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Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, Paspatis GA, Moss A, Libânio D, Lorenzo-Zúñiga V, Voiosu AM, Rutter MD, Pellisé M, Moons LMG, Probst A, Awadie H, Amato A, Takeuchi Y, Repici A, Rahmi G, Koecklin HU, Albéniz E, Rockenbauer LM, Waldmann E, Messmann H, Triantafyllou K, Jover R, Gralnek IM, Dekker E, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024. [PMID: 38670139 DOI: 10.1055/a-2304-3219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
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Affiliation(s)
- Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Gastroenterology, Evangelical Hospital, Vienna, Austria
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Mauro Risio
- Department of Pathology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy
| | - Gregorios A Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Vincente Lorenzo-Zúñiga
- Endoscopy Unit, La Fe University and Polytechnic Hospital / IISLaFe, Valencia, Spain
- Department of Medicine, Catholic University of Valencia, Valencia, Spain
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthew D Rutter
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
- Department of Gastroenterology, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Leon M G Moons
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, Ospedale A. Manzoni, Lecco, Italy
| | - Yoji Takeuchi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Gabriel Rahmi
- Hepatogastroenterology and Endoscopy Department, Hôpital européen Georges Pompidou, Paris, France
- Laboratoire de Recherches Biochirurgicales, APHP-Centre Université de Paris, Paris, France
| | - Hugo U Koecklin
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Teknon Medical Center, Barcelona, Spain
| | - Eduardo Albéniz
- Gastroenterology Department, Hospital Universitario de Navarra (HUN); Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lisa-Maria Rockenbauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Helmut Messmann
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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Wang X, Wang Y, Cao X, Zhang C, Miao L. Underwater versus conventional endoscopic mucosal resection for ≥10 mm sessile or flat colorectal polyps: A systematic review and meta-analysis. PLoS One 2024; 19:e0299931. [PMID: 38451998 PMCID: PMC10919657 DOI: 10.1371/journal.pone.0299931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND AND AIM Underwater endoscopic mucosal resection (UEMR) has been an emerging substitute for conventional EMR (CEMR). This systematic review and meta-analysis aimed at comparing the efficiency and safety of the two techniques for removing ≥10 mm sessile or flat colorectal polyps. METHODS PubMed, Cochrane Library and Embase databases were searched up to February 2023 to identify eligible studies that compared the outcomes of UEMR and CEMR. This meta-analysis was conducted on the en bloc resection rate, R0 resection rate, complete resection rate, procedure time, adverse events rate and recurrence rate. RESULTS Nine studies involving 1,727 colorectal polyps were included: 881 were removed by UEMR, and 846 were removed by CEMR. UEMR was associated with a significant increase in en bloc resection rate [Odds ratio(OR) 1.69, 95% confidence interval(CI) 1.36-2.10, p<0.00001, I2 = 33%], R0 resection rate(OR 1.52, 95%CI 1.14-2.03, p = 0.004, I2 = 31%) and complete resection rate(OR 1.67, 95%CI 1.06-2.62, p = 0.03, I2 = 0%) as well as a significant reduction in procedure time(MD ‒4.27, 95%CI ‒7.41 to ‒1.13, p = 0.008, I2 = 90%) and recurrence rate(OR 0.52, 95%CI 0.33-0.83, p = 0.006, I2 = 6%). Both techniques were comparable in adverse events rate. CONCLUSION UEMR can be a safe and efficient substitute for CEMR in removing ≥10 mm sessile or flat colorectal polyps. More studies verifying the advantages of UEMR over CEMR are needed to promote its application.
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Affiliation(s)
- Xue Wang
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yue Wang
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xueyan Cao
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chunmei Zhang
- Emergency Department, Luzhou People’s Hospital, Luzhou, Sichuan, China
| | - Lin Miao
- Medical Centre for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Abuelazm M, Awad AK, Mohamed I, Mahmoud A, Shaikhkhalil H, Shaheen N, Abdelwahab O, Afifi AM, Abdelazeem B, Othman MO. Cold polypectomy techniques for small and diminutive colorectal polyps: a systematic review and network meta-analysis of randomized controlled trials. Curr Med Res Opin 2023; 39:1329-1339. [PMID: 37735986 DOI: 10.1080/03007995.2023.2262374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/20/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE In the management of small and diminutive polyps, cold polypectomy is favored over electrocautery polypectomy. However, the optimal cold polypectomy technique is still controversial. Hence, this review aims to investigate the most effective cold technique for small and diminutive colorectal polyps. METHODS We conducted a systematic review and network meta-analysis synthesizing randomized controlled trials (RCTs) which were retrieved by systematically searching PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through 10 February 2023. R software, (R version 4.2.0) and meta-insight software were used to pool dichotomous outcomes using risk ratio (RR) presented with the corresponding confidence interval (CI). Our protocol was prospectively published in PROSPERO with ID: CRD42022345619. RESULTS Nineteen RCTs with 3649 patients and 4800 polyps were included in our analysis. Cold techniques (cold forceps polypectomy (CFP), jumbo forceps polypectomy (JFP), dedicated cold snare polypectomy (D-CSP), conventional cold snare polypectomy (C-CSP), underwater cold snare polypectomy (U-CSP), and cold snare endoscopic mucosal resection (CS-EMR) were included in our comparative analysis. CFP was less effective in achieving complete histological resection than C-CSP (RR: 1.10 with 95% CI [1.03-1.18]), CS-EMR (RR: 1.12 with 95% CI [1.02-1.23]), D-CSP (RR: 1.17 with 95% CI [1.04-1.32]), and U-CSP (RR: 1.21 with 95% CI [1.07-1.38]). However, the rest of the comparisons showed no difference. CONCLUSION CFP is the least effective method for small and diminutive polyps' removal, and any snare polypectomy technique will achieve better results, warranting more large-scale RCTs to investigate the most effective snare polypectomy technique.
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Affiliation(s)
| | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Islam Mohamed
- Department of Medicine, University of Missouri, Kansas City, MO, USA
| | | | | | - Nour Shaheen
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Ahmed M Afifi
- Department of Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, TX, USA
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Chowdhury AR, Kim JS, Xu M, Tom C, Narala R, Kong N, Lee H, Vazquez A, Sahakian A, Phan J, Buxbaum J. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: An updated meta-analysis of randomized controlled trials. Endosc Int Open 2023; 11:E935-E942. [PMID: 37818454 PMCID: PMC10562051 DOI: 10.1055/a-2150-9899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/12/2023] Open
Abstract
Background and study aims Colorectal malignancy is a leading cause of death. Conventional endoscopic mucosal resection (CEMR) is a strategy used to resect precancerous lesions that involves injecting fluid beneath a polyp to create a gap for resection. Underwater endoscopic mucosal resection (UEMR) is a newer method that forgoes injection, instead filling the intestinal cavity with water to facilitate polyp resection. Our aim was to compare the safety and efficacy of these approaches by synthesizing the most contemporary evidence. Methods PubMed, Embase, and Cochrane libraries were searched from inception through November 11, 2022 for randomized controlled trials (RCTs) comparing UEMR and CEMR for resection of colorectal lesions. The primary outcome was the rate of en bloc resection and secondary outcomes included recurrence, procedure time, and adverse events (AEs). Results A total of 2539 studies were identified through our systematic literature search. After screening, seven RCTs with a total of 1581 polyps were included. UEMR was associated with significantly increased rates of en bloc resection (RR 1.18 [1.03, 1.35]; I 2 = 76.6%) versus conventional approaches. No significant differences were found in procedure time, recurrence, or AEs. Conclusions UEMR is a promising effective technique for removal of colorectal lesions. The most contemporary literature indicates that it improves en bloc resection rate without increasing procedure time, recurrence, or AEs (PROSPERO ID CRD42022374935).
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Affiliation(s)
- Aneesa Rahman Chowdhury
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Jin Sun Kim
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Mimi Xu
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Chloe Tom
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Rachan Narala
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Niwen Kong
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Helen Lee
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Alejandro Vazquez
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Ara Sahakian
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - Jennifer Phan
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
| | - James Buxbaum
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, United States
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Chandan S, Bapaye J, Khan SR, Mohan BP, Ramai D, Dahiya DS, Bilal M, Draganov PV, Othman MO, Rodriguez Sánchez J, Kochhar GS. Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs. Endosc Int Open 2023; 11:E768-E777. [PMID: 37593155 PMCID: PMC10431976 DOI: 10.1055/a-2117-8327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/20/2023] [Indexed: 08/19/2023] Open
Abstract
Background and study aims Conventional endoscopic mucosal resection (C-EMR) is limited by low en-bloc resection rates, especially for large (> 20 mm) lesions. Underwater EMR (U-EMR) has emerged as an alternative for colorectal polyps and is being shown to improve en-bloc resection rates. We conducted a systematic review and meta-analysis comparing the two techniques. Methods Multiple databases were searched through November 2022 for randomized controlled trials (RCTs) comparing outcomes of U-EMR and C-EMR for colorectal polyps. Meta-analysis was performed to determine pooled proportions and relative risks (RRs) of R0 and en-bloc resection, polyp recurrence, resection time, and adverse events. Results Seven RCTs with 1458 patients (U-EMR: 739, C-EMR: 719) were included. The pooled rate of en-bloc resection was significantly higher with U-EMR vs C-EMR, 70.17% (confidence interval [CI] 46.68-86.34) vs 58.14% (CI 31.59-80.68), respectively, RR 1.21 (CI 1.01-1.44). R0 resection rates were higher with U-EMR vs C-EMR, 58.1% (CI 29.75-81.9) vs 44.6% (CI 17.4-75.4), RR 1.25 (CI 0.99-1.6). For large polyps (> 20 mm), en-bloc resection rates were comparable between the two techniques, RR 1.24 (CI 0.83-1.84). Resection times were comparable between U-EMR and C-EMR, standardized mean difference -1.21 min (CI -2.57 to -0.16). Overall pooled rates of perforation, and immediate and delayed bleeding were comparable between U-EMR and C-EMR. Pooled rate of polyp recurrence at surveillance colonoscopy was significantly lower with U-EMR than with C-EMR, RR 0.62 (CI 0.41-0.94). Conclusions Colorectal U-EMR results in higher en-bloc resection and lower recurrence rates when compared to C-EMR. Both techniques have comparable resection times and safety profiles.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology & Hepatology, Creighton University School of Medicine, Omaha, NE, United States, Omaha, United States
| | - Jay Bapaye
- Department of Medicine, Rochester General Health System, Rochester, NY, United States, Rochester, United States
| | - Shahab R. Khan
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States, Boston, United States
| | - Babu P. Mohan
- Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States
| | - Dushyant S. Dahiya
- Department of Medicine, Central Michigan University, Mount Pleasant, MI, United States, Saginaw, United States
| | - Mohammad Bilal
- Department of Gastroenterology, Minneapolis VA Health Care System, Minneapolis, MN, United States, Minneapolis, United States
| | - Peter V. Draganov
- Department of Gastroenterology, University of Florida, Gainesville, FL, United States, Gainesville, United States
| | - Mohamed O. Othman
- Department of Gastroenterology, Baylor College of Medicine, Houston, TX, United States, Houston, United States
| | - Joaquin Rodriguez Sánchez
- Endoscopy Unite, Hospital Universitario 12 de Octubre, Madrid, Comunidad de Madrid, Spain, Ciudad Real, Spain
| | - Gursimran S. Kochhar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, United States, Pittsburgh, United States
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Capogreco A, Alfarone L, Massimi D, Repici A. Cold resection for colorectal polyps: where we are and where we are going? Expert Rev Gastroenterol Hepatol 2023; 17:719-730. [PMID: 37318101 DOI: 10.1080/17474124.2023.2223976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Endoscopic resection of colonic precancerous lesions has been demonstrated to significantly decrease colorectal cancer (CRC) incidence and mortality. Among resection techniques, cold snare polypectomy (CSP) has been shown as a highly feasible, effective and safe option and is widely used in clinical practice, being regarded as the first-line technique for removal of small and diminutive colorectal polyps. On the other hand, conventional hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR), namely the gold standard treatments for larger polyps, may be occasionally associated to complications due to electrocautery injury. AREAS COVERED To overcome these shortcomings of electrocautery-based resection techniques, in the last few years CSP has been increasingly assessed as a treatment option for additional indications, with a focus on nonpedunculated colorectal polyps ≥10 mm. EXPERT OPINION This review aims to present current and widened indications of CSP discussing the latest findings from the most remarkable studies, with an insight into technical issues, novelties and potential advances in the near future.
