Endoscopic Mucosal Resection Of Polyps Research Articles

WEO Newsletter.

WEO Newsletter.

Technique for fine adjustment of snare size during endoscopic mucosal resection by a single endoscopist.

Performing endoscopic mucosal resection for polyps located in the hepatic flexure is always challenging. The two most important reasons that make removing polyps in the hepatic flexure difficult are the instability of the position of the endoscope and the difficulty in advancing the endoscope’s accessories while in that bent angle. To overcome the instability of the endoscopic position, the left pinkie maneuver can be applied [1]. The cases shown here demonstrate that an “open-and-retract maneuver of the snare” could solve the approach problem ([Video 1]).

Is underwater endoscopic mucosal resection of colon polyps superior to conventional techniques? A network analysis of endoscopic mucosal resection and submucosal dissection.

Background and study aims Evidence from recent trials comparing conventional endoscopic mucosal resection (EMR) to underwater EMR (UEMR) have matured. However, studies comparing UEMR to endoscopic submucosal dissection (ESD) are lacking. Hence, we sought to conduct a comprehensive network meta-analysis to compare the efficacy of UEMR, ESD, and EMR. Methods Embase and Medline databases were searched from inception to December 2020 for articles comparing UEMR with EMR and ESD. Outcomes of interest included rates of en bloc and complete polyp resection, risk of perforation and bleeding, and local recurrence. A network meta-analysis comparing all three approaches was conducted. In addition, a conventional comparative meta-analysis comparing UEMR to EMR was performed. Analysis was stratified according to polyp sizes (< 10 mm, ≥ 10 mm, and ≥ 20 mm). Results Twenty-two articles were included in this study. For polyps ≥ 10 mm, UEMR was inferior to ESD in achieving en bloc resection ( P = 0.02). However, UEMR had shorter operating time for polyps ≥ 10 mm ( P < 0.001), and ≥20 mm ( P = 0.019) with reduced perforation risk for polyps ≥ 10 mm ( P = 0.05) compared to ESD. In addition, en bloc resection rates were similar between UEMR and EMR, although UEMR had reduced recurrence for polyps ≥ 10 mm ( P = 0.013) and ≥ 20 mm ( P = 0.014). UEMR also had shorter mean operating than EMR for polyps ≥ 10 mm ( P < 0.001) and ≥ 20 mm ( P < 0.001). Risk of bleeding and perforation with UEMR and EMR were similar for polyp of all sizes. Conclusions UEMR has demonstrated technical and oncological outcomes comparable to ESD and EMR, along with a desirable safety profile. UEMR appears to be a safe and effective alternative to conventional methods for resection of polyps ≥ 10 mm.

Endoscopic resection outcomes and predictors of failed en bloc endoscopic mucosal resection of colorectal polyps ≤ 20 mm among advanced endoscopy trainees.

Background and study aims En bloc endoscopic mucosal resection (EMR) is preferred over piecemeal resection for polyps ≤ 20 mm. Data on colorectal EMR training are limited. We aimed to evaluate the en bloc EMR rate of polyps ≤ 20 mm among advanced endoscopy trainees and to identify predictors of failed en bloc EMR. Methods This was a multicenter prospective study evaluating trainee performance in EMR during advanced endoscopy fellowship. A logistic regression model was used to identify the number of procedures and lesion cut-off size associated with an en bloc EMR rate of ≥ 80 %. Multivariate analysis was performed to identify predictors of failed en bloc EMR. Results Six trainees from six centers performed 189 colorectal EMRs, of which 104 (55 %) were for polyps ≤ 20 mm. Of these, 57.7 % (60/104) were resected en bloc. Trainees with ≥ 30 EMRs (OR 6.80; 95 % CI: 2.80–16.50; P = 0.00001) and lesions ≤ 17 mm (OR 4.56;95 CI:1.23–16.88; P = 0.02) were more likely to be associated with an en bloc EMR rate of ≥ 80 %. Independent predictors of failed en bloc EMR on multivariate analysis included: larger polyp size (OR:6.83;95 % CI:2.55–18.4; P = 0.0001), right colon location (OR:7.15; 95 % CI:1.31–38.9; P = 0.02), increased procedural difficulty (OR 2.99; 95 % CI:1.13–7.91; P = 0.03), and having performed < 30 EMRs (OR: 4.87; 95 %CI: 1.05–22.61; P = 0.04). Conclusions In this pilot study, we demonstrated that a relatively low proportion of trainees achieved en bloc EMR for polyps ≤ 20 mm and identified procedure volume and lesion size thresholds for successful en bloc EMR and independent predictors for failed en bloc resection. These preliminary results support the need for future efforts to define EMR procedure competence thresholds during training.

Two Types of Polyp Shape Observed in the Stomach of Patients with Peutz-Jeghers Syndrome.

