Previously Attempted Large Nonpedunculated Colorectal Polyps Are Effectively Managed by Endoscopic Mucosal Resection

Abstract

INTRODUCTION: Endoscopic mucosal resection (EMR) is an effective therapy for naive large nonpedunculated colorectal polyps (N-LNPCPs). The best approach for the treatment of previously attempted LNPCPs (PA-LNPCPs) is undetermined. METHODS: EMR performance for PA-LNPCPs was evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by technical success (removal of all visible polypoid tissue during index EMR) and recurrence at first surveillance colonoscopy (SC1). Safety was assessed by clinically significant intraprocedural bleeding, deep mural injury types III–V, clinically significant post-EMR bleeding, and delayed perforation. RESULTS: From January 2012 to October 2019, 158 PA-LNPCPs and 1,134 N-LNPCPs underwent EMR. Median PA-LNPCP size was 30 mm (interquartile range 25–46 mm). Technical success was 93.0% and increased to 95.6% after adjusting for 2-stage EMR. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) was required for nonlifting polypoid tissue in 73 (46.2%). Median time to SC1 was 6 months (interquartile range 5–7 months). Recurrence occurred in 9 (7.8%). No recurrence was identified among 65 PA-LNPCPs which underwent margin thermal ablation at SC1 vs 9 (18.0%; P < 0.001) which did not. There were significant differences in resection duration (35 vs 25 minutes; P < 0.001), technical success (93.0% vs 96.6%; P = 0.026), and use of CAST (46.2% vs 7.6%; P < 0.001), between PA-LNPCPs and N-LNPCPs. When adjusting for 2-stage EMR, no difference in technical success was identified (95.6% vs 97.8%; P = 0.100). No differences in adverse events or recurrence were identified. DISCUSSION: EMR, using auxillary techniques where necessary, can achieve high technical success and low recurrence frequencies for PA-LNPCPs.

Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis

“…However, our data showed that operators in general agree about the settings for STSC. For STSC, universally, the soft coagulation mode is used with a current of 80 Watts and effect mode 4 on Erbe ENDO CUT Q 6 15 21 22 23 .…”

“…However, our data showed that operators in general agree about the settings for STSC. For STSC, universally, the soft coagulation mode is used with a current of 80 Watts and effect mode 4 on Erbe ENDO CUT Q [6,15,[21][22][23]. Settings for APC show more variation between operators, with currents between 30-70 Watts and a gasflow of 0.8-2.0 liters per min [18,19,24,25].…”

Transanal Endoscopic Microsurgical Submucosal Dissection for Recurrent Rectal Adenomas

“…Additionally, operating time was not significantly longer in the recurrent lesions group, further pointing out the importance of this approach in overcoming the problems caused by fibrosis. In comparison, several studies have shown significantly increased technical difficulty, longer procedure times, and lower success rates for both EMR and ESD for recurrent lesions [13, 16]. Especially in the case of flexible ESD, some authors point out that only ESD experts should perform these difficult procedures, and the findings of studies in reference centres may not be generalized to all institutions [15].…”

How to Manage the Large Nonpedunculated Colorectal Polyp

“…These findings have now been reproduced in complex lesion subgroups, including LNPCPs involving the anorectal junction 8 and previously attempted LNPCPs. 9 Before thermal ablation, all visible polypoid tissue should be removed. Expose 1-2 mm of the snare-tip and gently apply it using snare-tip soft coagulation (Effect 4, 80 W: ERBE Electromedizin, Tubingen, Germany), aiming to create a 3-to 5-mm rim of ablated tissue around the complete resection defect.…”