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Affiliation(s)
- Antonio Capogreco
- Department of Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Ludovico Alfarone
- Department of Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of biomedical scienses, Humanitas University, Milan, Italy
| | - Davide Massimi
- Department of Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Alessandro Repici
- Department of biomedical scienses, Humanitas University, Milan, Italy
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Rodríguez Sánchez J, Alvarez-Gonzalez MA, Pellisé M, Coto-Ugarte D, Uchima H, Aranda-Hernández J, Santiago García J, Marín-Gabriel JC, Riu Pons F, Nogales O, Carreño Macian R, Herreros-de-Tejada A, Hernández L, Patrón GO, Rodriguez-Tellez M, Redondo-Cerezo E, Sánchez Alonso M, Daca M, Valdivielso-Cortazar E, Álvarez Delgado A, Enguita M, Montori S, Albéniz E. Underwater versus conventional EMR of large nonpedunculated colorectal lesions: a multicenter randomized controlled trial. Gastrointest Endosc 2023; 97:941-951.e2. [PMID: 36572129 DOI: 10.1016/j.gie.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Underwater EMR (UEMR) is an alternative procedure to conventional EMR (CEMR) to treat large, nonpedunculated colorectal lesions (LNPCLs). In this multicenter, randomized controlled clinical trial, we aimed to compare the efficacy and safety of UEMR versus CEMR on LNPCLs. METHODS We conducted a multicenter, randomized controlled clinical trial from February 2018 to February 2020 in 11 hospitals in Spain. A total of 298 patients (311 lesions) were randomized to the UEMR (n = 149) and CEMR (n = 162) groups. The main outcome was the lesion recurrence rate in at least 1 follow-up colonoscopy. Secondary outcomes included technical aspects, en bloc resection rate, R0 resection rates, and adverse events, among others. RESULTS There were no differences in the overall recurrence rate (9.5% UEMR vs 11.7% CEMR; absolute risk difference, -2.2%; 95% CI, -9.4 to 4.9). However, considering polyp sizes between 20 and 30 mm, the recurrence rate was lower for UEMR (3.4% UEMR vs 13.1% CEMR; absolute risk difference, -9.7%; 95% CI, -19.4 to 0). The R0 resection showed the same tendency, with significant differences favoring UEMR only for polyps between 20 and 30 mm. Overall, UEMR was faster and easier to perform than CEMR. Importantly, the techniques were equally safe. CONCLUSIONS UEMR is a valid alternative to CEMR for treating LNPCLs and could be considered the first option of treatment for lesions between 20 and 30 mm due to its higher en bloc and R0 resection rates. (Clinical trial registration number: NCT03567746.).
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Affiliation(s)
- Joaquín Rodríguez Sánchez
- Endoscopy Unit, Hospital Universitario 12 de Octubre de Madrid, Madrid, Spain; Hospital General Universitario de Ciudad Real, Ciudad Real, Spain.
| | - Marco A Alvarez-Gonzalez
- Department of Digestive Diseases, Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - María Pellisé
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - David Coto-Ugarte
- Cruces University Hospital Endoscopy Unit Barakaldo, Basque Country, Spain
| | - Hugo Uchima
- Endoscopy Unit, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Javier Aranda-Hernández
- Endoscopy Unit, Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Santiago García
- Gastroenterology Department, Research Institute Segovia de Arana, Puerta de Hierro University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - José Carlos Marín-Gabriel
- Endoscopy Unit, Gastroenterology Department, "i+12 Research Institute," Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Fausto Riu Pons
- Gastroenterology Department, Endoscopy Unit, Hospital del Mar, Parc de Salut Mar, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Oscar Nogales
- Endoscopy Unit, Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Alberto Herreros-de-Tejada
- Gastroenterology Department, Research Institute Segovia de Arana, Puerta de Hierro University Hospital, Autonomous University of Madrid, Madrid, Spain
| | | | - G Oliver Patrón
- Hospital Manacor and Hospital Parque Llevant, Palma de Mallorca, Spain
| | | | - Eduardo Redondo-Cerezo
- Endoscopy Unit, Department of Gastroenterology and Hepatology, "Virgen de Las Nieves" University Hospital, Granada, Spain
| | | | - Maria Daca
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Mónica Enguita
- Methodology Unit,. Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra (HUN), Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain.
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8
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Sundaram S, Seth V, Jearth V, Giri S. Underwater versus conventional endoscopic mucosal resection for sessile colorectal polyps: an updated systematic review and meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:225-233. [PMID: 36148677 DOI: 10.17235/reed.2022.8956/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND underwater endoscopic mucosal resection (uEMR) without submucosal injection for sessile colorectal polyps was introduced as a new replacement for conventional EMR (cEMR). However, the optimal resection strategy remains a topic of debate. Hence, this meta-analysis was performed to compare the efficacy and safety of uEMR and cEMR in patients with sessile colorectal polyps. METHODS a comprehensive search of the literature from 2000 till January 2022 was performed from Medline, CENTRAL and Embase for randomized controlled trials (RCTs) comparing cEMR vs uEMR for colorectal polyps. The evaluated outcomes included en bloc resection, R0 resection, procedure time, overall bleeding and recurrence. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a random effect model. RESULTS six studies were included, out of which four were full-text articles and two were conference abstracts. En bloc resection (RR 1.26, 95 % CI: 1.00-1.60), R0 resection (RR 1.10, 95 % CI: 0.96-1.26), overall bleeding (RR 0.85, 95 % CI: 0.54-1.34) and recurrence rate (RR 0.75, 95 % CI: 0.45-1.27) were comparable between uEMR and cEMR. However, uEMR was associated with a shorter procedure time (mean difference [MD] -1.55 minutes, 95 % CI: -2.71 to -0.39). According to the subgroup analysis, uEMR led to a higher rate of en bloc resection (RR 1.41, 95 % CI: 1.07-1.86) and R0 resection (RR 1.19, 95 % CI: 1.01-1.41) for polyps ≥ 10 mm in size. CONCLUSION both uEMR and cEMR have a comparable safety and efficacy. For polyps larger than 10 mm, uEMR may have an advantage over cEMR and should be the topic for future studies.
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Affiliation(s)
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research
| | - Suprabhat Giri
- Gastroenterology, Nizam's Institute of Medical Sciences, India
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9
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Ashizawa H, Hotta K, Imai K, Ito S, Kishida Y, Takada K, Okumura T, Kawata N, Yoshida M, Maeda Y, Yamamoto Y, Minamide T, Sato J, Ishiwatari H, Matsubayashi H, Ono H. Efficacy and Safety of Gel Immersion Endoscopic Mucosal Resection for Non-Pedunculated Colorectal Polyps. Life (Basel) 2023; 13:life13030711. [PMID: 36983866 PMCID: PMC10051202 DOI: 10.3390/life13030711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/31/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Underwater endoscopic mucosal resection (UEMR) has become a popular endoscopic resection method for large colorectal neoplasms. However, visualization can be poor during UEMR due to the presence of intestinal fluid. Gel immersion endoscopic mucosal resection (GIEMR), using a specially developed gel (Viscoclear®, Otsuka Pharmaceutical Factory, Tokushima, Japan), can improve the visual field. However, reports of GIEMR for colorectal polyps are limited. Herein, we evaluated the short-term outcomes of GIEMR for non-pedunculated colorectal neoplasms (NPCRN). This single-center, retrospective, and observational study includes 25 lesions in 20 patients with NPCRN who underwent GIEMR between January and October 2022. The short-term outcomes and adverse events were evaluated. The lesion locations were as follows: right colon, 18 lesions; left colon, 7 lesions; and rectum, none. The median tumor diameter was 15 (IQR, 10–18) mm. Histological classification was as follows: sessile serrated lesion, 9 cases; adenoma, 12 cases; and intramucosal adenocarcinoma, 4 cases. The overall en bloc resection rates and R0 resection rates were 80% (20/25) and 72% (18/25). For NPCRN in 10–19 mm, the en bloc resection rate was 75% (12/16), with an R0 resection rate of 69% (11/16). No post-polypectomy bleeding, perforation, or post-coagulation syndrome were observed. The findings of our study provide preliminary evidence of the efficacy and safety of GIEMR for NPCRN. Therefore, GIEMR may be a promising novel endoscopic resection method for NPCRN.
