Hot Avulsion Research Articles

Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial.

Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed. Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months. From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition. Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.

Endoscopic submucosal dissection of a large sessile serrated lesion recurrence using an adaptive traction device.

Large serrated sessile lesions (SSLs) of the colon are challenging to resect completely because it is difficult to determine the margins. Therefore, recurrences are frequent and challenging to treat. For small recurrences (< 10 mm), there are a few possible resection strategies, such as underwater endoscopic mucosal resection (UEMR), endoscopic full-thickness resection (EFTR), and hot avulsion. There remains an ongoing debate as to the best way to remove larger recurrences when, because of the lesion size, EFTR risks incomplete removal (> 20 mm) or is impossible (> 30 mm) [1]. Hot avulsion usually requires several sessions to completely eradicate the recurrence. As a result, the only method for a complete single-session resection is dissection, but ESD in such lesions is challenging because of fibrosis and location (mostly in the right colon). Therefore, methods are needed to improve exposure and make dissection possible.

WEO Newsletter.

WEO Newsletter.

Need for adjunctive removal techniques for endoscopic mucosal resection of large non-pedunculated colonic polyps is predictive of recurrence

Abstract Background and study aims Endoscopic mucosal resection (EMR) allows for safe and effective removal of large non-pedunculated colon polyps, but recurrence remains a significant concern. Risk factors for recurrence have previously been reported, however, the significance of these factors have varied and has uncertain applicability with recent advances in EMR techniques. We aimed to evaluate rates and risk factors for recurrence in recent years from a major Canadian referral center. Patients and methods Consecutive patients between April 1, 2017 and March 1, 2019 who underwent piecemeal EMR were retrospectively identified. Patients with non-pedunculated colorectal polyps ≥ 2 cm removed by piecemeal EMR with available follow-up data were included. Results Five hundred and seventeen patients were reviewed, with 265 patients satisfying inclusion criteria. The median age was 67 years (IQR 14); 48 % were female. 15 % had a recurrence on follow-up endoscopy. Adjunctive removal techniques were utilized in 31 % of patients, 95 % of which was hot avulsion. The use of adjunctive removal techniques (OR 2.87, P = 0.004) and male gender (OR 3.31, P = 0.003) was significantly predictive of recurrence on multivariate analysis. Receiver operating curve characteristics demonstrated good performance of these factors in predicting recurrence (area under the curve = 0.70). Conclusions The use of adjunctive removal techniques, particularly hot avulsion and male gender are predictive of recurrence after piecemeal EMR of large non-pedunculated colorectal polyps. Male patients and those who require hot avulsion may be considered high risk for recurrence and warrant closer follow-up.

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.

ID: 3526465 HOT AVULSION FOR VISIBLE RESIDUAL NEOPLASIA AFTER EMR FOR LARGE POLYPS: OUTCOMES IN 265 CONSECUTIVE CASES

Hot avulsion (HA) uses a hot biopsy forceps with cutting current and mechanical traction of the entrapped tissue. Society guidelines recommend against using this device due to concern for transmural burn, perforation, and tissue destruction. We reintroduced this device (Andrawes S, GIE,2014) with different electrosurgical settings and mode of use, as a safe, efficient way to remove visible residual neoplasia. We retrospectively reviewed consecutive colonoscopies performed in a tertiary care center in which HA was used. Primary outcome was safety, with a secondary outcome being recurrence. Recurrence after resection of large colon polyps without adjunctive measures for occult residual neoplasia (e.g. snare tip soft coagulation, APC, cold forceps) is above 20%.

A61 USE OF ADJUNCTIVE REMOVAL TECHNIQUES FOR ENDOSCOPIC MUCOSAL RESECTION OF LARGE NON-PEDUNCULATED COLONIC POLYPS IS PREDICTIVE OF POLYP RECURRENCE

