Tip-in Endoscopic Mucosal Resection for en bloc Resection of a Large Pedunculated Polyp

AbstractSmall rectal neuroendocrine tumors (NETs) can be treated using cap-assisted endoscopic mucosal resection (EMR-C), which requires additional effort to apply a dedicated cap and snare. We aimed to evaluate the feasibility of a simpler modified endoscopic mucosal resection (EMR) technique, so-called anchored snare-tip EMR (ASEMR), for the treatment of small rectal NETs, comparing it with EMR-C. We retrospectively evaluated 45 ASEMR and 41 EMR-C procedures attempted on small suspected or established rectal NETs between July 2015 and May 2020. The mean (SD) lesion size was 5.4 (2.2) mm and 5.2 (1.7) mm in the ASEMR and EMR-C groups, respectively (p = 0.558). The en bloc resection rates of suspected or established rectal NETs were 95.6% (43/45) and 100%, respectively (p = 0.271). The rates of histologic complete resection of rectal NETs were 94.1% (32/34) and 88.2% (30/34), respectively (p = 0.673). The mean procedure time was significantly shorter in the ASEMR group than in the EMR-C group (3.12 [1.97] vs. 4.13 [1.59] min, p = 0.024). Delayed bleeding occurred in 6.7% (3/45) and 2.4% (1/41) of patients, respectively (p = 0.618). In conclusion, ASEMR was less time-consuming than EMR-C, and showed similar efficacy and safety profiles. ASEMR is a feasible treatment option for small rectal NETs.

Download Full-text

Endoscopic resection outcomes and predictors of failed en bloc endoscopic mucosal resection of colorectal polyps ≤ 20 mm among advanced endoscopy trainees

Endoscopy International Open ◽

10.1055/a-1578-1965 ◽

2021 ◽

Vol 09 (11) ◽

pp. E1820-E1826

Author(s):

William W. King ◽

Peter V. Draganov ◽

Andrew Y. Wang ◽

Dushant Uppal ◽

Amir Rumman ◽

...

Keyword(s):

Multivariate Analysis ◽

Endoscopic Mucosal Resection ◽

En Bloc Resection ◽

Lesion Size ◽

Bloc Resection ◽

Colorectal Polyps ◽

Polyp Size ◽

En Bloc ◽

Mucosal Resection ◽

Piecemeal Resection

Abstract Background and study aims En bloc endoscopic mucosal resection (EMR) is preferred over piecemeal resection for polyps ≤ 20 mm. Data on colorectal EMR training are limited. We aimed to evaluate the en bloc EMR rate of polyps ≤ 20 mm among advanced endoscopy trainees and to identify predictors of failed en bloc EMR. Methods This was a multicenter prospective study evaluating trainee performance in EMR during advanced endoscopy fellowship. A logistic regression model was used to identify the number of procedures and lesion cut-off size associated with an en bloc EMR rate of ≥ 80 %. Multivariate analysis was performed to identify predictors of failed en bloc EMR. Results Six trainees from six centers performed 189 colorectal EMRs, of which 104 (55 %) were for polyps ≤ 20 mm. Of these, 57.7 % (60/104) were resected en bloc. Trainees with ≥ 30 EMRs (OR 6.80; 95 % CI: 2.80–16.50; P = 0.00001) and lesions ≤ 17 mm (OR 4.56;95 CI:1.23–16.88; P = 0.02) were more likely to be associated with an en bloc EMR rate of ≥ 80 %. Independent predictors of failed en bloc EMR on multivariate analysis included: larger polyp size (OR:6.83;95 % CI:2.55–18.4; P = 0.0001), right colon location (OR:7.15; 95 % CI:1.31–38.9; P = 0.02), increased procedural difficulty (OR 2.99; 95 % CI:1.13–7.91; P = 0.03), and having performed < 30 EMRs (OR: 4.87; 95 %CI: 1.05–22.61; P = 0.04). Conclusions In this pilot study, we demonstrated that a relatively low proportion of trainees achieved en bloc EMR for polyps ≤ 20 mm and identified procedure volume and lesion size thresholds for successful en bloc EMR and independent predictors for failed en bloc resection. These preliminary results support the need for future efforts to define EMR procedure competence thresholds during training.

