Local recurrence and subsequent endoscopic treatment after endoscopic piecemeal mucosal resection with or without precutting in the colorectum

The efficacy and safety of precutting-endoscopic mucosal resection for colorectal tumors: a systematic review and meta-analysis

BACKGROUND

Several modified endoscopic mucosal resection (EMR) techniques have been reported for colorectal tumors. Precutting-EMR (PEMR) is a modification wherein a circumferential mucosal incision is made around a lesion to facilitate en bloc resection. This review compared the efficacy and safety of PEMR with conventional EMR for colorectal lesions.

METHODS

PubMed, Embase, Scopus, and Web of Science were searched for comparative studies available before February 15, 2024. This systematic review and meta-analysis were recorded in PROSPERO, identified as CRD42024509143.

RESULTS

Two hundred and eight studies underwent screening of which seven studies were found eligible. We found no significant difference in en bloc resection rates but complete resection rates were significantly better with PEMR. The duration of the procedure was significantly longer with PEMR as compared to EMR. There was no difference in the risk of delayed bleeding and recurrence between the two groups but the risk of perforation was significantly increased with PEMR.

CONCLUSIONS

The use of PEMR for colorectal lesions can improve complete resection rates, albeit at the cost of increased duration of the procedure and higher perforation rates compared to conventional EMR. PEMR may also have a tendency of better en bloc resection rates which needs to be confirmed by further studies.

Hybrid Versus Conventional Endoscopic Submucosal Dissection for Laterally Spreading Tumors (LSTs): A Retrospective Multicenter Study

Background and Aims

Endoscopic submucosal dissection (ESD) is an established treatment for laterally spreading tumors (LSTs). Hybrid ESD, a novel technique, is gaining popularity for colorectal neoplasms. This study aimed to compare hybrid ESD with conventional ESD for treating LSTs.

Methods

Data from patients with colorectal LSTs ≥ 10 mm who underwent ESD at six centers from May 2020 to April 2023 were analyzed retrospectively. The study assessed baseline characteristics, hospitalization costs, and outcomes (operative time, R0 resection rate, complications).

Results

890 patients were included: 490 underwent conventional ESD and 400 hybrid ESD. Hybrid ESD showed significantly shorter procedure times and lower hospitalization costs compared to conventional ESD. However, the R0 resection rate and lifting sign positivity were lower with hybrid ESD. Subgroup analysis indicated potential cost savings and shorter operative times for lesions 10-30 mm with hybrid ESD, without compromising R0 resection rates. For lesions ≥ 30 mm, hybrid ESD had lower R0 resection rates despite cost savings.

Conclusion

Hybrid ESD offers a viable alternative to conventional ESD for LSTs sized 10-30 mm, reducing procedure duration and costs while ensuring R0 resection.

Cold Versus Hot Endoscopic Mucosal Resection for Sessile Serrated Colorectal Polyps ≥10 mm: A Systematic Review and Meta-analysis

INTRODUCTION

We performed a systematic review and meta-analysis studying the efficacy and safety of cold versus hot endoscopic mucosal resection (EMR) for resection of sessile serrated polyps (SSPs) ≥10 mm.

METHODS

Multiple databases were searched until January 2023 for studies reporting outcomes of cold versus hot EMR for SSPs ≥10 mm. The primary outcome was the residual SSP rate. Secondary outcomes included technical success rate, R0 resection rate, and adverse events. We used standard meta-analysis methods using the random-effects model, and I2 % was used to assess heterogeneity.

RESULTS

Thirteen studies were included in the final analysis. In all, 1896 SSPs were included with a mean polyp size of 23.7 mm (range, 15.9 to 33). A total of 1452 SSPs were followed up for a median follow-up duration of 15.3 months (range, 6 to 37). The pooled residual SSP rate for cold EMR was 4.5% (95% CI: 1.0-17.4), and 5.1% (95% CI: 2.4-10.4) for hot EMR ( P =0.9). The pooled rates of technical success, R0 resection, immediate bleeding, and perforation were comparable. Hot EMR was significantly associated with lower piecemeal resection (59.2% vs. 99.3%, P <0.001), higher en-bloc resection (41.4% vs. 1.4%, P <0.001), and delayed bleeding rate (4% vs. 0.7%, P =0.05) compared to cold EMR.

CONCLUSIONS

Cold EMR has similar efficacy compared to hot EMR for resection of SSP ≥ 10 mm, despite limitations in piecemeal R0 resection rate reporting. Although hot EMR was associated with a higher rate of en-bloc resection, it also showed an increased risk of delayed bleeding compared to cold EMR.