Abstract Background Endoscopic mucosal resection (EMR) allows for safe and effective removal of large non-pedunculated colon polyps. However, prior studies have shown significant recurrence rates between 10–30% after EMR, which have led to recommendations for close endoscopic follow-up and the use of techniques such as snare tip soft coagulation (STSC) to EMR margins to prevent recurrence. Models such as the Size/Morphology/Site/Access score (SMSA) have been developed to aid in identifying polyp complexity and patients at high risk of recurrence. Numerous individual risk factors for recurrence have previously been reported, however the significance of these factors have varied between studies, with limited data from Canadian centres. Aims To evaluate predictors of recurrence for large non-pedunculated polyps following EMR. Methods Consecutive patients between April 1, 2017 to March 1, 2019 who underwent EMR were retrospectively identified from endoscopy unit administrative records. Patients with non-pedunculated colorectal polyps ≥ 2 cm that were removed by EMR were included if follow-up endoscopy data were available. Polyps found to contain invasive adenocarcinoma on histology and/or were referred for surgical resection were excluded. Patient demographic, pre-procedural, intra-procedural, and post-procedural data to time of first follow-up colonoscopy were extracted. Recurrence was defined as a positive pathology specimen from the EMR scar at follow-up. Adjunctive techniques were defined as the use of any non-snare resection or ablation technique for removal of visible adenoma at the time of the EMR. Chi-square and multivariate regression analyses were conducted for variables of interest. Results 517 patients underwent large polyp EMR during the study time period with 265 patients satisfying inclusion criteria. Median age of patients was 67 years (IQR 14); 48% were female. STSC was performed to EMR margins in 94% of cases. 30.9% and 69.1% of polyps were SMSA grade 3 and grade 4 respectively. Adjunctive removal techniques were utilized in 31% of patients, 95% of which was hot avulsion. 15% of patients had recurrence on follow-up endoscopy. Higher SMSA grade was associated with the use of adjunctive techniques (20% vs. 37%, p=0.006). The use of adjunctive removal techniques (OR 2.92, p=0.007) and male gender (OR 3.45, p=0.002) were the only factors found to be significantly predictive of recurrence on multivariate analysis. Conclusions Male gender and the use of adjunctive removal techniques, particularly hot avulsion, are independently predictive of recurrence after EMR of large complex colorectal polyps. Male patients and those who require hot avulsion may be considered high risk for recurrence and warrant closer follow-up. Funding Agencies None

S3471 Hot Avulsion for the Resection of Dysplastic Adenoma in IBD

S3471 Hot Avulsion for the Resection of Dysplastic Adenoma in IBD

Mo1727 HOT AVULSION OF RESIDUAL VISIBLE NEOPLASIA IN LARGE LATERALLY SPREADING TUMORS RESULTS IN LOW RECURRENCE RATES WITHOUT THE NEED OF ABLATION OF THE MARGINS

EMR of large laterally spreading tumors (LSTs) results in recurrent or residual adenomas (RRAs) ranging from 15 to 30%.Attempts to reduce this rate include careful optical attention to residual visible neoplasia with additional resection with cold biopsy forceps, wide margin snare excision, or ablation with argon plasma coagulation (APC).Invisible residual neoplasia has been addressed with snare tip soft coagulation of the margins,extended marginal excision,and APC which results in decreased recurrences.We introduced hot avulsion as a means to excise parts of the polyp not amenable to snare resection due to adherence to the submucosa, difficulty in snare orientation, and inability to entrap neoplastic tissue. Hot avulsion steps includes:1)Using a hot biopsy forceps to grasp visible residual neoplastic tissue;2)Application of continuous traction effectively tenting the tissue away from the resection base (in order to minimize possible thermal injury);3)Delivering short bursts of a cutting current resulting in tissue shearing.This method is efficient and employs readily available inexpensive accessories, and addresses recurrences related to central areas of the polyp as well as marginal residual neoplasia. A retrospective review of our endoscopy database was performed(5/16-9/19).Inclusion criteria included: EMR of polyps >2cm,use of hot avulsion, and at least one follow up colonoscopy.All index procedures for polypectomy were performed by single expert endoscopist (GBH). LSTs considered endoscopically unresectable (with features of invasive carcinoma) were excluded. 254 LSTs were resected using EMR and avulsion, of which 118 LSTs in108 patients met follow up criteria to be included in the study.The average age was 64 years with 65 females(60%).Average LST size was36mm. Most polyps were resected in the ascending colon(33%).Histopathologic examination revealed 29% tubular adenoma (TA),29% sessile serrated adenoma (SSA), and20% tubulovillous adenoma (TVA). High-grade dysplasia (HGD) was found in17.7% of polyps and intramucosal adenocarcinoma in 2%. 9 patients had more than one qualifying polyp for resection with EMR and avulsion .Average time to first follow up colonoscopy was eight months (3-36 months). Optically visible RRAs were found in 5 patients(4%)with repeat resection histology revealing TA(3), TVA(1)and SSA(1). Initial histopathology of patients with RRA included 2 TVA with HGD,1 TVA,1 TA, and 1 TA with HGD.Post-polypectomy biopsy of scar was performed in 100 out of the 118 cases. Hot avulsion as an adjunct to endoscopic mucosal resection results in very low recurrence rates equivalent to the lowest rates achieved with other more laborious adjunctive therapies. Moreover the strength of this study is the high rate of histologic interrogation of the scar(85%) not performed in most studies of recurrence.Adverse Events, Follow-up Colonoscopies and Recurrence Lesion CharacteristicsView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mo1293 FACTORS ASSOCIATED WITH LACK OF COMPLETE REMISSION OF INTESTINAL METAPLASIA IN PATIENTS WITH BARRETT’S ESOPHAGUS ASSOCIATED HIGH GRADE DYSPLASIA AND INTRAMUCOSAL CANCER