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Affiliation(s)
| | - Kinichi Hotta
- Correspondence: ; Tel.: +81-55-989-5222; Fax: +81-55-989-5783
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10
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Lenz L, Martins B, Andrade de Paulo G, Kawaguti FS, Baba ER, Uemura RS, Gusmon CC, Geiger SN, Moura RN, Pennacchi C, Simas de Lima M, Safatle-Ribeiro AV, Hashimoto CL, Ribeiro U, Maluf-Filho F. Underwater versus conventional EMR for nonpedunculated colorectal lesions: a randomized clinical trial. Gastrointest Endosc 2023; 97:549-558. [PMID: 36309072 DOI: 10.1016/j.gie.2022.10.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 10/06/2022] [Accepted: 10/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Conventional endoscopic mucosal resection (CEMR) is the standard modality for removing nonpedunculated colorectal lesions. Underwater endoscopic mucosal resection (UEMR) has emerged as an alternative method. There are few comparative studies between these techniques, especially evaluating recurrence. Therefore, the purpose of this trial was to compare CEMR and UEMR for the resection of colorectal lesions with respect to efficacy, safety, and recurrence rate. METHODS This was a randomized controlled trial of UEMR versus CEMR for naïve and nonpedunculated lesions measuring between 10 and 40 mm. The primary outcome was adenoma recurrence at 6 months after the resection. Secondary outcomes were rates of technical success, en bloc resection, and adverse events. Block randomization was used to assign patients. Tattooing was performed to facilitate localization of the scars and eventual recurrences. Endoscopic follow-up was scheduled at 6 months after the procedure. The sites of resections were examined with white-light imaging, narrow-band imaging (NBI), and conventional chromoscopy with indigo carmine followed by biopsies. RESULTS One hundred five patients with 120 lesions were included, with a mean size of 17.5 ± 7.1 (SD) mm. Sixty-one lesions were resected by UEMR and 59 by CEMR. The groups were similar at baseline regarding age, sex, average size, and histologic type. Lesions in the proximal colon in the CEMR group corresponded to 83% and in the UEMR group to 67.8% (P = .073). There was no difference between groups regarding success rate (1 failure in each group) and en bloc resection rate (60.6% UEMR vs 54.2% CEMR, P = .48). Intraprocedural bleeding was observed in 5 CEMRs (8.5%) and 2 UEMRs (3.3%) (P = .27). There was no perforation or delayed hemorrhage in either groups. Recurrence rate was higher in the CEMR arm (15%) than in the UEMR arm (2%) (P = .031). Therefore, the relative risk of 6-month recurrence rate in the CEMR group was 7.5-fold higher (95% CI, 0.98-58.20), with a number needed to treat of 7.7 (95% CI, 40.33-4.22). The higher recurrence rate in the CEMR group persisted only for lesions measuring 21 to 40 mm (35.7% vs 0%; P = .04). CONCLUSION This study demonstrated that UEMR was associated with a lower adenoma recurrence rate than was CEMR. Both endoscopic techniques were effective and had similar rates of adverse events for the treatment of nonpedunculated colorectal lesions.
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Affiliation(s)
- Luciano Lenz
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Fleury Medicina e Saude, São Paulo, São Paulo, Brazil.
| | - Bruno Martins
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Fleury Medicina e Saude, São Paulo, São Paulo, Brazil
| | | | - Fabio Shiguehissa Kawaguti
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Fleury Medicina e Saude, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Adriana Vaz Safatle-Ribeiro
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Centro de Diagnóstico em Gastroenterologia, São Paulo, São Paulo, Brazil
| | | | - Ulysses Ribeiro
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Centro de Diagnóstico em Gastroenterologia, São Paulo, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Centro de Diagnóstico em Gastroenterologia, São Paulo, São Paulo, Brazil
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11
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Ma X, Yang L, Leung J, Sheng J, He Y. Reply. Clin Gastroenterol Hepatol 2023; 21:854-855. [PMID: 35811049 DOI: 10.1016/j.cgh.2022.05.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Xianzong Ma
- Medical School of Chinese PLA, Beijing, China; Department of Gastroenterology, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lang Yang
- Department of Gastroenterology, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China; Senior Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Joseph Leung
- Section of Gastroenterology, Sacramento VA Medical Center, Mather, California
| | - Jianqiu Sheng
- Department of Gastroenterology, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yuqi He
- Department of Gastroenterology, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
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12
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Liu J, Duan S, Wang Y, Peng H, Kong Y, Yao S. Efficacy and safety of underwater endoscopic mucosal resection for ≤20 mm superficial non-ampullary duodenal epithelial tumors: Systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:1077806. [PMID: 36687419 PMCID: PMC9853979 DOI: 10.3389/fmed.2022.1077806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
Background and aims Superficial non-ampullary duodenal epithelial tumors (SNADETs) as a rare disease have gradually increased in recent years. Underwater endoscopic mucosal resection (UEMR) has emerged as a newly available option for the endoscopic resection of SNADETs. This study aimed to evaluate the efficacy and safety of UEMR for ≤20 mm SNADETs. Methods A literature search was performed across multiple databases, including PubMed, Embase, Scopus, and Clinical trials for studies containing tumors ≤20 mm published from January 1, 2012, to August 8, 2022. Outcomes examined were the pooled rates of en bloc resection, R0 resection, adverse events, and recurrence. Subgroup analyses of the resection rate were conducted stratified by sample size and polyp size. Results A total of 10 studies with UEMR performed in a total of 648 tumors were included for analysis. The pooled rate of en bloc resection and R0 resection was 88.2% (95% confidence interval (CI): 82.1-93.2) and 69.1% (95% CI: 62.2-76.1), respectively. The results showed pooled rate of intraoperative bleeding rate was 2.9% (95% CI: 0-9.0), delayed bleeding rate was 0.9% (95% CI: 0.1-2), recurrence rate was 1.5% (95% CI: 0-4.9). In the subgroup analysis, R0 and en-bloc resection rates were significantly higher in <10 mm than 10-20 mm SNADETs subgroups (R0 resection rate 83.1 vs. 48.6%; en bloc resection rate 100.0 vs. 84.0%, P < 0.05). Conclusion Underwater endoscopic mucosal resection was an effective and safe technique for the optional treatment for ≤20 mm SNADETs, especially of <10 mm. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022340578.
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Affiliation(s)
- Jixiang Liu
- Graduate School of Beijing University of Chinese Medicine, Beijing, China,Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Shaojie Duan
- Graduate School of Beijing University of Chinese Medicine, Beijing, China,Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Yichong Wang
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Hongye Peng
- Graduate School of Beijing University of Chinese Medicine, Beijing, China,Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Youjia Kong
- Graduate School of Beijing University of Chinese Medicine, Beijing, China,Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Shukun Yao
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China,*Correspondence: Shukun Yao,
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13
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Li X, Zhu H, Li F, Li R, Xu H. Different endoscopic treatments for small colorectal polyps: A systematic review, pair-wise, and network meta-analysis. Front Med (Lausanne) 2023; 10:1154411. [PMID: 37089613 PMCID: PMC10117900 DOI: 10.3389/fmed.2023.1154411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/17/2023] [Indexed: 04/25/2023] Open
Abstract
Background and study aims In recent years, cold snare polypectomy (CSP) has been increasingly used for small polyps (<10 mm) instead of hot snare polypectomy (HSP). However, evidence-based research regarding the effectiveness and safety of CSP and HSP are still lacking. Additionally, for 4-10 -mm non-pedunculated polyps, the polyp removal method is still controversial. Therefore, it is clinically significant to conduct pair-wise and network meta-analyses to assess such resection methods. Methods We searched PubMed, Embase, and the Cochrane library for randomized controlled trials (RCTs). Only studies that involved the resection of polyps <10 mm were included. Outcomes included the complete resection rate, polyp retrieval rate, procedure-related complications, and procedure times. Results Overall, 23 RCTs (5,352 patients) were identified. In meta-analysis compared CSP versus HSP for polyps <10 mm, CSP showed lower complete resection rate than HSP although with no statistically significant difference [odds ratio (OR): 0.77, 95% confidence interval (CI): 0.56-1.06]. CSP showed a lower risk of major post-polypectomy complications compared to HSP (OR: 0.28, 95% CI: 0.11-0.73). In the network meta-analysis for 4-10 mm non-pedunculated polyps, HSP, and endoscopic mucosal resection (EMR) showed a higher complete resection rate than CSP (OR: 2.7, 95% CI: 1.3-9.2 vs. OR: 2.6, 95% CI: 1.0-10) but a significantly longer time than CSP (WMD: 16.55 s, 95% CI [7.48 s, 25.25 s], p < 0.001), (WMD: 48.00 s, 95% CI [16.54 s, 79.46 s], p = 0.003). Underwater CSP ranked third for complete resection with no complications. Conclusion For <10 mm polyps, CSP is safer than HSP, especially for patients taking antithrombotic drugs. For 4-10 mm non-pedunculated polyps, HSP, and EMR have higher complete resection rates than CSP. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022315575.
