Download PDF
CC BY-NC-ND 4.0 · Endosc Int Open 2023; 11(08): E768-E777
DOI: 10.1055/a-2117-8327
Review

Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs

Saurabh Chandan 
1   Division of Gastroenterology & Hepatology, Creighton University School of Medicine, Omaha, NE, United States, Omaha, United States
,
Jay Bapaye
2   Department of Medicine, Rochester General Health System, Rochester, NY, United States, Rochester, United States (Ringgold ID: RIN6932)
,
Shahab R. Khan
3   Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States, Boston, United States (Ringgold ID: RIN1861)
,
Babu P. Mohan 
4   Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States (Ringgold ID: RIN22165)
,
Daryl Ramai
4   Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States (Ringgold ID: RIN22165)
,
Dushyant S. Dahiya 
5   Department of Medicine, Central Michigan University, Mount Pleasant, MI, United States, Saginaw, United States (Ringgold ID: RIN367854)
,
Mohammad Bilal 
6   Department of Gastroenterology, Minneapolis VA Health Care System, Minneapolis, MN, United States, Minneapolis, United States (Ringgold ID: RIN20040)
,
Peter V. Draganov
7   Department of Gastroenterology, University of Florida, Gainesville, FL, United States, Gainesville, United States
,
Mohamed O. Othman 
8   Department of Gastroenterology, Baylor College of Medicine, Houston, TX, United States, Houston, United States (Ringgold ID: RIN3989)
,
Joaquin Rodriguez Sánchez
9   Endoscopy Unite, Hospital Universitario 12 de Octubre, Madrid, Comunidad de Madrid, Spain, Ciudad Real, Spain
,
Gursimran S. Kochhar 
10   Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, United States, Pittsburgh, United States (Ringgold ID: RIN6596)
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background and study aims Conventional endoscopic mucosal resection (C-EMR) is limited by low en-bloc resection rates, especially for large (> 20 mm) lesions. Underwater EMR (U-EMR) has emerged as an alternative for colorectal polyps and is being shown to improve en-bloc resection rates. We conducted a systematic review and meta-analysis comparing the two techniques.

Methods Multiple databases were searched through November 2022 for randomized controlled trials (RCTs) comparing outcomes of U-EMR and C-EMR for colorectal polyps. Meta-analysis was performed to determine pooled proportions and relative risks (RRs) of R0 and en-bloc resection, polyp recurrence, resection time, and adverse events.

Results Seven RCTs with 1458 patients (U-EMR: 739, C-EMR: 719) were included. The pooled rate of en-bloc resection was significantly higher with U-EMR vs C-EMR, 70.17% (confidence interval [CI] 46.68–86.34) vs 58.14% (CI 31.59–80.68), respectively, RR 1.21 (CI 1.01–1.44). R0 resection rates were higher with U-EMR vs C-EMR, 58.1% (CI 29.75–81.9) vs 44.6% (CI 17.4–75.4), RR 1.25 (CI 0.99–1.6). For large polyps (> 20 mm), en-bloc resection rates were comparable between the two techniques, RR 1.24 (CI 0.83–1.84). Resection times were comparable between U-EMR and C-EMR, standardized mean difference –1.21 min (CI –2.57 to –0.16). Overall pooled rates of perforation, and immediate and delayed bleeding were comparable between U-EMR and C-EMR. Pooled rate of polyp recurrence at surveillance colonoscopy was significantly lower with U-EMR than with C-EMR, RR 0.62 (CI 0.41–0.94).

Conclusions Colorectal U-EMR results in higher en-bloc resection and lower recurrence rates when compared to C-EMR. Both techniques have comparable resection times and safety profiles.

Keywords

Endoscopy Upper GI Tract - Precancerous conditions & cancerous lesions (displasia and cancer) stomach - Endoscopic resection (ESD, EMRc, ...) - Polyps/adenomas/ ... - Colorectal cancer