Barrett’s esophagus (BE) is a well-established precursor of esophageal adenocarcinoma (EAC), which is associated with significant morbidity and mortality. Endoscopic therapy is the current preferred treatment modality for BE-associate high-grade dysplasia (HGD) and intramucosal cancer (IMC). However, little is known about the long-term efficacy of endoscopic therapy for the complete remission of intestinal metaplasia (CRIM), and its relationship with patient-oriented outcomes. The primary aim was to identify independent predictors of failure of CRIM in patients with BE associated HGD and IMC. The secondary aim was to compare adverse events associated with endoscopy therapy. Retrospective cohort study from a prospectively collected database of consecutive adult patients with BE and associated HGD and/or IMC that underwent an upper endoscopy between 2008 and 2018 in a tertiary care center in Canada. Patients that were treated with surgery, chemotherapy, radiotherapy or those without at least one year of follow-up were excluded. Patients’ characteristics were compared using chi-squared or Fisher exact tests for proportions. A multivariable logistic regression model was built to identify independent predictors of lack of CRIM. Of 328 patients with BE, 28% were diagnosed with HGD and 72% with IMC during the study period; 77% were male; mean age 65. Median follow up was 34 (range 12-117) months. Treatment for BE consisted of radiofrequency ablation (RFA), endoscopic mucosal resection (EMR) or hot avulsion (HA). The overall rate of CRIM was 63%; 67% for HGD and 61% for IMC. The median time to achieve CRIM was 20 (range 1-82) months. Rates of CRIM were 82% for younger (≤ 65 years) compared to 52% for older (> 65 years) patients, 59% for those with, and 92% for those without, a hiatal hernia (p<0.001), 78% for short-segment BE vs. 39% for long-segment BE (LSBE) (p<0.001). Patients with diabetes mellitus (p=0.0035) or hypertension (p=0.0016) were also less likely to achieve CRIM; sex, body mass index, smoking history, and dyslipidemia were not associated with CRIM. In multivariate analysis, the factors that remain associated with failure to achieve CRIM were older age (OR 2.26; 95% CI:1.22-4.30), hiatal hernia (OR 4.90; 95% CI:1.61-21.40) and LSBE (OR 3.78; 95% CI:2.21-6.58). Overall incidence of adverse events (predominantly strictures requiring dilation) was 42%; 35% for HGD and 46% for IMC, which was more frequent in the CRIM (48%) compared to the non-CRIM groups (35%) (p=0.029). Older patients, those with a hiatal hernia, and LSBE are predictors of failure to achieve CRIM with endoscopic therapy. These patients may need more aggressive treatment in order to achieve CRIM, but potentially at a cost of an increased rate of esophageal strictures.

Su1072 ENDOSCOPIC MANAGEMENT OF RESIDUAL OR RECURRENT NEOPLASIA FOLLOWING PIECEMEAL ENDOSCOPIC MUCOSAL RESECTION IS EFFICACIOUS.