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Affiliation(s)
- Xuanhan Li
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - He Zhu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Fudong Li
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Ri Li
- Department of Library, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hong Xu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, Jilin, China
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14
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Hu X, Wu M, Han SX, Liu WH. The effect of making one plus one greater than two: endoscopic double snare resection of an esophageal leiomyoma. Endosc Int Open 2022; 10:E1514-E1516. [PMID: 36397867 PMCID: PMC9666061 DOI: 10.1055/a-1934-1613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Xiao Hu
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Min Wu
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Sheng-xi Han
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei-hui Liu
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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15
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Tziatzios G, Papaefthymiou A, Facciorusso A, Papanikolaou IS, Antonelli G, Marco S, Frazzoni L, Fuccio L, Paraskeva KD, Hassan C, Repici A, Sharma P, Rex DK, Triantafyllou K, Messmann H, Gkolfakis P. Comparative efficacy and safety of resection techniques for treating 6 to 20mm, nonpedunculated colorectal polyps: A systematic review and network meta-analysis. Dig Liver Dis 2022:S1590-8658(22)00741-1. [PMID: 36336608 DOI: 10.1016/j.dld.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Various endoscopic resection techniques have been proposed for the treatment of nonpedunculated colorectal polyps sized 6-20 mm, however the optimal technique still remains unclear. METHODS A comprehensive literature review was conducted for randomized controlled trials (RCTs), investigating the efficacy of endoscopic treatments for the management of 6-20 mm nonpedunculated colorectal polyps. Primary outcomes were complete and en bloc resection rates and adverse event rate was the secondary. Effect size on outcomes is presented as risk ratio (RR; 95% confidence interval [CI]). RESULTS Fourteen RCTs (5219 polypectomies) were included. Endoscopic mucosal resection(EMR) significantly outperformed cold snare polypectomy(CSP) in terms of complete [(RR 95%CI): 1.04(1.00-1.07)] and en bloc resection rate [RR:1.12(1.04-1.21)]. EMR was superior to hot snare polypectomy (HSP) [RR:1.04(1.00-1.08)] regarding complete resection, while underwater EMR (U-EMR) achieved significantly higher rate of en bloc resection compared to CSP [RR:1.15(1.01-1.30)]. EMR yielded the highest ranking for complete resection(SUCRA-score 0.81), followed by cold-snare EMR(CS-EMR,SUCRA-score 0.76). None of the modalities was different regarding adverse event rate compared to CSP, however EMR and CS-EMR resulted in fewer adverse events compared to HSP [RR:0.44(0.26-0.77) and 0.43(0.21-0.87),respectively]. CONCLUSION EMR achieved the highest performance in resecting 6-20 mm nonpedunculated colorectal polyps, with this effect being consistent for polyps 6-9 and ≥10 mm; findings supported by very low quality of evidence.
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Affiliation(s)
- Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece.
| | | | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia AOU, Ospedali Riunity Viale Pinto, Foggia, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
| | - Giulio Antonelli
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy; Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli Hospital, Ariccia, Rome, Italy
| | - Spadaccini Marco
- Department of Endoscopy, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | | | - Cesare Hassan
- IRCCS Humanitas Research Hospital, Endoscopic Unit, Department of Gastroenterology, Milan, Italy
| | - Alessandro Repici
- IRCCS Humanitas Research Hospital, Endoscopic Unit, Department of Gastroenterology, Milan, Italy
| | - Prateek Sharma
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas School of Medicine, Kansas, United States; Division of Gastroenterology, Veteran Affairs Medical Center, Kansas, Missouri, United States
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University Hospital, Indianapolis, Indiana, United States
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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16
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Nomura H, Tsuji S, Utsunomiya M, Kawasaki A, Tsuji K, Yoshida N, Takemura K, Katayanagi K, Minato H, Doyama H. Resection depth and layer of underwater versus conventional endoscopic mucosal resection of intermediate-sized colorectal polyps: A pilot study. Endosc Int Open 2022; 10:E1037-E1044. [PMID: 35979030 PMCID: PMC9377830 DOI: 10.1055/a-1864-6452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 05/30/2022] [Indexed: 12/24/2022] Open
Abstract
Background and study aims Curability of colorectal tumors is associated with resection depth and layer in endoscopic resection. Underwater endoscopic mucosal resection (UEMR) has not undergone sufficient histopathological evaluation. We conducted a pilot study to compare the effectiveness, including resection depth and layer, of UEMR and conventional endoscopic mucosal resection (CEMR). Patients and methods This study was a single-center, retrospective study. Patients with colorectal lesions were treated by UEMR or CEMR between January 2018 and March 2020. Eligible patients were selected from included patients in a 1:1 ratio using propensity score matching. We compared the resection depth and layer and treatment results between the UEMR and CEMR groups. Results We evaluated 55 patients undergoing UEMR and 291 patients undergoing CEMR. Using propensity score matching, we analyzed 54 lesions in each group. The proportion of specimens containing submucosal tissue was 100 % in both groups. The median thickness of the submucosal tissue was significantly greater in the CEMR group than in the UEMR group [1235 µm (95 % confidence interval [CI], 1020-1530 µm) vs. 950 µm (95 % CI, 830-1090 µm), respectively]. However, vertical margins were negative in all lesions in both groups. Conclusions Our findings suggest that the median thickness of submucosal tissue in the UEMR group was about 1,000 μm. Even though the resection depth achieved with UEMR was more superficial than that achieved with CEMR, UEMR may be a treatment option, especially for colorectal lesions ≤ 20 mm in diameter without suspicious findings of submucosal deeply invasive cancer.
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Affiliation(s)
- Hiroki Nomura
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Manami Utsunomiya
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Azusa Kawasaki
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kunihiro Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Naohiro Yoshida
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kenichi Takemura
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kazuyoshi Katayanagi
- Department of Diagnostic Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroshi Minato
- Department of Diagnostic Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
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17
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Nomura T, Nakamura H, Sugimoto S, Oyamada J, Ito K, Kamei A. Clip-line-assisted underwater endoscopic mucosal resection for duodenal adenoma. Endoscopy 2022; 54:E968-E969. [PMID: 35913064 PMCID: PMC9736821 DOI: 10.1055/a-1884-9194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tatsuma Nomura
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan,Department of Gastroenterology, Mie Prefectural Shima Hospital, Shima, Mie, Japan
| | - Haruka Nakamura
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan,Department of Gastroenterology, Mie Prefectural Shima Hospital, Shima, Mie, Japan
| | - Shinya Sugimoto
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Jun Oyamada
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Keiichi Ito
- Department of Gastroenterology, Mie Prefectural Shima Hospital, Shima, Mie, Japan
| | - Akira Kamei
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan
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18
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Yen AW, Leung JW, Koo M, Leung FW. Safety and effectiveness of underwater cold snare resection without submucosal injection of large non-pedunculated colorectal lesions. Endosc Int Open 2022; 10:E791-E800. [PMID: 35692912 PMCID: PMC9187401 DOI: 10.1055/a-1784-4523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022] Open
Abstract
Background and study aims Adverse events are uncommon with cold snaring, but cold techniques are generally reserved for lesions ≤ 9 mm out of concern for incomplete resection or inability to mechanically resect larger lesions. In a non-distended, water-filled lumen, colorectal lesions are not stretched, enabling capture and en bloc resection of large lesions. We assessed the effectiveness and safety of underwater cold snare resection (UCSR) without submucosal injection (SI) of ≥ 10 mm non-pedunculated, non-bulky (≤ 5 mm elevation) lesions with small, thin wire snares. Patients and methods Retrospective analysis of an observational cohort of lesions removed by UCSR during colonoscopy. A single endoscopist performed procedures using a small thin wire (9-mm diameter) cold or (10-mm diameter) hybrid snare. Results Fifty-three lesions (mean 15.8 mm [SD 6.9]; range 10-35 mm) were removed by UCSR from 44 patients. Compared to a historical cohort, significantly more lesions were resected en bloc by UCSR (84.9 % [45/53]; P = 0.04) compared to conventional endoscopic mucosal resection (EMR) (64.0 % [32/50]). Results were driven by high en bloc resection rates for 10- to 19-mm lesions (97.3 % [36/37]; P = 0.01). Multiple logistic regression analysis adjusted for potential confounders showed en bloc resection was significantly associated with UCSR compared to conventional EMR (OR 3.47, P = 0.027). Omission of SI and forgoing prophylactic clipping of post-resection sites did not result in adverse outcomes. Conclusions UCSR of ≥ 10 mm non-pedunculated, non-bulky colorectal lesions is feasible with high en bloc resection rates without adverse outcomes. Omission of SI and prophylactic clipping decreased resource utilization with economic benefits. UCSR deserves further evaluation in a prospective comparative study.
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Affiliation(s)
- Andrew W. Yen
- Sacramento Veterans Affairs Medical Center, VANCHCS, Division of Gastroenterology, Mather, California, United States,University of California Davis School of Medicine, Sacramento, California, United States
| | - Joseph W. Leung
- Sacramento Veterans Affairs Medical Center, VANCHCS, Division of Gastroenterology, Mather, California, United States,University of California Davis School of Medicine, Sacramento, California, United States
| | - Malcom Koo
- Graduate Institution of Long-term Care, Tzu Chi University of Science and Technology, Hualien City, Hualien, Taiwan,Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Felix W. Leung
- Sepulveda Ambulatory Care Center, VAGLAHS, Division of Gastroenterology, North Hills, California, United States,David Geffen School of Medicine at UCLA, Los Angeles, California, United States
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19
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A Comparison of Incomplete Resection Rate of Large and Small Colorectal Polyps by Cold Snare Polypectomy. Clin Gastroenterol Hepatol 2022; 20:1163-1170. [PMID: 34798334 DOI: 10.1016/j.cgh.2021.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are limited data regarding the safety and efficacy of cold snare polypectomy (CSP) for large colorectal polyps. We evaluated factors affecting the clinical outcomes of CSP for polyps between 5 and 15 mm in size. METHODS This was a prospective single-center observational study involving 1000 patients undergoing colonoscopy. Polyps (5-15 mm) were removed using CSP, and biopsies were taken from the resection margin. The primary outcome was the incomplete resection rate (IRR), and was determined by the presence of residual neoplasia on biopsy. Correlations between IRR and polyp size, morphology, histology, and resection time were assessed by generalized estimating equation model. RESULTS A total of 440 neoplastic polyps were removed from 261 patients. The overall IRR was 2.27%, 1.98% for small (5-9 mm) vs 3.45% for large (10-15 mm) polyps (P = .411). In univariate analysis, the IRR was more likely to be related to sessile serrated lesions (odds ratio [OR], 6.93; 95% confidence interval [CI], 1.88-25.45; P = .004), piecemeal resection (OR, 11.83; 95% CI, 1.20-116.49; P = .034), and prolonged resection time >60 seconds (OR, 7.56; 95% CI, 1.75-32.69; P = .007). In multivariable regression analysis, sessile serrated lesions (OR, 6.45; 95% CI, 1.48-28.03; P = .013) and resection time (OR, 7.39; 95% CI, 1.48-36.96; P = .015, respectively) were independent risk factors for IRR. Immediate bleeding was more frequent with resection of large polyps (6.90% vs 1.42%; P = .003). No recurrence was seen on follow-up colonoscopy in 37 cases with large polyps. CONCLUSIONS CSP is safe and effective for removal of colorectal polyps up to 15 mm in size, with a low IRR. (ClinicalTrials.gov; Number: NCT03647176).
