14% 0-43% ESD 3 3 46 79-91% 54-63% 0-9% 0% 0-9% 0-4% Hybrid technique 4 3 84 98-100% N/A 0-2% 0-4% 0% 0-17% Avulsion 2 121 100% N/A 0-3% 5-6% 0% 15-17% Cap-assisted EMR 5 2 82 97% N/A 0-9% 9% 0% 19% Ablation 1 26 96% N/A 0% 4% 0% 26% 1clinically significant post-endoscopic resection bleeding.2Endoscopic full-thickness resection.3Endoscopic submucosal dissection.4Includes hybrid EFTR and Dissection enabled scaffold-assisted resection.5Includes cap-assisted EMR alone and cap-assisted EMR ± cold avulsion ± ablation.

S130 Distal Cap-Assisted Endoscopic Mucosal Resection Is a Safe and Effective Technique for Resection of Non-Lifting or Adherent Colorectal Polyps: An International, Multicenter, Retrospective Study

S130 Distal Cap-Assisted Endoscopic Mucosal Resection Is a Safe and Effective Technique for Resection of Non-Lifting or Adherent Colorectal Polyps: An International, Multicenter, Retrospective Study

Cap-Assisted Endoscopic Mucosal Resection for Rectal Neuroendocrine Tumors: An Effective Option

Introduction: The incidence of rectal neuroendocrine tumors (r-NETs) is increasing, and most small r-NETs can be treated endoscopically. The optimal endoscopic approach is still debatable. Conventional endoscopic mucosal resection (EMR) leads to frequent incomplete resection. Endoscopic submucosal dissection (ESD) allows higher complete resection rates but is also associated with higher complication rates. According to some studies, cap-assisted EMR (EMR-C) is an effective and safe alternative for endoscopic resection of r-NETs. Aims: This study aimed to evaluate the efficacy and safety of EMR-C for r-NETs ≤10 mm without muscularis propria invasion or lymphovascular infiltration. Methods: Single-center prospective study including consecutive patients with r-NETs ≤10 mm without muscularis propria invasion or lymphovascular invasion confirmed by endoscopic ultrasound (EUS), submitted to EMR-C between January 2017 and September 2021. Demographic, endoscopic, histopathologic, and follow-up data were retrieved from medical records. Results: A total of 13 patients (male: 54%; n = 7) with a median age of 64 (interquartile range: 54–76) years were included. Most lesions were located at the lower rectum (69.2%, n = 9), and median lesion size was 6 (interquartile range: 4.5–7.5) mm. On EUS evaluation, 69.2% (n = 9) of tumors were limited to muscularis mucosa. EUS accuracy for the depth of invasion was 84.6%. We found a strong correlation between size measurements by histology and EUS (r = 0.83, p < 0.01). Overall, 15.4% (n = 2) were recurrent r-NETs and had been pretreated by conventional EMR. Resection was histologically complete in 92% (n = 12) of cases. Histologic analysis revealed grade 1 tumor in 76.9% (n = 10) of cases. Ki-67 index was inferior to 3% in 84.6% (n = 11) of cases. The median procedure time was 5 (interquartile range: 4–8) min. Only 1 case of intraprocedural bleeding was reported and was successfully controlled endoscopically. Follow-up was available in 92% (n = 12) of cases with a median follow-up of 6 (interquartile range: 12–24) months with no evidence of residual or recurrent lesion on endoscopic or EUS evaluation. Conclusion:EMR-C is fast, safe, and effective for resection of small r-NETs without high-risk features. EUS accurately assesses risk factors. Prospective comparative trials are needed to define the best endoscopic approach.

Author commentary on Veronique R. H. Van der Voort et al.

Veronique R. H. Van der Voort et al. Efficacy and safety of cap-assisted endoscopic mucosal resection for treatment of nonlifting colorectal polyps

Efficacy and safety of cap-assisted endoscopic mucosal resection for treatment of nonlifting colorectal polyps.

BACKGROUND : Suboptimal lifting increases complexity of endoscopic mucosal resection (EMR) for benign colorectal polyps. Cap-assisted EMR (EMR-C) may allow fibrotic polyp tissue to be captured in the snare. This study evaluated the efficacy and safety of EMR-C for benign nonlifting colorectal polyps. METHODS : This was a multicenter study, which prospectively registered all EMR-C procedures (2016-2018) for presumed benign nonlifting colorectal polyps. RESULTS : 70 nonlifting polyps with a median size of 25 mm (interquartile range [IQR] 15-40) were treated with EMR-C. Complete polyp removal was achieved in 68 (97.1 %), including 47 (67.1 %) with EMR-C alone. Overall, 66 polyps showed benign histology, and endoscopic follow-up after a median of 6 months (IQR 6-10) showed recurrence in 19.7 %. First (n = 10) and second (n = 2) benign recurrences were all treated endoscopically. Deep mural injury type III-V occurred in 7.4 % and was treated successfully with clips. CONCLUSION : EMR-C may be an alternative therapeutic option for removal of benign nonlifting polyp tissue. Although recurrence still occurs, repeat endoscopic therapy usually leads to complete polyp clearance.

