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

Abstract

Background and study aims Endoscopic mucosal resection of large non-pedunculated colorectal polyps is characterized by a high risk of recurrence. Thermal ablation of the mucosal defect margins may reduce recurrence in these lesions, but a systematic overview of the current evidence is lacking.

Methods We searched PubMed, Embase and Cochrane until July 2021, for studies on thermal ablation of mucosal defect margins of large non-pedunculated colorectal polyps. Main goal of this meta-analysis was to identify pooled risk difference of recurrence between thermal ablation vs. no adjuvant treatment. Secondary goal was to identify pooled recurrence rate after snare tip soft coagulation (STSC) and argon plasma coagulation (APC).

Results Ten studies on thermal ablation of mucosal defect margins were included, with three studies on argon plasma coagulation, six studies on snare tip soft coagulation and one study comparing both treatment modalities, representing a total of 316 APC cases and 1598 STSC cases. Overall pooled risk difference of recurrence was –0.17 (95 % confidence interval [CI] –0.22 to –0.12) as compared to no adjuvant treatment. Pooled risk difference was –0.16 (95 % CI –0.19 to –0.14) for STSC and –0.26 (95 % CI –0.80 to 0.28) for APC. Pooled recurrence rate was 4 % (95 % CI 2 % to 8 %) for STSC and 9 % (95 % CI 4 % to 19 %) for APC.

Conclusions Thermal ablation of mucosal defect margins significantly reduces recurrence rate in large non-pedunculated colorectal lesions compared to no adjuvant treatment. While no evidence for superiority exists, STSC may be preferred over APC, because this method is the most evidence-based, and cost-effective modality.

• References

• 1 Meulen LWT, van der Zander OEW, Bogie RMM. et al. Evaluation of polypectomy quality indicators of large, nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort. Gastrointest Endosc 2021; 94: 1085-1095.e2
• 2 Ahlenstiel G, Hourigan LF, Brown G. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80: 668-676
• 3 Fuccio L, Hassan C, Ponchon T. et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86: 74-86
• 4 Hassan C, Recipi A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65: 806-820
• 5 Tate DJ, Desomer L, Klein A. et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017; 85: 647-656
• 6 Klein A, Tate DJ, Jayasekeran V. et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology 2019; 156: 604-613
• 7 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions-Recommendations by the US Multi-Society Task Force on colorectal cancer. Gastroenterology 2020; 158: 1095-1129
• 8 Ferlitsh M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 9 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6: e1000100
• 10 Hayden JA, van der Windt DA, Cartwright JL. et al. Assessing bias in studies of prognostic factors. Ann Intern Med 2013; 158: 280-286
• 11 Wells GA, Shea B, OʼConnell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (Accessed April 3, 2021)
• 12 R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/ (Accessed March 12, 2021)
• 13 Viechtbauer W. Conducting Meta-Analyses in R with the metafor Package. J Stat Softw 2010; 36: 1-48
• 14 Egger M, Davey Smith G. et al. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629-634
• 15 Sidhu M, Shahidi N, Gupta S. et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology 2021; 161: 163-170
• 16 Kandel P, Werlang ME, Ahn IR. et al. Prophylactic snare tip soft coagulation and its impact on adenoma recurrence after colonic endoscopic mucosal resection. Dig Dis Sci 2019; 64: 3300-3306
• 17 Kemper G, Turan AS, Schoon EJ. et al. Endoscopic techniques to reduce recurrence rates after colorectal EMR: systematic review and meta-analysis. Surg Endosc 2021; 35: 5422-5429
• 18 Brooker JC, Saunders BP, Shah SG. et al. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest Endosc 2002; 55: 371-375
• 19 Albuquerque W, Arantes VN, Coelho LG. et al. Complementation by argon plasma coagulation after endoscopic piecemeal resection of large colorectal adenomas. Rev Col Bras Cir 2013; 40: 404-408
• 20 Chattree A, Rutter MD. The use of argon plasma coagulation to prevent colorectal polyp recurrence following piecemeal endoscopic mucosal resection. Gut 2015; 64: A68
• 21 Park EY, Baek DH, Song GA. et al. Long-term outcomes of endoscopically resected laterally spreading tumors with a positive histological lateral margin. Surg Endosc 2019; 34: 3999-4010
• 22 Shahidi N, Sidhu M, Vosko S. et al. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69: 673-680
• 23 Shahidi N, Vosko S, Gupta S. et al. Previously attempted large nonpedunculated colorectal polyps are effectively managed by endoscopic mucosal resection. Am J Gastroenterol 2021; 116: 958-966
• 24 Katsinelos P, Lazaraki G, Chatzimavroudis G. et al. A retrospective comparative study of argon plasma versus polypectomy snare tip coagulation: effect on recurrence rate after resection of large laterally spreading type lesions. Ann Gastroenterol 2019; 32: 178-184
• 25 Raju GS, Lum P, Abu-Sbeih H. et al. Cap-fitted endoscopic mucosal resection of ? 20mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate. Endosc Int Open 2020; 8: E115-E121
• 26 Whitfield AM, Burgess NG, Bahin FF. et al. Histopathological effects of electrosurgical interventions in an in vivo porcine model of colonic endoscopic mucosal resection. Gut 2022; 71: 864-870
• 27 Belderbos TD, Leenders M, Moons LM. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-402
• 28 Lee EY, Bourke MJ. EMR should be the first-line treatment for large laterally spreading colorectal lesions. Gastrointest Endosc 2016; 84: 326-328
• 29 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 30 Oka S, Tanaka S, Saito Y. et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 2015; 110: 697-707
• 31 Arezzo A, Passera R, Marchese N. et al. Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United European Gastroenterol J 2016; 4: 18-29
• 32 Oka S, Tanaka S, Kanao H. et al. Therapeutic strategy for colorectal laterally spreading tumor. Dig Endosc 2009; 21: S43-S46
• 33 Bahin FF, Heitman SJ, Rasouli KN. et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67: 1965-1973
• 34 Fukuda H, Takeuchi Y, Shoji A. et al. Curative value of underwater endoscopic mucosal resection for submucosally invasive colorectal cancer. J Gastroenterol Hepatol 2021; 36: 2471-2478
• 35 Bahin FF, Pellise M, Williams SJ. et al. Extended endoscopic mucosal resection does not reduce recurrence compared with standard endoscopic mucosal resection of large laterally spreading colorectal lesions. Gastrointest Endosc 2016; 84: 997-1006
• 36 Emmanuel A, Williams S, Gulati S. et al. Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence. Gastrointest Endosc 2021; 94: 368-375
• 37 Yang D, Draganov PV, King W. et al. Margin marking before colorectal endoscopic mucosal resection and its impact on neoplasia recurrence (with video). Gastrointest Endosc 2022; 95: 956-965
• 38 Motz VL, Lester C, Moyer MT. et al. Hybrid argon plasma coagulation-assisted endoscopic mucosal resection for large sessile colon polyps to reduce local recurrence: a prospective pilot study. Endoscopy 2022; 54: 580-584