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20
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Takeuchi Y, Shichijo S, Uedo N, Ishihara R. Underwater endoscopic mucosal resection for colorectal lesions: Can it be an “Underwater” revolution? DEN OPEN 2022; 2:e84. [PMID: 35310727 PMCID: PMC8828230 DOI: 10.1002/deo2.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/13/2021] [Accepted: 11/20/2021] [Indexed: 11/07/2022]
Abstract
Underwater endoscopic mucosal resection (UEMR) is a newly developed technique for the removal of colorectal, duodenal, esophageal, gastric, ampullary, and small intestinal lesions. We performed a PubMed literature search for articles reporting UEMR outcomes for colorectal polyps. Four randomized controlled trials, nine non‐randomized prospective trials, 16 retrospective studies, and 27 case reports were selected for assessment of the efficacy and safety of UEMR. We summarized the therapeutic outcomes of UEMR in each category according to the lesion characteristics [small size (<10 mm), intermediate size (10–19 mm), large size (≥20 mm), recurrent lesion, and rectal neuroendocrine tumor], and calculated the incidence of adverse events among the included articles. As the treatment outcomes for small polyps appeared similar between UEMR and conventional endoscopic mucosal resection (CEMR), UEMR can be a standard procedure for small colorectal polyps suspicious for high‐grade dysplasia to avoid incomplete removal of occult invasive cancer by cold snare polypectomy. As UEMR showed satisfactory outcomes for intermediate‐size lesions and recurrent lesions after endoscopic resection, UEMR can be a standard procedure for these lesions. Regarding large lesions and rectal neuroendocrine tumors, comparisons of UEMR with current standard methods for them were lacking, and further investigations are warranted. Adverse events appeared comparable or less frequent for UEMR compared with CEMR but still existed. Therefore, careful implementation of this new technique in clinical practice is important for its widespread use.
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Affiliation(s)
- Yoji Takeuchi
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
- Department of Genetic Oncology Division of Hereditary Tumors Osaka International Cancer Institute Osaka Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology Osaka International Cancer Institute Osaka Japan
- Endoscopy Center Osaka International Cancer Institute Osaka Japan
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21
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Thiruvengadam SS, Fung BM, Barakat MT, Tabibian JH. Endoscopic Mucosal Resection: Best Practices for Gastrointestinal Endoscopists. Gastroenterol Hepatol (N Y) 2022; 18:133-144. [PMID: 35506001 PMCID: PMC9053487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Endoscopic mucosal resection (EMR) is an endoscopic technique used to remove sessile or flat lesions from the gastrointestinal tract. This article reviews EMR and focuses on large colorectal polyps, which constitute the most common indication for EMR. Various methods of polyp evaluation can help gastroenterologists determine whether EMR is feasible and whether referral to an advanced endoscopist may be necessary. Techniques for performing EMR include conventional hot-snare EMR with submucosal injection and electro-cautery snare removal of colorectal lesions, as well as alternative EMR techniques such as cold-snare EMR and underwater EMR. Key adverse events associated with EMR include bleeding, perforation, and post-polypectomy coagulation syndrome. Finally, as residual or recurrent polyp formation is possible regardless of EMR technique, this article addresses the importance of surveillance post-EMR and the patients who are at highest risk for polyp recurrence.
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Affiliation(s)
- Sushrut Sujan Thiruvengadam
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Brian M. Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
| | - Monique T. Barakat
- Divisions of Adult and Pediatric Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California
| | - James H. Tabibian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
- Division of Gastroenterology, Department of Medicine, Olive View–UCLA Medical Center, Sylmar, California
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22
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Rashid MU, Alomari M, Afraz S, Erim T. EMR and ESD: Indications, techniques and results. Surg Oncol 2022; 43:101742. [DOI: 10.1016/j.suronc.2022.101742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/21/2022] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
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23
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Kagemoto K, Takeuchi Y, Okamoto K. Modified underwater endoscopic mucosal resection for a laterally spreading tumor: "Underwater" snaring and "undergas" resection. Dig Endosc 2022; 34:e32-e33. [PMID: 34888959 DOI: 10.1111/den.14203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Kaizo Kagemoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Yoji Takeuchi
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan.,Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koichi Okamoto
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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24
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Tan DJH, Ng CH, Lim XC, Lim WH, Yuen LZH, Koh JH, Nistala KRY, Ho KY, Chong CS, Muthiah MD. Is underwater endoscopic mucosal resection of colon polyps superior to conventional techniques? A network analysis of endoscopic mucosal resection and submucosal dissection. Endosc Int Open 2022; 10:E154-E162. [PMID: 35047346 PMCID: PMC8759939 DOI: 10.1055/a-1633-3230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Xiong Chang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Linus Zhen Han Yuen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jin Hean Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Khek-Yu Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Choon Seng Chong
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Mark D. Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
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25
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Tziatzios G, Gkolfakis P, Papadopoulos V, Papanikolaou IS, Fuccio L, Facciorusso A, Ebigbo A, Gölder SK, Probst A, Messmann H, Triantafyllou K. Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions. Ann Gastroenterol 2021; 34:757-769. [PMID: 34815641 PMCID: PMC8596214 DOI: 10.20524/aog.2021.0647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/24/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece (Georgios Tziatzios, Ioannis S. Papanikolaou, Konstantinos Triantafyllou)
| | - Paraskevas Gkolfakis
- Department of Gastroenterology Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (Paraskevas Gkolfakis)
| | - Vasilios Papadopoulos
- Department of Gastroenterology, Koutlimbaneio & Triantafylleio General Hospital, Larissa, Greece (Vasilios Papadopoulos)
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece (Georgios Tziatzios, Ioannis S. Papanikolaou, Konstantinos Triantafyllou)
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy (Lorenzo Fuccio)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Italy (Antonio Facciorusso)
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Stefan Karl Gölder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany (Alanna Ebigbo, Stefan Karl Gölder, Andreas Probst, Helmut Messmann)
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece (Georgios Tziatzios, Ioannis S. Papanikolaou, Konstantinos Triantafyllou)
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26
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Nagl S, Ebigbo A, Goelder SK, Roemmele C, Neuhaus L, Weber T, Braun G, Probst A, Schnoy E, Kafel AJ, Muzalyova A, Messmann H. Underwater vs Conventional Endoscopic Mucosal Resection of Large Sessile or Flat Colorectal Polyps: A Prospective Randomized Controlled Trial. Gastroenterology 2021; 161:1460-1474.e1. [PMID: 34371000 DOI: 10.1053/j.gastro.2021.07.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/26/2021] [Accepted: 07/29/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Conventional endoscopic mucosal resection (CEMR) with submucosal injection is the current standard for the resection of large, nonmalignant colorectal polyps. We investigated whether underwater endoscopic mucosal resection (UEMR) is superior to CEMR for large (20-40mm) sessile or flat colorectal polyps. METHODS In this prospective randomized controlled study, patients with sessile or flat colorectal polyps between 20 and 40 mm in size were randomly assigned to UEMR or CEMR. The primary outcome was the recurrence rate after 6 months. Secondary outcomes included en bloc and R0 resection rates, number of resected pieces, procedure time, and adverse events. RESULTS En bloc resection rates were 33.3% in the UEMR group and 18.4% in the CEMR group (P = .045); R0 resection rates were 32.1% and 15.8% for UEMR vs CEMR, respectively (P = .025). UEMR was performed with significantly fewer pieces compared to CEMR (2 pieces: 45.5% UEMR vs 17.7% CEMR; P = .001). The overall recurrence rate did not differ between both groups (P = .253); however, subgroup analysis showed a significant difference in favor of UEMR for lesions of >30 mm to ≤40 mm in size (P = .031). The resection time was significantly shorter in the UEMR group (8 vs 14 minutes; P < .001). Adverse events did not differ between both groups (P = .611). CONCLUSIONS UEMR is superior to CEMR regarding en bloc resection, R0 resection, and procedure time for large colorectal lesions and shows significantly lower recurrence rates for lesions >30 mm to ≤40 mm in size. UEMR should be considered for the endoscopic resection of large colorectal polyps.
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Affiliation(s)
- Sandra Nagl
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany.
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Karl Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Christoph Roemmele
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Lukas Neuhaus
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Tobias Weber
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Georg Braun
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Elisabeth Schnoy
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | | | - Anna Muzalyova
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
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27
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Tseng CW, Hsieh YH, Lin CC, Koo M, Leung FW. Heat sink effect of underwater polypectomy in a porcine colon model. BMC Gastroenterol 2021; 21:406. [PMID: 34706664 PMCID: PMC8554837 DOI: 10.1186/s12876-021-01985-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/08/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Underwater polypectomy without the need for submucosal injection has been reported. A heat-sink effect by immersing the polyp in water was proposed but no such experiment has been performed to support the claim. We compared the temperature rise on the serosal side during polypectomy between air- and water-filled colon. METHOD Freshly harvested porcine colons were placed in a metal tray with cautery electrode pad attached to its bottom. An upper endoscope was used with a cap and a rubber band mounted to the distal end. A mucosal site was randomly selected and identified on its serosal surface with a marker while suction was applied. Suction was applied again and a ligation band was applied to create a polyp. A cautery snare grasped the artificial polyp just below the band. An assistant placed the tip of a thermometer at the marked site on the serosal surface to record the baseline temperature before cautery and the highest temperature during polypectomy. Seven polypectomies in air and underwater were performed. RESULTS Mean (standard deviation) baseline temperature were 23.3 (0.6) °C and 23.4 (0.6) °C in the air and water groups, respectively. The maximum rise in temperature during polypectomy was 6.1 (4.5) °C and 1.4 (1.0) °C in the air and water groups, respectively (P = 0.004). CONCLUSIONS The maximum temperature rise during polypectomy was significantly less when polypectomy was performed underwater, supporting the hypothesis that a heat-sink effect does exist during underwater polypectomy.