Cold EMR vs. Hot EMR for the removal of sessile serrated polyps larger than 10 mm: a systematic review and meta-analysis

BACKGROUND

Endoscopic mucosal resection (EMR) appears to be a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. To assess the effectiveness and safety of EMR for removing SSPs ≥ 10 mm, we conducted this systematic review and meta-analysis.

METHODS

We conducted a thorough search of Embase, PubMed, Cochrane, and Web of Science databases for relevant studies reporting on EMR of SSPs ≥ 10 mm, up until December 2023. Our primary endpoints of interest were rates of technical success, residual SSPs, and adverse events (AE).

RESULTS

Our search identified 426 articles, of which 14 studies with 2262 SSPs were included for analysis. The rates of technical success, AEs, and residual SSPs were 100%, 2.0%, and 3.1%, respectively. Subgroup analysis showed that the technical success rates were the same for polyps 10-19 and 20 mm, and en-bloc and piecemeal resection. Residual SSPs rates were similar in en-bloc and piecemeal resection, but much lower in cold EMR (1.0% vs. 4.2%, P = 0.034). AEs rates were reduced in cold EMR compared to hot EMR (0% vs. 2.9%, P = 0.168), in polyps 10-19 mm compared to 20 mm (0% vs. 4.1%, P = 0.255), and in piecemeal resection compared to en-bloc (0% vs. 0.7%, P = 0.169).

CONCLUSIONS

EMR is an effective and safe technique for removing SSPs ≥ 10 mm. The therapeutic effect of cold EMR is superior to that of hot EMR, with a lower incidence of adverse effects.

PROSPERO REGISTRATION NUMBER

CRD42023388959.

Adenoma Recurrence after Endoscopic Piecemeal Mucosal Resection of Colorectal Flat Lesions: Applicability of the Sydney EMR Recurrence Tool in a Non-Tertiary Centre

<b><i>Introduction:</i></b> Endoscopic mucosal resection (EMR) is the treatment of choice for non-invasive colorectal flat lesions. When endoscopic piecemeal mucosal resection (EPMR) is performed, endoscopic surveillance is necessary due to the risk of recurrence. The Sydney EMR Recurrence Tool (SERT) is a 0–4 scale that classifies lesions according to size, occurrence of intraprocedural bleeding (IPB) and presence of high-grade dysplasia (HGD). Our goal is to evaluate the applicability of SERT in predicting adenoma recurrence (AR) after EPMR. <b><i>Methods:</i></b> This is a retrospective single-centre study with inclusion of lateral spreading lesions ≥20 mm, consecutively resected by EPMR from March 2010 to February 2018, with at least 1 endoscopic re-evaluation. <b><i>Results:</i></b> A total of 181 lesions were included, corresponding to 174 patients with a mean age of 68 years and male gender predominance (61%; <i>n</i> = 106). The most frequent location was the ascending colon (34%; <i>n</i> = 62). Lesions were assessed according to Paris Classification (PC): 0-IIa: 39% (<i>n</i> = 71); 0-IIb: 24% (<i>n</i> = 43); 0-IIa + Is: 23% (<i>n</i> = 42); 0-IIa + IIb: 6% (<i>n</i> = 11); 0-IIa + IIc: 2% (<i>n</i> = 3). The mean size of the lesions was 33 ± 11 mm, with 25 (14%) being ≥40 mm. IPB occurred in 9 cases (5%), and 44 lesions (24%) displayed HGD. Sixty-six lesions (36.5%) were classified as SMSA (size, morphology, site, and access score) level 4. Adjunctive therapy with argon plasma coagulation (APC) was used in 37% (<i>n</i> = 67) of cases. The 6-month AR rate was 16% (<i>n</i> = 29). According to SERT groups, the AR rate was: SERT 0: 12% (14/120); SERT 1: 17% (6/35); SERT 2: 25% (3/12); SERT 3: 30% (3/10); SERT 4: 75% (3/4). Two of the three SERT variables (size ≥40 mm and IPB) were associated with recurrence at 6 months (<i>p</i> &#x3c; 0.05). HGD and the remaining tested variables (age, gender, localization, accessibility, PC, use of APC/biopsy forceps and occurrence of delayed bleeding) were not associated with AR. SERT 0 lesions showed an inferior risk of 6-month AR (adjusted OR = 2.62; <i>p</i> = 0.035), with a negative predictive value of 88%. SMSA correlated with SERT (<i>p</i> &#x3c; 0.001) and SMSA level 4 was associated with 6-month AR (<i>p</i> = 0.007). Lesions classified both as SERT 0 and SMSA level &#x3c;4 had the lowest 6-month recurrence rate (9.2%). The 24-month recurrence rate was 23% (<i>n</i> = 41). When applying the Kaplan-Meier method, cumulative recurrence was significantly lower in SERT 0 lesions (<i>p</i> = 0.006, log-rank test). <b><i>Discussion/Conclusion:</i></b> Resection of flat colorectal lesions by EPMR has a considerable risk of recurrence, mostly in SERT 1–4 lesions. SERT 0 lesions, especially with SMSA level &#x3c;4, show a lower risk of recurrent adenoma, which might allow longer intervals to first endoscopic surveillance in the future.