The characteristics of gastric polyps in patients with Peutz-Jeghers (PJ) syndrome (PJS) have not been fully investigated. The objective of this study was to reveal the endoscopic and pathologic findings of gastric polyps in patients with PJS. We reviewed 11 patients with PJS treated at 6 institutions, and summarized the endo-scopic and pathologic features of their gastric polyps. The polyps were mainly classified into 2 types: (i) soli-tary or sporadic polyps > 5 mm, reddish in color with a sessile or semi-pedunculated morphology (n = 9); and (ii) multiple sessile polyps ≤ 5 mm with the same color tone as the peripheral mucosa (n = 9). Patients who underwent endoscopic mucosal resection for polyps > 5 mm were diagnosed with PJ polyps (n = 2), whereas those who underwent biopsy were diagnosed with hyperplastic polyps. Polyps ≤ 5 mm were pathologically diagnosed as fundic gland polyps or hyperplastic polyps. This study revealed that patients with PJS present with 2 types of polyps in the stomach. Endoscopic mucosal resection of polyps > 5 mm seems necessary for the pathologic diagnosis of PJ polyps.

Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review.

Background and study aims Cold snare endoscopic mucosal resection (EMR) is being increasingly utilized for non-pedunculated polyps ≥ 20 mm due to adverse events associated with use of cautery. Larger studies evaluating adenoma recurrence rate (ARR) and risk factors for recurrence following cold snare EMR of large polyps are lacking. The aim of this study was to define ARR for polyps ≥ 20 mm removed by cold snare EMR and to identify risk factors for recurrence. Patients and methods A retrospective chart review of colon cold snare EMR procedures performed between January 2015 and July 2019 at a tertiary care medical center was performed. During this period, 310 non-pedunculated polyps ≥ 20 mm were excised using cold snare EMR with follow-up surveillance colonoscopy. Patient demographic data as well as polyp characteristics at the time of index and surveillance colonoscopy were collected and analyzed. Results A total of 108 of 310 polyps (34.8 %) demonstrated adenoma recurrence at follow-up colonoscopy. Patients with a higher ARR were older ( P = 0.008), had endoscopic clips placed at index procedure ( P = 0.017), and were more likely to be Asian and African American ( P = 0.02). ARR was higher in larger polyps ( P < 0.001), tubulovillous adenomas ( P < 0.001), and polyps with high-grade dysplasia ( P = 0.003). Conclusions Although cold snare EMR remains a feasible alternative to hot snare polypectomy for resection of non-pedunculated polyps ≥ 20 mm, endoscopists must also carefully consider factors associated with increased ARR when utilizing this technique.

PWE-107 Short-Term Clinical Outcomes of Endoscopic Resection of Giant (&gt;3CMS) Colorectal Polyps: Could it Be A Safe Colon Sparing Therapeutic Option?

Introduction Modern endoscopic practice offers definitive management of colorectal polyps. However the role of this colon sparing minimally invasive modality is not clearly established in technically challenging “giant” polyps. Aim of this study was to evaluate the safety & short-term clinical outcomes of endoscopic resection of large colorectal polyps measuring 3 cm or more. Methods All patients with colorectal polyps measuring ≥3 cm who underwent endoscopic or surgical treatment in our hospital from 2009 to 2016 were included in the study. Patient demographics & clinical data were collected from endoscopic and hospital database. Results Over seven year period, 100 patients (median age: 72 years) were identified but complete data was available for 98 patients (25 right colon & 73 left colon). Median colorectal polyp size was 4.5 cm (range: 3–16 cm, & majority of polyps were in the rectum & sigmoid colon (69/98,69%) & predominantly sessile Paris type 1 s polyps. Four patients (4/98,4.1%) decided not to have treatment. Sixty-eight polyps (68/94,72.3%) were removed by endoscopic mucosal resection (EMR) or piece meal technique, of these fourteen patients (14/68,20.6%) needed more than one EMR session for the complete removal of the polyp. During follow-up, six patients (6/68,8.8%) who underwent previous EMR required additional surgical procedure in order to obtain complete polyp clearance. Following initial endoscopic assessment, surgical resection was deemed appropriate in twenty-six patients (26/94,26.5%) due to difficult location of the polyp & suspected/confirmed malignancy. Majority of the removed polyps were tubulovillous adenoma on histological confirmation. In the endoscopy group, twelve patients in endoscopy group (12/68,17.6%) had high-grade dysplasias (HGD) & four patients had invasive cancers (4/68,5.9%), of which two were considered cured & other two patients underwent further surgery. Among the surgical group seven (7/26,27%) & five (5/26,19%) patients had invasive cancer & HGD respectively. There were twelve procedure-related adverse events (12/68,17.6%) occurred in the endoscopy group, mainly occurred between 2008 & 2013 (eight minor bleeding requiring clips or additional cauterization). We have encountered only four complications between 2014 & 2016 (two minor & one major bleeding & one incidence of hypotension) despite performing more polypectomies. Outcome data for the surgical group was not available at present. Conclusion Colorectal EMR for polyps of ≥3 cm can be performed at experienced endoscopy centres with a low rate of major complications. This modality offers a safe non-surgical option in management of large colorectal lesions especially in the elderly patients. Disclosure of Interest None Declared