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Affiliation(s)
- Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi, 62247, Taiwan.,School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi, 62247, Taiwan. .,School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan.
| | - Chung-Chih Lin
- Department of Mechanical and Computer-Aided Engineering, National Formosa University, Yilan, Taiwan
| | - Malcolm Koo
- Graduate Institute of Long-Term Care, Tzu Chi University of Science and Technology, Hualien, Taiwan.,Dalla Lana School of Public Health, University of Toronto, Ontario, ON, Canada
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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28
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Yuan X, Gao H, Liu C, Cui H, Zhang Z, Xie J, Lu H, Xu L. Effectiveness and safety of the different endoscopic resection methods for 10- to 20-mm nonpedunculated colorectal polyps: A systematic review and pooled analysis. Saudi J Gastroenterol 2021; 27:331-341. [PMID: 34643573 PMCID: PMC8656331 DOI: 10.4103/sjg.sjg_180_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND We performed a systematic review and pooled analysis to assess the effectiveness and safety of different endoscopic resection methods for 10- to 20-mm nonpedunculated colorectal polyps. METHODS Articles in PubMed, EMBASE, and the Cochrane Library related to the common endoscopic treatment of 10- to 20-mm nonpedunculated polyps published as of April 2020 were searched. Primary outcomes were the R0 resection rate and en bloc resection rate. Secondary outcomes were safety and the recurrence rate. Meta-regression and subgroup analysis were also performed. RESULTS A total of 36 studies involving 3212 polyps were included in the final analysis. Overall, the effectiveness of resection methods with a submucosal uplifting effect, including endoscopic mucosal resection (EMR), cold EMR and underwater EMR (UEMR), was better than that of methods without a nonsubmucosal uplifting effect [R0 resection rate, 90% (95% confidence interval (CI) 0.81-0.94, I2 = 84%) vs 82% (95% CI 0.78-0.85, I2 = 0%); en bloc resection rate 85% (95% CI 0.79-0.91, I2 = 83%) vs 74% (95% CI 0.47-0.94, I2 = 94%)]. Regarding safety, the pooled data showed that hot resection [hot snare polypectomy, UEMR and EMR] had a higher risk of intraprocedural bleeding than cold resection [3% (95% CI 0.01-0.05, I2 = 68%) vs 0% (95% CI 0-0.01, I2 = 0%)], while the incidences of delayed bleeding, perforation and post-polypectomy syndrome were all low. CONCLUSIONS Methods with submucosal uplifting effects are more effective than those without for resecting 10- to 20-mm nonpedunculated colorectal polyps, and cold EMR is associated with a lower risk of intraprocedural bleeding than other methods. Additional research is needed to verify the advantages of these methods, especially cold EMR.
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Affiliation(s)
- Xin Yuan
- School of Medicine, Ningbo University, Ningbo First Hospital, Zhejiang, China
| | - Hui Gao
- School of Medicine, Ningbo University, Ningbo First Hospital, Zhejiang, China
| | - Cenqin Liu
- Department of Gastroenterology, Ningbo First Hospital, Zhejiang, China
| | - Hongyao Cui
- Department of Gastroenterology, Haishu Second Hospital, Zhejiang, China
| | - Zhixin Zhang
- Department of Gastroenterology, Ningbo First Hospital, Zhejiang, China
| | - Jiarong Xie
- Department of Gastroenterology, Ningbo First Hospital, Zhejiang, China
| | - Hongpeng Lu
- Department of Gastroenterology, Ningbo First Hospital, Zhejiang, China
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Zhejiang, China,Address for correspondence: Dr. Lei Xu, Department of Gastroenterology, Ningbo First Hospital. No. 59 Liuting Street, Ningbo - 315010, China. E-mail:
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29
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Chang L. Underwater or conventional endoscopic mucosal resection for intermediate‐sized colorectal neoplasm? ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Li‐Chun Chang
- Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan
- Health Management Center National Taiwan University Hospital Taipei Taiwan
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Fukuda H, Takeuchi Y, Shoji A, Miyake M, Matsueda K, Inoue T, Waki K, Shimamoto Y, Kono M, Iwagami H, Nakahira H, Matsuura N, Shichijo S, Maekawa A, Kanesaka T, Yamamoto S, Higashino K, Uedo N, Ishihara R. Curative value of underwater endoscopic mucosal resection for submucosally invasive colorectal cancer. J Gastroenterol Hepatol 2021; 36:2471-2478. [PMID: 33788311 DOI: 10.1111/jgh.15513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 01/13/2021] [Accepted: 03/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Occasionally, colorectal tumors without characteristics of deep submucosal invasion are found to be invasive upon pathological evaluation after endoscopic resection (ER). Because the resection depth for underwater endoscopic mucosal resection (UEMR) has not been clarified, we evaluated the feasibility of UEMR for pathologically invasive colorectal cancer (pT1-CRC). METHODS We retrospectively investigated data on the backgrounds and outcomes of patients with pT1-CRC who underwent UEMR between January 2014 and June 2019 at our institute. As a reference standard, the backgrounds and outcomes of pT1-CRCs that had undergone conventional EMR (CEMR) were also investigated. RESULTS Thirty-one patients (median age, 68 years [range, 32-88 years]; 22 men [71%]) were treated with UEMR. Median lesion size was 17 mm (range, 6-50 mm). The endoscopic complete resection rate was 100%. The overall en bloc resection rate was 77%, and the VM0, HM0, and R0 resection rates were 81%, 58%, and 55%, respectively. In cases of pT1a (invasion <1000 μm)-CRC (n = 14), the en bloc, VM0, and R0 resection rates were 92%, 100%, and 71%, respectively. Seventeen patients (five with risk factors for lymph node metastasis and 12 without) were followed up, and no local recurrence and distant metastasis were observed during the follow-up period (median follow-up period, 18 months [range, 6-62 months]) after UEMR. The outcomes of UEMR seemed to be comparable with those of CEMR (n = 32). CONCLUSIONS The VM0 rate of UEMR for pT1-CRC, especially for pT1a-CRC, without characteristics of deep submucosal invasion seems feasible.
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Affiliation(s)
- Hiromu Fukuda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ayaka Shoji
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Muneaki Miyake
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Katsunori Matsueda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takahiro Inoue
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kotaro Waki
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yusaku Shimamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Mitsuhiro Kono
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyoshi Iwagami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroko Nakahira
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Akira Maekawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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Chandan S, Khan SR, Kumar A, Mohan BP, Ramai D, Kassab LL, Draganov PV, Othman MO, Kochhar GS. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021; 94:471-482.e9. [PMID: 33385463 DOI: 10.1016/j.gie.2020.12.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Major limitations with conventional EMR (C-EMR) include high rates of polyp recurrence and low en-bloc resection rates, especially for lesions >20 mm in size. Underwater EMR (U-EMR) has emerged as an alternate technique for en-bloc resection of larger lesions. We conducted a systematic review and meta-analysis comparing the efficacy and safety of the 2 techniques. METHODS Multiple databases were searched through June 2020 for studies that compared outcomes of U-EMR and C-EMR for colorectal lesions. Meta-analysis was performed to determine pooled odds ratios (ORs) of successful R0, en-bloc, and piecemeal resection of colorectal lesions. We compared the rates of polyp recurrence at follow-up, diagnostic accuracy for colorectal cancer, and adverse events with the 2 techniques. RESULTS Eleven studies, including 4 randomized controlled trials (RCTs) with 1851 patients were included in the final analysis. A total of 1071 lesions were removed using U-EMR, and 1049 lesions were removed using C-EMR. Although U-EMR had an overall superior en-bloc resection rate compared with C-EMR (OR, 1.9; 95% confidence interval [CI], 1-3.5; P = .04), both techniques were comparable in terms of polyps >20 mm in size (OR, 0.8; 95% CI, 0.3-2.1; P = .75), R0 resection (OR, 3.1; 95% CI, 0.74-12.6; P = .14), piecemeal resection (OR, 3.1; 95% CI, 0.74-12.6; P = .13), and diagnostic accuracy for colorectal cancer (OR, 1.1; 95% CI, 0.6-1.8; P = .82). There were lower rates of polyp recurrence (OR, 0.3; 95% CI, 0.1-0.8; P = .01) and incomplete resection (OR, 0.4; 95% CI, 0.2-0.5; P = .001) with U-EMR. Both techniques have comparable resection times and safety profiles. CONCLUSIONS Our results support the use of U-EMR over C-EMR for successful resection of colorectal lesions. Further randomized controlled trials are needed to evaluate the efficacy of U-EMR for resecting polyps >20 mm in size.
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Affiliation(s)
- Saurabh Chandan
- Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Shahab R Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anand Kumar
- Gastroenterology & Hepatology, Lenox Hill Hospital, New York, New York, USA
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daryl Ramai
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, New York, USA
| | - Lena L Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter V Draganov
- Gastroenterology, University of Florida Health, Gainesville, Florida, USA
| | - Mohamed O Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Chua TY, Kyanam Kabir Baig KR, Leung FW, Ashat M, Jamidar PA, Mulki R, Singh A, Yu JX, Lightdale JR. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020. Gastrointest Endosc 2021; 94:441-451. [PMID: 34147512 DOI: 10.1016/j.gie.2021.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.