Does precutting prior to endoscopic piecemeal resection of large colorectal neoplasias reduce local recurrence? A KASID multicenter study

BACKGROUND

It would be expected that local recurrence could be reduced by performing precutting (with sufficient margins) prior to endoscopic piecemeal mucosal resection (EPMR). We explored the clinical outcomes and local recurrence after precutting EPMR of large colorectal neoplasias.

METHODS

Between January 2005 and December 2015, in total, 223 patients with colorectal neoplasias ≥ 2 cm in diameter removed via EPMR in four tertiary hospitals were enrolled. The patients were divided into a precut EPMR group (n = 62) and a non-precut EPMR group (n = 161). We retrospectively evaluated clinical outcomes and factors associated with local recurrence.

RESULTS

The mean total procedure time was significantly shorter in the non-precut EPMR group than in the precut EPMR group. However, the number of pieces, and the complete resection and recurrence rates, did not differ significantly [for the latter, precut 8.1% vs. non-precut 9.9%, P = 0.668]. The complete resection rate, number of pieces, and use of argon plasma coagulation (APC) were significantly associated with the local recurrence rate on univariate analysis. In the Cox's proportional hazards model, prophylactic APC [hazard ratio 0.307, 95% confidence interval (CI) 0.114-0.823; P = 0.019] and complete resection rate (odds ratio 0.083, 95% CI 0.011-0.655; P = 0.018) were significantly associated with the local recurrence rate.

CONCLUSION

Precutting prior to EPMR did not significantly reduce the local recurrence rate or the number of resected pieces. Histologically complete resection, reducing the number of pieces, and prophylactic APC seem to be important in terms of reducing local recurrence.

Efficacy and Safety of Endoscopic Resection of Sessile Serrated Polyps 10 mm or Larger: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

The best method for endoscopic resection of sessile serrated polyps (SSP) 10 mm or larger is unclear; studies report variable outcomes in comparison to conventional adenomas. We performed a systematic review and meta-analysis to assess the efficacy and safety of resection of SSPs 10 mm or larger in size.

METHODS

We searched the PubMed/MEDLINE, Google Scholar, Embase, and Cochrane databases for studies reporting data on endoscopic resection of SSPs 10 mm or larger, through May 31st, 2019. The primary outcome was rate of residual SSP, which was the rate of residual SSP found at the polypectomy site during the first follow-up colonoscopy. Secondary outcomes were: technical success (rate of complete macroscopic resection), R0 resection rate (complete histological resection with absence of any polyp tissue at the lateral and deep margins after en-bloc resection), and adverse events (immediate or delayed bleeding and perforation). We performed IQR,group analyses for outcomes based on polyp size and resection techniques. Pooled proportion rates (%) or odds ratio with 95% CIs with heterogeneity (I²) and P < .05.

RESULTS

A total of 14 studies met the inclusion criteria: 911 patients (50.2% male; mean age, 62.8 ± 4.9 years) who underwent resection of 1137 SSPs (574 SSPs ≥ 20 mm) with a median polyp size of 19.4 mm (interquartile range, 15.9-29.6 mm). Follow-up information was available for 832 SSPs with a median follow-up duration of 12 months (interquartile range, 6-22.5 months). Piecemeal resection was performed in 58.5% SSPs. The pooled residual SSP rate was 4.3% (95% CI, 2%-6.5%). There was a higher residual SSP rate for polyps ≥ 20 mm compared to 10-19 mm (5.9% vs 1.2%; odds ratio, 3.02; 95% CI, 1-9.2; P = .049). Cold endoscopic mucosal resection (EMR) had significantly lower rates of delayed bleeding (0 vs 2.3%; P = .03) and residual polyp rate (0.9% vs 5%; P=.01) compared to hot EMR, based on univariate analysis. In multi-variate analysis there was no difference in residual polyp rate. There was no significant difference in other outcomes based on the size or method of resection.