Download Full-text

Efficacy of precutting endoscopic mucosal resection with full or partial circumferential incision using a snare tip for difficult colorectal lesions

Endoscopy ◽

10.1055/a-0956-6879 ◽

2019 ◽

Vol 51 (09) ◽

pp. 871-876 ◽

Cited By ~ 4

Author(s):

Naohisa Yoshida ◽

Ken Inoue ◽

Osamu Dohi ◽

Ritsu Yasuda ◽

Ryohei Hirose ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

Complete Resection ◽

Benign Lesions ◽

Resection Rate ◽

En Bloc ◽

Mucosal Resection ◽

Therapeutic Outcomes ◽

Mucosal Incision

Abstract Background We analyzed the efficacy of precutting endoscopic mucosal resection (EMR), which is a method of making a full or partial circumferential mucosal incision around a tumor with a snare tip for en bloc resection. Methods We reviewed cases from 2011 to 2018 in which precutting EMR (n = 167) and standard EMR (n = 557) were performed for lesions of 10 – 30 mm. Precutting EMR was indicated for benign lesions of 20 – 30 mm or lesions of < 20 mm for which standard EMR was difficult. Through propensity score matching of the two groups, the therapeutic outcomes for 35 lesions of ≥ 20 mm and 98 lesions of < 20 mm in each group were analyzed. Results In the two sizes of lesion, there were significant differences between the precutting and standard groups in the en bloc resection rate (≥ 20 mm 88.6 % vs. 48.5 %, P < 0.001; < 20 mm 98.0 % vs. 85.7 %, P = 0.004) and the histological complete resection rate (≥ 20 mm 71.4 % vs. 42.9 %, P = 0.02; < 20 mm 87.8 % vs. 67.3 %, P < 0.001). Conclusion Precutting EMR enabled high en bloc resection rates in cases involving difficult lesions.

Download Full-text

Endoscopic mucosal resection with an additional working channel (EMR+) in a porcine ex vivo model: a novel technique to improve en bloc resection rate of snare polypectomy

Endoscopy International Open ◽

10.1055/a-0996-8050 ◽

2020 ◽

Vol 08 (02) ◽

pp. E99-E104 ◽

Cited By ~ 3

Author(s):

Richard F. Knoop ◽

Edris Wedi ◽

Golo Petzold ◽

Sebastian C.B. Bremer ◽

Ahmad Amanzada ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Ex Vivo ◽

En Bloc Resection ◽

Bloc Resection ◽

Resection Rate ◽

Ex Vivo Model ◽

En Bloc ◽

Novel Technique ◽

Mucosal Resection ◽

Flat Lesions

Abstract Background and study aims Recently, a new external additional working channel (AWC) was introduced by which conventional endoscopic mucosal resection (EMR) can be improved to a technique termed “EMR+”. We first evaluated this novel technique in comparison to classical EMR in flat lesions. Methods The trial was prospectively conducted in an ex vivo animal model with porcine stomachs placed into the EASIE-R simulator. Prior to intervention, standardized lesions were set by coagulation dots, measuring 1, 2, 3 or 4 cm. Results Overall, 152 procedures were performed. EMR and EMR+ were both very reliable in 1-cm lesions, each showing en bloc resection rates of 100 %. EMR+ en bloc resection rate was significantly higher in 2-cm lesions (95.44 % vs. 54.55 %, P = 0.02), in 3-cm lesions (86.36 % vs. 18.18 %, P < 0.01) and also in 4-cm lesions (60.00 % vs. 0 %, P < 0.01). Perforations occurred only in EMR+ procedures in 4-cm lesions (3 of 20; 15 %). Conclusions With its grasp-and-snare technique, EMR+ facilitates en bloc resection of larger lesions compared to conventional EMR. In lesions 2 cm and larger, EMR+ has demonstrated advantages, especially concerning en bloc resection rate. At 3 cm, EMR+ reaches its best discriminatory power whereas EMR+ has inherent limits at 4 cm and in lesions of that size, other techniques such as ESD or surgery should be considered.