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Affiliation(s)
- Tiffany Y Chua
- Division of Digestive Diseases, Harbor-University of California Los Angeles, Torrance, California, USA
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Felix W Leung
- VA Sepulveda Ambulatory Care Center, North Hills, California, USA
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ajaypal Singh
- Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica X Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Yamashina T, Hanaoka N, Setoyama T, Watanabe J, Banno M, Marusawa H. Efficacy of Underwater Endoscopic Mucosal Resection for Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis. Cureus 2021; 13:e17261. [PMID: 34540484 PMCID: PMC8448267 DOI: 10.7759/cureus.17261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 12/24/2022] Open
Abstract
Recently, underwater endoscopic mucosal resection (UEMR) without submucosal injection was introduced as a new replacement for conventional EMR (CEMR) and was reported to be useful for resecting large colonic polyps. Here, we aimed to assess the efficacy and safety of these two methods by a systematic review and meta-analysis. We comprehensively searched multiple databases until July 2021 to identify randomized controlled trials (RCTs) comparing UEMR with CEMR. The primary outcomes were the proportion of R0 resection and mean procedure time, and the secondary outcomes were the proportion of en bloc resection and all adverse events. Three reviewers independently searched for articles, extracted data, and assessed the risk of bias. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. This study was registered in www.protocols.io (Protocol Integer ID: 40849). We included six RCTs (1,374 polyps). We judged that a meta-analysis was not available, and the data were summarized narratively for the proportion of R0 resection. Regarding procedure time, UEMR likely resulted in a large reduction (mean difference = -64.3 seconds; 95% confidence interval (CI) = -122.5 to -6.0 seconds; I2 = 86%; moderate certainty of evidence). UEMR likely resulted in a large increase in en bloc resection (odds ratio = 1.85; 95% CI = 1.15 to 2.98; I2 = 60%; moderate certainty of evidence). Percentages of adverse events were 0-17% with CEMR and 0-16% with UEMR. In summary, UEMR might have higher efficacy than CEMR in the endoscopic resection of nonpedunculated colorectal polyps, with likely a large reduction in procedure time.
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Affiliation(s)
- Takeshi Yamashina
- Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, JPN
- Gastroenterology and Hepatology, Kansai Medical University Medical Center, Moriguchi, JPN
| | - Noboru Hanaoka
- Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, JPN
| | - Takeshi Setoyama
- Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, JPN
| | - Jun Watanabe
- Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Masahiro Banno
- Department of Systematic Reviewers, Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, JPN
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, JPN
- Department of Psychiatry, Seichiryo Hospital, Nagoya, JPN
| | - Hiroyuki Marusawa
- Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, JPN
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Higher rate of en bloc resection with underwater than conventional endoscopic mucosal resection: A meta-analysis. Dig Liver Dis 2021; 53:958-964. [PMID: 34059445 DOI: 10.1016/j.dld.2021.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Previous meta-analysis including nonrandomized studies showed marginal benefit of underwater endoscopic mucosal resection(U-EMR) compared to conventional EMR(C-EMR) in terms of polypectomy outcomes. We evaluated U-EMR compared to C-EMR in the treatment of colorectal polyps with respect to effectiveness and safety by analyzing only randomized controlled trials(RCTs). MATERIAL AND METHODS PubMed and Cochrane Library databases were searched for RCTs published until 11/2020, evaluating U-EMR vs. C-EMR regarding en bloc resection, post-endoscopic resection adenoma recurrence, complete resection, adverse events rates and difference in resection time. Abstracts from Digestive Disease Week, United European Gastroenterology Week and ESGE Days meetings were also searched. Effect size on outcomes is presented as risk ratio(RR; 95% confidence interval[CI]) or mean difference(MD; 95%CI). The I2 test was used for quantifying heterogeneity, while Grading of Recommendations Assessment, Development and Evaluation(GRADE) was used to assess strength of evidence. RESULTS Six RCTs analyzing outcomes from 1157 colorectal polypectomies(U-EMR589;C-EMR,568) were included. U-EMR associated with significant higher rate of en bloc resection compared to C-EMR [RR(95%CI):1.26(1.01-1.58); Chi² for heterogeneity=30.43, P<0.0001; I²=84%, GRADE: Very low]. This effect was more prominent regarding resection of polyps sized ≥20 mm compared to polyps <20 mm [RR(95%CI):1.64(1.22-2.20) vs. 1.10(0.98-1.23)]. Post-resection recurrence [RR(95%CI):0.52(0.28-0.94);GRADE:Low] was lower significantly in U-EMR group. In contrast, no significant difference was detected between U-EMR and C-EMR regarding complete resection [RR(95%CI): 1.06(0.91-1.24) GRADE:Very low] and adverse events occurrence[RR(95%CI):1.00 (0.72-1.39); GRADE:Low]. CONCLUSION Meta-analysis of RCTs supports that U-EMR resection achieves higher rate of en bloc resection compared to conventional EMR. This effect is driven when resecting large(≥20 mm) polyps.
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Li DF, Lai MG, Yang MF, Zou ZY, Xu J, Peng RM, Xiong F, Wei C, Zhang DG, Xu ZL, Wang LS, Yao J. The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: systematic review and meta-analysis. Endoscopy 2021; 53:636-646. [PMID: 32767283 DOI: 10.1055/a-1234-8918] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a promising strategy for nonpedunculated colorectal polyp removal. However, the efficacy and safety of the technique for the treatment of ≥ 10-mm colorectal polyps remain unclear. We aimed to comprehensively assess the efficacy and safety of UEMR for polyps sized 10-19 mm and ≥ 20 mm. METHODS PubMed, EMBASE, and the Cochrane Library databases were searched for relevant articles from January 2012 to November 2019. Primary outcomes were the rates of adverse events and residual polyps. Secondary outcomes were the complete resection, en bloc resection, and R0 resection rates. RESULTS 18 articles including 1142 polyps from 1093 patients met our inclusion criteria. The overall adverse event and residual polyp rates were slightly lower for UEMR when removing colorectal polyps of 10-19 mm vs. ≥ 20 mm (3.5 % vs. 4.3 % and 1.2 % vs. 2.6 %, respectively). The UEMR-related complete resection rate was slightly higher for colorectal polyps of 10-19 mm vs. ≥ 20 mm (97.9 % vs. 92.0 %). However, the en bloc and R0 resection rates were dramatically higher for UEMR removal of polyps of 10-19 mm vs. ≥ 20 mm (83.4 % vs. 36.1 % and 73.0 % vs. 40.0 %, respectively). In addition, univariate meta-regression revealed that polyp size was an independent predictor for complete resection rate (P = 0.03) and en bloc resection (P = 0.01). CONCLUSIONS UEMR was an effective and safe technique for the removal of ≥ 10-mm nonpedunculated colorectal polyps. However, UEMR exhibited low en bloc and R0 resection rates for the treatment of ≥ 20-mm polyps.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ming-Guang Lai
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Mei-Feng Yang
- Department of Hematology, Yantian District People's Hospital, Shenzhen, Guangdong, China
| | - Zhi-Yuan Zou
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jing Xu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Ru-Mei Peng
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, Hunan, China
| | - Feng Xiong
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Cheng Wei
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
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Garg R, Singh A, Aggarwal M, Bhalla J, Mohan BP, Burke C, Rustagi T, Chahal P. Underwater Endoscopic Mucosal Resection for 10 mm or Larger Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis. Clin Endosc 2021; 54:379-389. [PMID: 33910271 PMCID: PMC8182235 DOI: 10.5946/ce.2020.276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Recent studies have reported the favorable outcomes of underwater endoscopic mucosal resection (UEMR) for colorectal polyps. We performed a systematic review and meta-analysis evaluating the efficacy and safety of UEMR for nonpedunculated polyps ≥10 mm.
Methods We performed a comprehensive search of multiple databases (through May 2020) to identify studies reporting the outcomes of UEMR for ≥10 mm nonpedunculated colorectal polyps. The assessed outcomes were recurrence rate on the first follow-up, en bloc resection, incomplete resection, and adverse events after UEMR.
Results A total of 1276 polyps from 16 articles were included in our study. The recurrence rate was 7.3% (95% confidence interval [CI], 4.3–12) and 5.9% (95% CI, 3.6–9.4) for nonpedunculated polyps ≥10 and ≥20 mm, respectively. For nonpedunculated polyps ≥10 mm, the en bloc resection, R0 resection, and incomplete resection rates were 57.7% (95% CI, 42.4–71.6), 58.9% (95% CI, 42.4–73.6), and 1.5% (95% CI, 0.8–2.6), respectively. The rates of pooled adverse events, intraprocedural bleeding, and delayed bleeding were 7.0%, 5.4%, and 2.9%, respectively. The rate of perforation and postpolypectomy syndrome was 0.8%.
Conclusions Our systematic review and meta-analysis demonstrates that UEMR for nonpedunculated colorectal polyps ≥10 mm is safe and effective with a low rate of recurrence.
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Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Jaideep Bhalla
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Carol Burke
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Choi AY, Moosvi Z, Shah S, Roccato MK, Wang AY, Hamerski CM, Samarasena JB. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc 2021; 93:378-389. [PMID: 33068608 DOI: 10.1016/j.gie.2020.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Underwater EMR (UEMR) has emerged as an attractive alternative to conventional EMR (CEMR) for the resection of colorectal polyps. The purpose of this systematic review and meta-analysis was to compare UEMR and CEMR for the resection of colorectal polyps with respect to efficacy and safety. METHODS A literature search was performed across multiple databases, including MEDLINE/PubMed, The Cochrane Library, CINAHL, Google Scholar, and Scopus, for studies that were published until May 2020. Only studies that compared the resection of colorectal polyps using UEMR with CEMR were included. Outcomes examined included rates of en bloc resection, recurrence, postprocedure bleeding, perforation, and resection time. RESULTS Seven studies totaling 1237 polyps were included: 614 polyps were resected with UEMR and 623 polyps with CEMR. UEMR was associated with a significant increase in the rate of overall en bloc resection (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.42-2.39; P < .001; I2 = 38%), with subgroup analysis showing a significant increase in the rates of en bloc resection in polyps ≥20 mm (OR, 1.51; 95% CI, 1.06-2.14; P = .02; I2 = 44%) but not in polyps <20 mm (OR, 1.07; 95% CI, .65-1.76; P = .80; I2 = 27%), and with a significant reduction in the rate of recurrence (OR, .30; 95% CI, .16-.57; P = .0002; I2 = 0%), again driven by improvements in polyps ≥20 mm. There was no significant difference in postprocedure bleeding (OR, 1.11; 95% CI, .57-2.17; P = .76; I2 = 0%) or perforation (OR, .72; 95% CI, .19-2.83; P = .64; I2 = 0%). CONCLUSIONS The results of this systematic review and meta-analysis demonstrate that UEMR is a safe and efficacious alternative to CEMR. With appropriate training, UEMR may be strongly considered as a first-line option for resection of colorectal polyps.
