Hybrid APC Colon EMR, A Novel Approach to Reduce Local Recurrence

Abstract

BACKGROUND AND AIMS: Endoscopic mucosal resection (EMR) has become the standard for removing large colon polyps but has a 10%-30% recurrence rate using standard techniques. Data shows improved recurrence rates with focal therapy of the edge of the resection base using cautery. We examine a novel technique, hybrid APC assisted EMR, which treats both the edge and the base with cautery to assess its effect on local recurrence. METHODS:We reviewed all EMRs of polyps >2 cm by a single endoscopist with 6-month follow-up from May 2018 to November 2019 using both standard EMR as well as hybrid APC assisted EMR to assess local recurrence as well adverse events.RESULTS: Forty-eight patients with 59 polyps removed by EMR had full 6 month follow up with a mean age of 66.1 years of age, 45% were female. Thirty polyps were removed by hybrid APC assisted EMR and 29 removed with standard EMR. Overall, 0 (0%) polyps in the h-APC arm had local recurrence while 6 (20.7%) in the standard group had histological proven local recurrence (P = 0.01). Postresection bleeding occurred in 6 patients, 2 in the hAPC arm and 4 in the standard arm (P = 0.41). CONCLUSION:In this retrospective pilot study, hybrid APC assisted EMR was superior to conventional EMR for local recurrence after removal of large colon polyps and trended towards a less post-EMR bleeds.

Hybrid Argon Plasma Coagulation for Barrett’s Esophagus and for Colonic Mucosal Resection—A Systematic Review and Meta-Analysis

“…These reports enrolled 164 subjects, from whom 195 non-pedunculated polyps were removed (166 with hAPC-assisted EMR). Polyps’ size was similar among studies, as was the rate of complete lifting; however, the percentage of en bloc resection varied: 6% in the study by Motchum et al [ 10 ] and 28.8% in that by Levenick et al [ 12 ]. Regarding the hAPC technique, even though the settings were similar (effect 30–50, prior to thermal ablation with 40 watts), both the eschar base and peripheral edges were always ablated only in two of the studies [ 11 , 12 ].…”

“…Three studies [ 10 , 11 , 12 ] evaluated the use of hAPC after EMR of colonic polyps, two of which were prospective [ 10 , 11 ] ( Table 2 ). These reports enrolled 164 subjects, from whom 195 non-pedunculated polyps were removed (166 with hAPC-assisted EMR).…”

“…Another field where hAPC has been generating interest is in the adjuvant management of large (>20 mm) non-pedunculated colorectal lesions [ 10 , 11 , 12 ] which carry a significant risk of submucosal invasive cancer [ 13 ]. The mainstay for these polyps’ resection is endoscopic mucosal resection (EMR), mostly in a piecemeal fashion.…”

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

“…Given the concerns for potential residual microscopic tissue within the EMR resection bed, novel adjuvant techniques such as hAPC applied to the resection bed are undergoing evaluation. Notably, an early pilot study has shown a significant reduction in recurrence, with a 0% recurrence rate at SC1 in patients undergoing adjunctive hAPC versus 20.7% (p=0.01) in the standard EMR arm [5]. However, data from larger comparative studies are needed.…”

“…Adjuvant techniques such as the application of snare-tip soft coagulation (STSC) to EMR defect edges and hybrid APC (hAPC) have been shown to reduce recurrence from potential non-visible residual microscopic tissue [4,5]. Additionally, new adjunc-Need for adjunctive removal techniques for endoscopic mucosal resection of large non-pedunculated colonic polyps is predictive of recurrence tive techniques such as the use of hot avulsion and cold avulsion with snare-tip soft coagulation (CAST) have been shown to be efficacious in recent years to manage macroscopic polyp tissue not amenable to snare resection [6][7][8].…”