Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions

Tate, David J.; Bahin, Farzan F.; Desomer, Lobke; Sidhu, Mayenaaz; Gupta, Vikas; Bourke, Michael J.

doi:10.1055/s-0043-119215

Cited by 42 publications

(86 citation statements)

References 25 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Most pEGCs were located in the gastric antrum (60/135, 44.4%) ( Table 2). The median size of pEGCs was 20 mm (interquartile range [IQR], [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30], and this was larger in the expanded criteria (30 mm; IQR, 25-40) and outside criteria groups (30 mm; IQR, 20-50) versus the LGD LGD was commonly located in the antrum (24/42, 57.1%). The most common morphology of pEGC was Paris 0-IIa (54/135, 40.0%).…”

Section: Lesion Assessmentmentioning

confidence: 99%

“…At the surveillance procedure (4 months) a small residual at the scar was treated with cold forceps avulsion and adjuvant snare tip soft coagulation. 19 At second surveillance (10 months) a depressed, demarcated area was detected adjacent to the scar, and the patient was referred for surgery. The surgical specimen demonstrated HGD only.…”

Section: Endoscopic Surveillancementioning

confidence: 99%

See 1 more Smart Citation

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

Tate

Klein

Sidhu

et al. 2019

Gastrointestinal Endoscopy

Self Cite

View full text Add to dashboard Cite

Background and Aims: Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgerysparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen-confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort. Methods: Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months. Results: Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence. Conclusions: ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only.

show abstract

Section: Lesion Assessmentmentioning

confidence: 99%

Section: Endoscopic Surveillancementioning

confidence: 99%

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

Tate

Klein

Sidhu

et al. 2019

Gastrointestinal Endoscopy

Self Cite

View full text Add to dashboard Cite

show abstract

“…Hot avulsion as part of EMR is often performed using a low voltage current to reduce the risk of thermal injury. Advocates of cold avulsion 11,12 cite concern about the risk of grasping and injuring the muscularis propria during hot avulsion. Some endoscopists follow cold avulsion with soft coagulation treatment of the avulsion defect using the snare tip.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

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

Kumar

Broadley

Rex

2019

Gastrointestinal Endoscopy

View full text Add to dashboard Cite

Background: Excision of all visible neoplastic tissue is the goal of endoscopic mucosal resection (EMR) of colorectal laterally spreading tumors (LSTs). Flat and fibrotic tissue can resist snaring. Ablation of visible polyps is associated with high recurrence rates. Avulsion is a technique to continue resection when snaring fails. Methods: We retrospectively analyzed colonic EMRs of 564 consecutive referred polyps between 2015 and 2017. Hot avulsion was used when snaring was unsuccessful. Polyps treated with and without avulsion were compared. Results: Hot avulsion was used in 20.9% (n=112) of all resected lesions. The recurrence rates on follow up colonoscopy were 17.52% in avulsion group versus 16.02% in the non-avulsion group (p= 0.76). Hot avulsion was associated with a trend toward higher rates of delayed hemorrhage (5.35% vs 2.58%; p=0.15) and post-coagulation syndrome (1.8% vs 0.47%; p=0.15), but polyps treated with any avulsion were larger than those in which no avulsion was used (p=<0.001). There were an insufficient number of adverse events to perform a multivariable analysis testing the effects of avulsion, size, and location on the risk of overall adverse events. Conclusion: Unlike previous reports of using argon plasma coagulation to treat visible polyp during EMR, hot avulsion of visible/fibrotic neoplasia was associated with similar EMR efficacy compared with cases that did not require hot avulsion. The safety profile of hot avulsion appears acceptable.

show abstract

“…Longitudinal recurrence studies have examined recurrence of mostly !20-mm large polyps that were removed piecemeal. 2,[14][15][16][17][18] For clinical practice, marking each polyp site would not be feasible, and a follow-up period of several years to the first surveillance colonoscopy would further hinder assessment of incomplete resection in a prospective fashion. The method applied in this study provides an alternative approach to examine incomplete resection.…”

Section: Discussionmentioning

confidence: 99%

Metachronous Neoplasias Arise in a Higher Proportion of Colon Segments From Which Large Polyps Were Previously Removed, and Can be Used to Estimate Incomplete Resection of 10–20 mm Colorectal Polyps

Adler

Toy

Anderson

et al. 2019

Clinical Gastroenterology and Hepatology

View full text Add to dashboard Cite

Incomplete resection of polyps could be an important cause of post-colonoscopy colorectal cancer. However, it is difficult to study progression of incompletely removed polyps or their clinical importance. We aimed to estimate incomplete polyp resection using risk of metachronous neoplasia per colon segment. METHODS:We performed a retrospective study of 1031 patients (6186 colon segments) who initially underwent resection of a large (10-20 mm) neoplastic polyp at 2 academic medical centers (from 2000 through 2012) and then underwent a subsequent colonoscopy within 0.5 to 5 years. We determined the proportions of metachronous neoplasia in colon segments from which a single large neoplastic polyp was removed and in segments without prior neoplasia. We then used the absolute difference in proportions between these groups to estimate the rate of incomplete resection. Our analysis assumed that development of metachronous neoplasia in each colon segment was the consequence of a newly grown polyp, a previously missed polyp, or an incompletely removed polyp. RESULTS:Metachronous neoplasia was detected in 177 of 757 segments (23.4%) with a single large polyp, and in 438 of 4232 segments (10.3%) without any neoplasia at baseline colonoscopy (P < .001). Resections were therefore estimated to be incomplete in 13.0% of segments (95% CI,. This proportion was greater for sections with non-pedunculated polyps (18.3%; 95% CI, 14.2-22.5) than pedunculated polyps (3.5%; 95% CI, -0.7 to -11.3; P < .001). A higher proportion of piecemeal resections appeared to be incomplete (28.0%; 95% CI, 20.2-35.7) than of en bloc resections (9.2%; 95% CI, 5.9-12.5) (P < .001). No differences in incomplete resection were associated with polyp histology. CONCLUSION:Metachronous neoplasia arises in a significantly higher proportion of colon segments from which a polyp was previously removed. Based on these data, we estimate that 13% of all large polyps are incompletely resected and 18% of large non-pedunculated polyps are incompletely resected. These findings indicate that incomplete resection could be a risk factor for later development of neoplasia. Segment metachronous neoplasia might be used as a marker of resection quality.

show abstract

Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions

Abstract: CAST is a safe, effective, and surgery-sparing therapy for the majority of non-lifting LSLs. It is easy to use, inexpensive, and does not require additional equipment.

Cited by 42 publications

References 25 publications

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

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

Metachronous Neoplasias Arise in a Higher Proportion of Colon Segments From Which Large Polyps Were Previously Removed, and Can be Used to Estimate Incomplete Resection of 10–20 mm Colorectal Polyps

Contact Info

Product

Resources

About