Endoscopic mucosal resection (EMR) is the primary treatment method for complex colon polyps. Current guidelines recommend surveillance colonoscopy at 6 months following piecemeal EMR due to residual or recurrent neoplasia (RN) rate of up to 15%. There is limited data on management outcomes when RN occurs. The primary aim of this study was to evaluate the efficacy of endoscopic management of RN following EMR. We conducted a retrospective cohort study of patients who had RN on surveillance colonoscopy following EMR of a large colon polyp by 3 gastroenterologists with EMR expertise at a single center between 2010 and June 2019. The primary outcome was successful resolution of the RN, defined as at least one surveillance colonoscopy without neoplasia seen at the EMR site. Among 483 polyps resected in 407 patients, RN was identified on first surveillance colonoscopy (SC1) in 59 cases (12.2%). Four cases of RN were not felt amenable to endoscopic resection and referred to surgery. Endoscopic resection was performed in the remaining 55 cases (Table). The majority (91%) of RN had visibly abnormal tissue at the prior EMR site; only 9% had RN diagnosed on biopsy of an apparently normal scar. Resection was performed utilizing a variety of techniques: underwater EMR (12.7%), hot EMR (36.4%), cold EMR (5.5%), snare resection (16.4%), and cold forceps (29.1%), respectively. Adjunctive therapies were used in 45.5% of resections, with APC in 30.9%, cold forceps in 20.0%, hot avulsion in 7.3%, and soft coagulation in 3.6% of cases. Additional follow up surveillance colonoscopy data until RN was resolved was available for 44 cases. One patient had intramucosal adenocarcinoma within RN pathology on their second surveillance colonoscopy (SC2) and was referred for surgical management. The majority (70.5%) had no RN at SC2, while 27.3% required additional endoscopic treatment of RN with subsequent resolution on further surveillance colonoscopy (Figure). In total, 89.6% of patients with RN were confirmed to have been successfully treated. Among the 472 polyps resected with EMR with sufficient follow up, endoscopic treatment of the polyp was successful in 98.9% of cases. Although recurrent or residual neoplasia is common after piecemeal polypectomy, it is adequately treated in nearly all patients. Use of multiple resection modalities may be necessary for successful treatment based on our observations. Thus, concerns for RN should not significantly impact decision to perform EMR for colorectal polyps.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A novel non-thermal resection tool in endoscopic management of scarred polyps.

Background and study aims Scarred polyps are challenging to resect using conventional endoscopic mucosal resection (EMR) techniques. The aim of this pilot study was to assess the feasibility of the EndoRotor device in resecting scarred polyps arising from previous endoscopic resection attempts. Patients and methods This was a prospective pilot study of patients with scarred colonic polyps treated using EndoRotor carried out in two centers. Results A total of 19 patients were included in this study. The overall cure rate using EndoRotor was 84 %; 10 patients (52.6 %) achieved cure after one attempt and six patients (31.5 %) achieved cure after two attempts. A total of three patients who had polyp recurrence after the first EndoRotor resection were referred for either endoscopic submucosal dissection (2 patients) or surgery (1 patient) due to difficult access. There were no perforations, delayed bleeding, post-polypectomy syndrome or complications requiring surgery. Conclusions In this pilot study, the novel non-thermal device (EndoRotor) has been demonstrated to be a safe and effective technique in challenging management of scarred polyps. Further randomized controlled trials comparing this technique with APC, hot avulsion, ESD and endoscopic full-thickness resection are required to ascertain the utility of EndoRotor in the hands of non-expert endoscopists.

Hot Avulsion in Colorectal Endoscopic Mucosal Resection

One of the fundamental principles of effective colorectal endoscopic mucosal resection (EMR) is to resect all visible neoplastic tissue. However, some

Safety and efficacy of hot avulsion as an adjunct to EMR (with videos)

Excision of all visible neoplastic tissue is the goal of EMR of colorectal laterally spreading tumors. Flat and fibrotic tissue can resist snaring. Ablation of visible polyps is associated with high recurrence rates. Avulsion is a technique to continue resection when snaring fails. We retrospectively analyzed colonic EMRs of 564 consecutive referred polyps between 2015 and 2017. Hot avulsion was used when snaring was unsuccessful. Polyps treated with and without avulsion were compared. Hot avulsion was used in 20.9% (n= 112) of all resected lesions. The recurrence rates on follow-up colonoscopy were 17.52% in the avulsion group versus 16.02% in the non-avulsion group (P= .76). Hot avulsion was associated with a trend toward higher rates of delayed hemorrhage (5.35% vs 2.58%; P= .15) and post-coagulation syndrome (1.8% vs 0.47%; P= .15), but polyps treated with any avulsion were larger than those in which no avulsion was used (P< .001). There were an insufficient number of adverse events to perform a multivariable analysis to test the effects of avulsion, size, and location on the risk of overall adverse events. Unlike previous reports of using argon plasma coagulation to treat visible polyps during EMR, hotavulsion of visible/fibrotic neoplasia was associated with similar EMR efficacy compared with cases that did not require hot avulsion. The safety profile of hot avulsion appears acceptable.