Download Full-text

Endoscopic Mucosal Resection of a Proximal Esophageal Pyogenic Granuloma

Case Reports in Gastrointestinal Medicine ◽

10.1155/2019/9869274 ◽

2019 ◽

Vol 2019 ◽

pp. 1-4

Author(s):

Elias Estifan ◽

Varun Patel ◽

Matthew Grossman

Keyword(s):

Endoscopic Mucosal Resection ◽

English Literature ◽

Muscularis Propria ◽

Pyogenic Granuloma ◽

En Bloc Resection ◽

Bloc Resection ◽

Capillary Hemangioma ◽

Prognostic Information ◽

En Bloc ◽

Mucosal Resection

Pyogenic Granuloma (PG), also known as lobular capillary hemangioma, is usually seen as a polypoid red lesion found on the skin or the mucosal surface of the oral cavity. PG of the gastrointestinal tract is rare, in particular involving the esophagus, only 14 cases have been reported in the English literature. We present an 80-year-old male who underwent endoscopy for evaluation of dysphagia and was found to have a single, red, bilobed 10 mm polyp with adherent white exudate approximately 19 cm from the incisors. Endoscopic ultrasound was performed with a 20 mHz miniprobe which showed the lesion contained to the mucosal layer with no muscularis propria invasion. A decision was made to perform endoscopic mucosal resection (EMR). A mixture of saline and methylene blue was injected into the submucosal plane to raise the lesion with subsequent successful mucosal hot snare resection. The resection defect was then approximated and closed with a hemostatic clip to prevent bleeding. Pathology of the specimen revealed small capillary vessels growing in a lobular architecture with an edematous stroma and a florid inflammatory infiltrate representing a pyogenic granuloma. EMR allows for an en bloc resection of mucosal lesions with tumor-free margins, thereby providing both diagnostic and prognostic information. Comparing EMR with the novel technique of endoscopic submucosal dissection (ESD), the incidence of bleeding and perforation is much lower; making EMR the best and safest resection option for this rare hemangioma. In this case, we demonstrate that EMR is a safe technique in removing a pyogenic granuloma in the esophagus.

Download Full-text

Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial

BMC Gastroenterology ◽

10.1186/s12876-020-01457-y ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Zhixin Zhang ◽

Yonghong Xia ◽

Hongyao Cui ◽

Xin Yuan ◽

Chunnian Wang ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Polyps ◽

Efficacy And Safety ◽

Resection Rate ◽

En Bloc ◽

Randomized Controlled ◽

Mucosal Resection ◽

Group 1

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.

Download Full-text

OC.01.6 UNDERWATER ENDOSCOPIC MUCOSAL RESECTION: THE THIRD WAY FOR EN BLOC RESECTION OF COLONIC LESIONS?

Digestive and Liver Disease ◽

10.1016/s1590-8658(16)30018-4 ◽

2016 ◽

Vol 48 ◽

pp. e74

Author(s):

A. Amato ◽

F. Radaelli ◽

S. Paggi ◽

E. Rondonotti ◽

G. Spinzi

Keyword(s):

Endoscopic Mucosal Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

En Bloc ◽

Third Way ◽

The Third ◽

Mucosal Resection

Download Full-text

Is underwater endoscopic mucosal resection of colon polyps superior to conventional techniques? A network analysis of endoscopic mucosal resection and submucosal dissection

Endoscopy International Open ◽

10.1055/a-1633-3230 ◽

2022 ◽

Vol 10 (01) ◽

pp. E154-E162

Author(s):

Choon Seng Chong ◽

Mark D. Muthiah ◽

Darren Jun Hao Tan ◽

Cheng Han Ng ◽

Xiong Chang Lim ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Meta Analysis ◽

Operating Time ◽

En Bloc Resection ◽

Bloc Resection ◽

Colon Polyps ◽

En Bloc ◽

Oncological Outcomes ◽

Mucosal Resection ◽

Submucosal Dissection

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.

Download Full-text