PTU-039 Outcome of endoscopic mucosal resection of 424 large sessile colonic polyps (≥20 mm) over a 9 year period: a single centre experience and analysis of change with time

Introduction Endoscopic mucosal resection (EMR) is now standard for resection of large sessile colonic polyps. We aimed to assess the clinical outcome of colonic EMR of polyps ≥2 cm size at a University Hospital and changes over a 9 year period. Method Data was collected for all sessile colonic polyps ≥20 mm removed by EMR between 2006 and 2014 by 3 endoscopists. Patient demographics, resection technique, completeness of initial resection, recurrence rate at first surveillance (SC1), polyp eradication at 2 nd surveillance after at least 1 year (SC2) and complication rates were analysed. Results 564 patients were assessed for EMR, 424 completed EMRs (BCSP138, Symptomatic286). Of the 140 not having complete EMR, 65 with no attempt at EMR were referred for surgery (cancer 31, technical difficulty 34).32 EMR was attempted but abandoned; all were referred for surgery (cancer 18, benign polyp 14). Finally, 43 had no intervention (13 declined, 22 non-adenomatous polyps, 8 moved away). Mean age 68.7 years (range 25–93), male 226 (53%), female 198 (47%). Mean polyp size 33 mm (median 30 mm). Polyp site right colon 27%, transverse 5%, left 68% (rectum 58%, sigmoid 4%, descending 6%). Piecemeal EMR 381 (90%),’en bloc’43 (10%). Those who have undergone surveillance, recurrence was found in 56/284 (19.7%) at initial SC1 (mean 7 month; range 2–36) and was endoscopically treated in 53/56 (94.6%); 3/56 (5.4%) referred for surgical resection (2 cancer, 1 non lifting). Complete eradication after one year SC2 (mean 16 months; range 5–51) 211/234 (90.2%) with recurrence in 23 (9.8%)–22/23 endoscopically resected. Overall complication rate 17/424 (4%):caecal perforation 1/424 (0.2%) and post polypectomy pain syndrome 14 (3.3%) all treated conservatively; delayed bleeding 2 (0.5%) required endoscopic therapy to achieve haemostasis. No deaths. For each 3 year period (2006–8, 2009–11, 2012–14), there was reduction in number of polyps not treated endoscopically or requiring surgery (overall decrease of 15.7%), incomplete EMR referred for surgical resection (overall decrease of 2.3%) and recurrence at first SC1(overall decrease 16.3%). There were increases in numbers of EMRs performed (overall increase 26%), mean polyp size resected (+7 mm), level 3 and 4 polypectomies (3.7 and 7%) and complete eradication rate at SC1 (16.3%). Conclusion This EMR series of 424 sessile colonic polyps >2 cm was performed by 3 operators over a 9 year period; 19.7% had recurrence at initial surveillance, most managed endoscopically, with eradication rate at 1 year of over 90% (22/23 one year recurrences treated endoscopically). Time trends showed progressive reduction in recurrence and a trend for larger, more complex polyps to be resected endoscopically, with a corresponding drop in surgical management, demonstrating improvement in outcome with time. Disclosure of interest None Declared.

PTH-054 Is Time Allocated For Colonoscopic Endoscopic Mucosal Resection Enough?

IntroductionColorectal cancer is the third commonest cancer in the United Kingdom with 35000 patients newly diagnosed per annum Evidence has shown that resection of adenomatous colonic polyps decreases the occurrence...

Endoscopic mucosal resection of 161 cases of large sessile or flat colorectal polyps

Objective. Large sessile or flat colorectal polyps, which are traditionally treated surgically, may be amenable to endoscopic mucosal resection (EMR), often using a piecemeal method. Appropriate selection of lesions and a careful technique may enhance the efficacy of EMR for polyps ≥20 mm in diameter without compromising safety. The aim of this study was to identify the factors that may be predictive of the risk of polyp recurrence. Material and methods. A retrospective analysis was conducted on the outcome of 161 polyps ≥20 mm in diameter, treated by piecemeal EMR at a single centre using the “lift and cut” technique. All records were reviewed for polyp size, site, morphology and histology. Polypectomy technique, patient follow-up, polyp recurrence and surgical interventions were also recorded. Results. Over an 8-year period, 161 colonic polyps measuring ≥20 mm were removed by EMR. Follow-up data were available for 149 cases (93%) with a mean polyp diameter of 32.5 mm; the total success rate of endoscopic polyp removal was 95.4%. The number of cases requiring 1, 2, 3, 4 and 6 attempts at EMR was 89 (60%), 36 (24%), 14 (9%), 2 (1.3%) and 1 (0.7%), respectively. Recurrence was significantly related to polyp size (p<0.001). There was no statistically significant relationship between site and recurrence. Seven patients (4.6%) underwent surgical intervention after EMR because of failed clearance. There were no post-EMR perforations and significant bleeding was reported in only two patients (1.7%). Conclusions. With careful attention to technique, piecemeal EMR is a safe option for the resection of most sessile and flat colorectal polyps ≥20 mm in size. A stricter follow-up may be required for larger lesions because of a higher risk of recurrence.