Anchoring the snare tip is a feasible endoscopic mucosal resection method for small rectal neuroendocrine tumors

Small rectal neuroendocrine tumors (NETs) can be treated using cap-assisted endoscopic mucosal resection (EMR-C), which requires additional effort to apply a dedicated cap and snare. We aimed to evaluate the feasibility of a simpler modified endoscopic mucosal resection (EMR) technique, so-called anchored snare-tip EMR (ASEMR), for the treatment of small rectal NETs, comparing it with EMR-C. We retrospectively evaluated 45 ASEMR and 41 EMR-C procedures attempted on small suspected or established rectal NETs between July 2015 and May 2020. The mean (SD) lesion size was 5.4 (2.2) mm and 5.2 (1.7) mm in the ASEMR and EMR-C groups, respectively (p = 0.558). The en bloc resection rates of suspected or established rectal NETs were 95.6% (43/45) and 100%, respectively (p = 0.271). The rates of histologic complete resection of rectal NETs were 94.1% (32/34) and 88.2% (30/34), respectively (p = 0.673). The mean procedure time was significantly shorter in the ASEMR group than in the EMR-C group (3.12 [1.97] vs. 4.13 [1.59] min, p = 0.024). Delayed bleeding occurred in 6.7% (3/45) and 2.4% (1/41) of patients, respectively (p = 0.618). In conclusion, ASEMR was less time-consuming than EMR-C, and showed similar efficacy and safety profiles. ASEMR is a feasible treatment option for small rectal NETs.

Comparing long-term outcomes between endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for type II esophagogastric junction neoplasm

BackgroundEndoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are used to remove esophagogastric junction (EGJ) neoplasm. This study aimed to compare feasibility, safety, and effectiveness between ESD and EMR to help endoscopists choose treatment methods.MethodsA total of 130 patients with EGJ neoplasm underwent endoscopic resection, including 52 patients with EMR and 78 patients with ESD. Cap-assisted EMR (EMRC) was performed with typical sequences. Larger lesions required removal in multiple pieces (i.e., piecemeal EMR). The ESD procedures were included that marking the periphery of the lesion, submucosa injected, circumferentially cutting and submucosal dissection. Resection time, adverse events, en bloc resection rate, R0 resection rate and recurrence rate were compared between the two groups.ResultsThere were no significant differences in demographic characteristics or histopathological features between the two groups. Resection time was longer in the ESD group than in the EMR group (64.4±33.9 vs. 22.1±8.0 minutes; P<0.01). Adverse events were more common in the ESD group than in the EMR group (16.7% vs. 3.8%; P=0.03), including bleeding (7.7% vs. 3.8%), perforation (5.1% vs. 0%) and stenosis (5.1% vs. 0%). The en bloc resection rate and R0 resection rate were much higher in the ESD group than in the EMR group (98.7% and 92.3% vs. 23.1% and 23.1%, respectively; P<0.01). The 5-year overall survival rate and disease-free survival rate were 100% vs. 92.0% and 100% vs. 90.1% between the ESD and EMR groups, respectively (P=0.01 and P=0.01). The 5-year cancer-specific survival rate was 100% vs. 96.0% between the ESD and EMR groups (P=0.08). The recurrence rate was lower in the ESD group than in the EMR group (0% vs. 9.6%; P=0.01).ConclusionsESD is an acceptable first-line endoscopic treatment for type II EGJ neoplasm, however, it is time-consuming and has a higher rate of adverse events. Furthermore, EMR is a safe and alternative technique, particularly when EMR could achieve en bloc resection.

Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions.

Endoscopic mucosal resection (EMR) is a technique allowing efficacious and minimally invasive resection of precancerous lesions across the entire gastrointestinal tract. However, conventional EMR, involving injection of fluid into the submucosal space, is imperfect, given the high rate of recurrence of post-endoscopic resection adenoma, especially after piecemeal resection. In light of these observations, modifications of the technique have been proposed to overcome the weakness of conventional EMR. Some of them were designed to maximize the chance of en bloc resection—cap-assisted EMR, underwater EMR, tip-in EMR, precutting, assisted by ligation device—while others were designed to minimize the complications (cold EMR). In this review, we present their modes of action and summarize the evidence regarding their efficacy and safety.