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Affiliation(s)
- Alyssa Y Choi
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Zain Moosvi
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Sagar Shah
- University of California, Irvine School of Medicine, Irvine, California, USA
| | - Mary Kathryn Roccato
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher M Hamerski
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Jason B Samarasena
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
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El Rahyel A, McWhinney CD, Parsa N, Lahr RE, Vemulapalli KC, Rex DK. Room temperature water infusion during colonoscopy insertion induces rectosigmoid colon mucus production. Endoscopy 2020; 52:1118-1121. [PMID: 32458999 DOI: 10.1055/a-1182-5211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Water filling during colonoscopy improves several colonoscopy outcomes. We evaluated an anecdotal observation that room temperature water filling during colonoscope insertion results in mucus production in the left colon, which may impair mucosal visualization during withdrawal. METHODS We performed 55 colonoscopies with either water or saline filling during insertion, and video recorded the examinations. Three blinded observers scored the amount of mucus visible on the video recordings. RESULTS 29 patients had water filling and 26 patients had saline filling during insertion. Demographic features, procedure indications, volume of infused fluid, and insertion time to the cecum were similar in the two groups. All three blinded observers rated the mucus as greater after water filling than after saline (median 3 out of 5 vs. 1 out of 5; P < 0.001), with a kappa value for interobserver agreement of 0.364 (P < 0.001). CONCLUSION Room temperature water filling is associated with mucus production by the rectosigmoid colon, requiring additional cleansing during withdrawal.
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Affiliation(s)
- Ahmed El Rahyel
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Connor D McWhinney
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Garg R, Singh A, Mohan BP, Mankaney G, Regueiro M, Chahal P. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1884-E1894. [PMID: 33269325 PMCID: PMC7695518 DOI: 10.1055/a-1287-9621] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Underwater endoscopic mucosal resection (UEMR) for colorectal polyps has been reported to have good outcomes in recent studies. We conducted a systematic review and meta-analysis comparing the effectiveness and safety of UEMR to conventional EMR (CEMR). Methods A comprehensive search of multiple databases (through May 2020) was performed to identify studies that reported outcome of UEMR and CEMR for colorectal lesions. Outcomes assessed included incomplete resection, rate of recurrence, en bloc resection, adverse events (AEs) for UEMR and CEMR. Results A total of 1,651 patients with 1,704 polyps were included from nine studies. There was a significantly lower rate of incomplete resection (odds ratio [OR]: 0.19 (95 % confidence interval (CI), 0.05-0.78, P = 0.02) and polyp recurrence (OR: 0.41, 95 % CI, 0.24-0.72, P = 0.002) after UEMR. Compared to CEMR, rates overall complications (relative risk [RR]: 0.66 (95 % CI, 0.48-0.90) ( P = 0.008), and intra-procedural bleeding (RR: 0.59, 95 % CI, 0.41-0.84, P = 0.004) were significantly lower with UEMR. The recurrence rate was also lower for large non-pedunculated polyps ≥ 10 mm (OR 0.24, 95 % CI, 0.10-0.57, P = 0.001) and ≥ 20 mm (OR 0.14, 95 % CI, 0.02-0.72, P = 0.01). The rates of en bloc resection, delayed bleeding, perforation and post-polypectomy syndrome were similar in both groups ( P > 0.05). Conclusions In this systematic review and meta-analysis, we found that UEMR is more effective and safer than CEMR with lower rates of recurrence and AEs. UEMR use should be encouraged over CEMR.
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Affiliation(s)
- Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic, Ohio, United States
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Babu P. Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, United States
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
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Kamal F, Khan MA, Lee-Smith W, Khan Z, Sharma S, Tombazzi C, Ahmad D, Ismail MK, Howden CW, Binmoeller KF. Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1264-E1272. [PMID: 33015327 PMCID: PMC7508646 DOI: 10.1055/a-1214-5692] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/25/2020] [Indexed: 12/28/2022] Open
Abstract
Background Recently, underwater endoscopic mucosal resection (UEMR) has shown promising results in the management of colorectal polyps. Some studies have shown better outcomes compared to conventional endoscopic mucosal resection (EMR). We conducted this systematic review and meta-analysis to compare UEMR and EMR in the management of colorectal polyps. Methods We searched several databases from inception to November 2019 to identify studies comparing UEMR and EMR. Outcomes assessed included rates of en bloc resection, complete macroscopic resection, recurrent/residual polyps on follow-up colonoscopy, complete resection confirmed by histology and adverse events. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a fixed effect model. Heterogeneity was assessed by I 2 statistic. Funnel plots and Egger's test were used to assess publication bias. We used the Newcastle-Ottawa scale (NOS) for assessment of quality of observational studies, and the Cochrane tool for assessing risk of bias for RCTs Results Seven studies with 1291 patients were included; two were randomized controlled trials and five were observational. UEMR demonstrated statistically significantly better efficacy in rates of en bloc resection, pooled RR 1.16 (1.08, 1.26), complete macroscopic resection, pooled RR 1.28 (1.18, 1.39), recurrent/residual polyps; pooled RR 0.26 (0.12, 0.56) and complete resection confirmed by histology; pooled RR 0.75 (0.57, 0.98). There was no significant difference in adverse events (AEs); pooled RR 0.68 (0.44, 1.05). Conclusions This meta-analysis found statistically significantly better rates of en bloc resection, complete macroscopic resection, and lower risk of recurrent/residual polyps with UEMR compared to EMR. We found no significant difference in AEs between the two techniques.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Muhammad Ali Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Wade Lee-Smith
- Carlson and Mulford Libraries, University of Toledo, Ohio, United States
| | - Zubair Khan
- Division of Gastroenterology, University of Texas – Houston, Houston, Texas, United States
| | - Sachit Sharma
- Division of Internal Medicine, University of Toledo, Ohio, United States
| | - Claudio Tombazzi
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Dina Ahmad
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mohammad Kashif Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Colin W. Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Kenneth F. Binmoeller
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, United States
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Zhang Z, Xia Y, Cui H, Yuan X, Wang C, Xie J, Tong Y, Wang W, Xu L. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial : (UEMR vs. CEMR for small size non-pedunculated colorectal polyps). BMC Gastroenterol 2020; 20:311. [PMID: 32967616 PMCID: PMC7510164 DOI: 10.1186/s12876-020-01457-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a recently developed technique and can be performed during water-aided or ordinary colonoscopy for the treatment of colorectal polyps. The objective of this clinical trial was to evaluate the efficacy and safety of UEMR in comparison with conventional endoscopic mucosal resection (CEMR) of small non-pedunculated colorectal polyps. METHODS Patients with small size, non-pedunculated colorectal polyps (4-9 mm in size) who underwent colonoscopic polypectomy were enrolled in this multicenter randomized controlled clinical trial. The patients were randomly allocated to two groups, an UEMR group and a CEMR group. Efficacy and safety were compared between groups. RESULTS In the intention-to-treat (ITT) analysis, the complete resection rate was 83.1% (59/71) in the UEMR group and 87.3% (62/71) in the CEMR group. The en-bloc resection rate was 94.4% (67/71) in the UEMR group and 91.5% (65/71) in the CEMR group (difference 2.9%; 90% CI - 4.2 to 9.9%), showed noninferiority (noninferiority margin - 5.7% < - 4.2%). No significant difference in procedure time (81 s vs. 72 s, P = 0.183) was observed. Early bleeding was observed in 1.4% of patients in the CEMR group (1/71) and 1.4% of patients in the UEMR group (1/71). None of the patients in the UEMR group complained of postprocedural bloody stool, whereas two patients in the CEMR group (2/64) reported this adverse event. CONCLUSION Our results indicate that UEMR is safer and just as effective as CEMR in En-bloc resection for the treatment of small colorectal polyps as such, UEMR is recommended as an alternative approach to excising small and non-pedunculated colorectal adenomatous polyps. TRIAL REGISTRATION Clinical Trials.gov, NCT03833492 . Retrospectively registered on February 7, 2019.
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Affiliation(s)
- Zhixin Zhang
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Yonghong Xia
- Department of Gastroenterology, Ninghai Second Hospital, Ningbo, 315600, China
| | - Hongyao Cui
- Department of Gastroenterology, Haishu Second Hospital, Ningbo, 315000, China
| | - Xin Yuan
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Chunnian Wang
- Ningbo Clinical and Pathological Diagnosis Center, Ningbo, 315021, China
| | - Jiarong Xie
- College of Medicine, Ningbo University, Ningbo, 315211, China.,Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China
| | - Yarong Tong
- Department of Gastroenterology, Ninghai Second Hospital, Ningbo, 315600, China
| | - Weihong Wang
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China.
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, 315010, China.
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Yen AW, Leung JW, Shao PP, Leung FW. Total water exchange colonoscopy to mitigate infection risks due to aerosolization during colonoscopy. ADVANCES IN DIGESTIVE MEDICINE 2020. [PMCID: PMC7461168 DOI: 10.1002/aid2.13229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Andrew W. Yen
- Division of Gastroenterology Sacramento VA Medical Center, VA Northern California HealthCare System Mather CA USA
- Division of Gastroenterology University of California Davis School of Medicine Sacramento CA USA
| | - Joseph W. Leung
- Division of Gastroenterology Sacramento VA Medical Center, VA Northern California HealthCare System Mather CA USA
- Division of Gastroenterology University of California Davis School of Medicine Sacramento CA USA
| | - Paul P. Shao
- Division of Gastroenterology West LA VAMC, VA GLA Health System Los Angeles CA USA
- Division of Gastroenterology David Geffen School of Medicine, University of California Los Angeles Los Angeles CA USA
| | - Felix W. Leung
- Division of Gastroenterology West LA VAMC, VA GLA Health System Los Angeles CA USA
- Division of Gastroenterology David Geffen School of Medicine, University of California Los Angeles Los Angeles CA USA
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43
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Anderson JC. Use of Total Underwater Colonoscopy to Navigate Endoscopic Challenges. Clin Gastroenterol Hepatol 2020; 18:1427-1430. [PMID: 32109632 DOI: 10.1016/j.cgh.2020.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/05/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine, Dartmouth Medical, Hanover, New Hampshire; Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut.
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