CONCLUSIONS

In a systematic review and meta-analysis, we found that SSPs ≥ 10 mm can be safely resected with low residual polyp rates. Polyp size ≥ 20 mm is a significant factor for residual polyp. Compared to hot EMR, cold EMR is associated with a lower rate of delayed bleeding. Randomized controlled trials comparing hot and cold resection are needed to standardize techniques and optimize outcomes.

Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video)

BACKGROUND AND AIMS

Conventional EMR using a hot snare is the standard of care for resection of large (≥20 mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly because of electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). This study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized ≥20 mm.

METHODS

All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps ≥20 mm over a 2-year period, from January 2016 to December 2017, were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records.

RESULTS

CSP-EMR was performed on 204 polyps sized ≥20 mm in 186 patients (men, 33.8%; median age, 68 years). SC1 for 164 polyps (80.4%) at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% confidence interval, 3%-11%). SC2 for 113 polyps (72.9%) at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% confidence interval, .9%-8.5%) after a normal SC1. Intraprocedural bleeding was successfully treated in 4 patients (2.2%), whereas 7 patients (3.8%) experienced self-limited clinically significant post-EMR bleeding and 1 patient (.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events.

CONCLUSIONS

CSP-EMR of sessile colonic polyps ≥20 mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR and to further determine the polyp morphologies that are best suited for CSP-EMR.

Cost of Endoscopic Submucosal Dissection Versus Endoscopic Piecemeal Mucosal Resection in the Colorectum

BACKGROUND

Few studies have compared the costs of colorectal endoscopic submucosal dissection (ESD) and endoscopic piecemeal mucosal resection (EPMR).

AIMS

Here, we aimed to investigate the cost-effectiveness of these approaches by analyzing clinical outcomes and costs.

METHODS

Data from patients undergoing colorectal ESD and EPMR were retrospectively reviewed. Clinical outcomes (procedure time, complete resection, and recurrence) were compared, and total direct costs (procedural and follow-up) were assessed.

RESULTS

Data from 429 ESD and 115 EPMR patients were included in the analysis. The complete resection rate was significantly higher (83.9% vs. 32.2%, p < 0.001), recurrence rate was lower (0.5% vs. 7.1%, p < 0.001), procedure time was longer (55.4 ± 47.0 vs. 25.6 ± 32.7 min, p < 0.001), and total direct procedural costs at the initial resection were higher (1480.0 ± 728.0 vs. 729.8 ± 299.7 USD, p < 0.001) in the ESD group than in the EPMR group. The total number of surveillance endoscopies was higher in the EPMR group (1.7 ± 1.5 vs. 1.3 ± 1.1, p = 0.003). The cumulative total costs of ESD and EPMR were comparable at 3 and 2 years' follow-up in the adenoma and mucosal/superficial submucosal cancer subgroups, respectively.

CONCLUSIONS

Colorectal ESD was associated with higher complete resection and lower recurrence rates. EPMR showed shorter procedure times and similar cumulative total direct costs. ESD or EPMR should be chosen based on both clinical outcomes and cost-effectiveness.

Clinical outcomes of submucosal colorectal cancer diagnosed after endoscopic resection: a focus on the need for surgery

Background/Aims

We aimed to investigate the proportion of and risk factors for residual cancer and/or lymph node metastasis after surgery was performed because of high-risk pathological features in endoscopic resection specimen of suspected superficial submucosal colorectal cancer (SSMC).

Methods

We reviewed medical records of 497 patients (58.8 ± 9.8 years, 331 males) undergoing endoscopic resection of suspected SSMC. High-risk pathological features included: deep submucosal cancer invasion ≥ 1,000 μm; positive lymphovascular and/or perineural invasion; poorly differentiated adenocarcinoma; and positive resection margin. We investigated the occurrence of additional surgery and residual cancer and/or lymph node involvement in the surgical specimen.

Results

En bloc resection was performed in 447 patients (89.9%). High-risk pathological features were detected in 372 patients (74.8%). Additional surgery was performed in 336 of 372 patients with high-risk pathological features. Of these, 47 surgical specimens (14.0%) showed residual cancer and/or lymph node metastasis. Piecemeal resection was more common in those with residual cancer and/or lymph node involvement than those without (9/47 [19.1%] vs. 24/289 [8.3%], P= 0.032). Positive resection margin was also significantly associated with positive residual cancer and/or lymph node involvement. As the number of high-risk pathological features increased, the risk of regional lymph node metastasis increased proportionally (P= 0.002).

Conclusions

High-risk pathological features were frequently detected after endoscopic resection of suspected SSMC while residual cancer and/or lymph node metastasis were not commonly present in the additional surgical specimen. Further optimized strategy for proper endoscopic management of suspected SSMC is necessary.