French comment on article Hot avulsion may be effective as salvage treatment for focal Barrett's esophagus remaining after endoscopic therapy for dysplasia or early cancer: a preliminary study

French comment on article Hot avulsion may be effective as salvage treatment for focal Barrett's esophagus remaining after endoscopic therapy for dysplasia or early cancer: a preliminary study

Hot avulsion may be effective as salvage treatment for focal Barrett’s esophagus remaining after endoscopic therapy for dysplasia or early cancer: a preliminary study

Both endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are used to treat Barrett's esophagus (BE) complicated by dysplasia and intramucosal cancer. However, focal areas of BE can remain after otherwise successful application of these techniques. We report the results of hot avulsion using a hot biopsy forceps to resect these residual focal areas. This was a retrospective study from a prospective database in a tertiary reference center from August 2013 to May 2015. All included patients had undergone hot avulsion for eradication of residual focal areas of BE that were ≤ 1 cm and not suspicious for dysplasia, following at least one previous endoscopic treatment for dysplasia or intramucosal cancer. 35 patients harboring 124 residual areas of 1 - 7 mm were treated with hot avulsion. After a mean follow-up of 17.4 months, all patients achieved complete eradication of residual focal BE. One of the patients required a second hot avulsion treatment. Hot avulsion provided samples in all cases but limited the assessment of dysplasia (cautery artifact) in 20.2 % of them. The only complication was bleeding in two patients, which was easily stopped by soft coagulation. Hot avulsion appears to be effective and safe in removing focal BE ≤ 1 cm at its greatest length remaining after endoscopic treatment for dysplasia or early cancer. Further studies are required before this technique can be considered the standard of care.

Tu1573 Hot Avulsion Provides a Second Chance At Completing Barrett's Eradication

The complete eradication of metaplastic columnar mucosa is recommended for patients who have had dysplasia in the context of Barrett's esophagus (BE). Hot avulsion (HA) technique has been already described for difficult or remnant colonic polyp resection but not in BE.

Hot avulsion: a modification of an existing technique for management of nonlifting areas of a polyp (with video)

Endoscopic management of the nonlifting areas of a colonic polyp is a significant challenge. The traditional approach has been to use ablative techniques with mixed long-term results. To evaluate the safety and efficacy of hot avulsion (HA), a modification in the use of hot biopsy forceps in the management of the nonlifting areas of a colonic polyp. Retrospective review of data from a prospectively maintained colonic Endoscopic Mucosal Resection database. Tertiary referral hospital. Twenty patients in whom HA was used as part of the polypectomy technique. Location and size of polyp, reasons for nonlifting, immediate success, residual rates, and adverse events. In our 20 patients studied, the main reasons for nonlifting were scarring from previous EMR attempts in 55% and scarring from previous biopsy in 35%. Mean size of avulsion was 4.4 mm (range, 1-15 mm). At the index procedure, HA was successful in removing macroscopic adenomatous tissue in all patients. At follow-up examinations, 85% (17/20) had no macroscopic or microscopic neoplasia residual and 15% (3/20) had a small area of residual that was easily treated with repeat HA. There were no immediate or long-term adverse events. Nonrandomized, single-center experience. HA appears to be a safe and effective adjunct treatment to snare polypectomy for nonlifting areas of a colonic polyp. Further randomized multicenter studies are required with direct comparison to established techniques.

Tu1436 Hot Avulsion: a New Technique for the Non Lifting Polyp

Endoscopic management of non-lifting polyps poses a significant challenge. Traditionally laser and more recently argon plasma coagulation (APC) have been used with disappointing long term results. We describe our experience with a new hot avulsion (HA) technique for treatment of these polyps.