Comparison of underwater and conventional endoscopic mucosal resection for removing sessile colorectal polyps: a propensity-score matched cohort study

Abstract

Background and study aims Endoscopic mucosal resection (EMR) is a standard method for removing sessile colorectal polyps ≥ 10 mm. Recently, underwater EMR (UEMR) has been introduced as a potential alternative. However, the effectiveness and safety of UEMR compared with conventional EMR is un clear.

Patients and methods In this 1:1 propensity score (PS) matched retrospective cohort study, we compared the en bloc resection rates, procedure time, intraprocedural and delayed bleeding rates, and incidence of muscle layer injury. We also performed subgroup analyses by sizes of polyps (< 20 mm and ≥ 20 mm).

Results Among 350 polyps in 315 patients from August 2012 to November 2017, we identified 121 PS-matched pairs. Mean polyp size was 16.8 mm. With similar en bloc resection rates (EMR: 82.6 % vs. UEMR: 87.6 %, rate difference: 5.0, 95 % confidence interval [95 % CI]: – 4 to 13.9 %), UEMR demonstrated a shorter resection time (10.8 min vs. 8.6 min, difference: – 2.2 min, 95 % CI: – 4.1 to – 0.3 min) and a lower intraprocedural bleeding rate (15.7 % vs. 5.8 %, rate difference: – 9.9 %, 95 % CI: – 17.6 to – 2.2 %). Incidence of delayed bleeding and muscle layer injury were low in both groups. For polyps < 20 mm, effectiveness and safety outcomes were similar in both groups. For polyps ≥ 20 mm (42 PS-matched pairs), the UEMR group has a comparable en bloc resection rate with shorter procedure time and superior safety outcomes

Conclusions UEMR achieved an en bloc resection rate comparable to conventional EMR with less intraprocedural bleeding and a shorter procedure time.

^* Drs. Chien and Hsieh: These authors contributed equally.

• References

• 1 Ferlay JSI, Ervik M, Dikshit R. et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013
• 2 Zauber AG, Winawer SJ, OʼBrien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 3 Fisher DA, Shergill AK, Early DS. et al. Role of endoscopy in the staging and management of colorectal cancer. Gastrointest Endosc 2013; 78: 8-12
• 4 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endoscopy 2015; 27: 417-434
• 5 Ferlitsch 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
• 6 Ahmad NA, Kochman ML, Long WB. et al. Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases. Gastrointest Endosc 2002; 55: 390-396
• 7 Hwang JH, Konda V, Abu Dayyeh BK. et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
• 8 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
• 9 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.e646
• 10 Binmoeller KF, Weilert F, Shah J. et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012; 75: 1086-1091
• 11 Uedo N, Nemeth A, Johansson GW. et al. Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy 2015; 47: 172-174
• 12 Uedo N, Nemeth A, Toth E. et al. Underwater endoscopic mucosal resection of a large depressed adenoma in the ileum. Endoscopy 2014; 46 (Suppl. 01) E336-337
• 13 Binmoeller KF, Hamerski CM, Shah JN. et al. Underwater EMR of adenomas of the appendiceal orifice (with video). Gastrointest Endosc 2016; 83: 638-642
• 14 Hamada K, Uedo N, Tanishita H. Underwater endoscopic mucosal resection of an intramucosal carcinoma located from the lower rectum to the anal canal. Digest Endosc 2018; 30: 119-120
• 15 Yamasaki Y, Uedo N, Takeuchi Y. et al. Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas. Endoscopy 2018; 50: 154-158
• 16 Anderloni A, Murino A, Jovani M. et al. Underwater endoscopic mucosal resection of a duodenal neuroendocrine tumor. Gastrointest Endosc 2016; 83: 259-260
• 17 Yamashina T, Tumura T, Maruo T. et al. Underwater endoscopic mucosal resection: a new endoscopic method for resection of rectal neuroendocrine tumor grade 1 (carcinoid) ≤10 mm in diameter. Endosc Int Open 2018; 6: E111-e114
• 18 Kim HG, Thosani N, Banerjee S. et al. Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 2014; 80: 1094-1102
• 19 Schenck RJ, Jahann DA, Patrie JT. et al. Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 2017; 31: 4174-4183
• 20 Cadoni S. Underwater endoscopic colorectal polyp resection: Feasibility in everyday practice. United Europ Gastroenterol J 2018; 6: 454-462
• 21 Walker E, Nowacki AS. Understanding equivalence and noninferiority testing. J Gen Intern Med 2011; 26: 192-196
• 22 Nakajima T, Saito Y, Tanaka S. et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013; 27: 3262-3270
• 23 Kawamura T, Sakai H, Ogawa T. et al. Feasibility of underwater endoscopic mucosal resection for colorectal lesions: a single center study in Japan. Gastroenterol Res 2018; 11: 274-279
• 24 Aronchick CA. Bowel preparation scale. Gastrointest Endos 2004; 60: 1037-1038 ; author reply 1038 – 1039
• 25 Anderson MA, Ben-Menachem T, Gan SI. et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
• 26 Acosta RD, Abraham NS, Chandrasekhara V. et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83: 3-16
• 27 [Anonymous] The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 28 [Anonymous] Update on the paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578
• 29 Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Statistics 2011; 10: 150-161
• 30 Sidhu M, Tate DJ, Desomer L. et al. The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy 2018; 50: 684-692
• 31 Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Statistics Med 2009; 28: 3083-3107
• 32 Binmoeller KF, Hamerski CM, Shah JN. et al. Attempted underwater en bloc resection for large (2 – 4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc 2015; 81: 713-718
• 33 Wang AY, Flynn MM, Patrie JT. et al. Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc 2014; 28: 1348-1354
• 34 Curcio G, Granata A, Ligresti D. et al. Underwater colorectal EMR: remodeling endoscopic mucosal resection. Gastrointest Endosc 2015; 81: 1238-1242
• 35 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
• 36 Benson 3rd AB, Venook AP, Bekaii-Saab T. et al. Colon cancer, version 3.2014. J Nat Comp Cancer Network 2014; 12: 1028-1059
• 37 Repici A, Pellicano R, Strangio G. et al. Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes. Dis Colon Rectum 2009; 52: 1502-1515
• 38 Siau K, Ishaq S, Cadoni S. et al. Feasibility and outcomes of underwater endoscopic mucosal resection for ≥ 10 mm colorectal polyps. Surg Endosc 2017;
• 39 Ponugoti PL, Rex DK. Perforation during underwater EMR. Gastrointestinal endoscopy 2016; 84: 543-544
• 40 Sandhu DS, Lee YJ, Gerke H. Underwater endoscopic mucosal resection (UEMR): an alternative for removal of large sessile colorectal polyps. Minerva gastroenterologica e dietologica 2017;
• 41 Bhurwal A, Bartel MJ, Heckman MG. et al. Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia. Gastrointest Endosc 2016; 84: 959-968.e957
• 42 Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet (London, England) 2002; 359: 248-252