Supporting information



Publication History

Received: 01 March 2023

Accepted after revision: 20 June 2023

Accepted Manuscript online:
26 June 2023

Article published online:
16 August 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin 2020; 70: 7-30
    CrossrefPubMedSearch in Google Scholar
  • 2 Doubeni CA, Corley DA, Quinn VP. et al. Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: a large community-based study. Gut 2018; 67: 291-298
    CrossrefPubMedSearch in Google Scholar
  • 3 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434
    CrossrefPubMedSearch in Google Scholar
  • 4 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
    Search in Google Scholar
  • 5 Hwang JH, Konda V, Abu Dayyeh BK. et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
    CrossrefPubMedSearch in Google Scholar
  • 6 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
    CrossrefPubMedSearch in Google Scholar
  • 7 Belderbos TD, Leenders M, Moons LM. et al. Local recurrence after EMR of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-402
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Tate DJ, Sidhu M, Bar-Yishay I. et al. Impact of en bloc resection on long-term outcomes after endoscopic mucosal resection: a matched cohort study. Gastrointest Endosc 2020; 91: 1155-1163.e1151
    CrossrefPubMedSearch in Google Scholar
  • 9 Chandan S, Facciorusso A, Ramai D. et al. Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (> 20 mm) non pedunculated colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2022; 10: E74-E81
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Binmoeller KF. Underwater EMR without submucosal injection: Is less more?. Gastrointest Endosc 2019; 89: 1117-1119
    CrossrefPubMedSearch in Google Scholar
  • 11 Uedo N, Nemeth A, Johansson GW. et al. Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy 2015; 47: 172-174
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Barclay RL, Percy DB. Underwater endoscopic mucosal resection without submucosal injection (UEMR) for large colorectal polyps: A community-based series. Am J Surg 2020; 220: 693-696
    CrossrefPubMedSearch in Google Scholar
  • 13 Chandan S, Khan SR, Kumar A. et al. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021; 94: 471-482.e479
    CrossrefPubMedSearch in Google Scholar
  • 14 Garg R, Singh A, Mohan BP. et al. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8: E1884-E1894
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Li P, Ma B, Gong S. et al. Underwater endoscopic mucosal resection for colorectal lesions: a meta-analysis. Surg Endosc 2021; 35: 3003-3013
    CrossrefPubMedSearch in Google Scholar
  • 16 Choi AY, Moosvi Z, Shah S. et al. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc 2021; 93: 378-389
    CrossrefPubMedSearch in Google Scholar
  • 17 Bramer WM, Giustini D, de Jonge GB. et al. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc 2016; 104: 240-243
    CrossrefPubMedSearch in Google Scholar
  • 18 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int J Surg 2021; 88: 105906
    Search in Google Scholar
  • 19 Engels EA, Schmid CH, Terrin N. et al. Heterogeneity and statistical significance in meta-analysis: an empirical study of 125 meta-analyses. Stat Med 2000; 19: 1707-1728
    CrossrefPubMedSearch in Google Scholar
  • 20 Atkins D, Eccles M, Flottorp S. et al. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group. BMC health services research 2004; 4: 38
    CrossrefPubMedSearch in Google Scholar
  • 21 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
    CrossrefPubMedSearch in Google Scholar
  • 23 Sutton AJAK, Jones DR. et al. Methods for meta-analysis in medical research. New York: J. Wiley; 2000
    Search in Google Scholar
  • 24 Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959; 22: 719-748
    PubMedSearch in Google Scholar
  • 25 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
    CrossrefPubMedSearch in Google Scholar
  • 26 Duval S, Tweedie R. Trim and fill: a simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455-463
    CrossrefPubMedSearch in Google Scholar
  • 27 Yen AW, Leung JW, Wilson MD. et al. Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video). Gastrointest Endosc 2020; 91: 643-654.e642
    CrossrefPubMedSearch in Google Scholar
  • 28 Nagl S, Ebigbo A, Goelder SK. et al. Underwater vs conventional endoscopic mucosal resection of large sessile or flat colorectal polyps: a prospective randomized controlled trial. Gastroenterology 2021; 161: 1460-1474.e1461
    CrossrefPubMedSearch in Google Scholar
  • 29 Zhang Z, Xia Y, Cui H. et al. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial : (UEMR vs. CEMR for small size non-pedunculated colorectal polyps). BMC Gastroenterol 2020; 20: 311
    CrossrefPubMedSearch in Google Scholar
  • 30 Yamashina T, Uedo N, Akasaka T. et al. Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology 2019; 157: 451-461.e452
    CrossrefPubMedSearch in Google Scholar
  • 31 Lenz L, Martins B, Andrade de Paulo G. et al. Underwater versus conventional endoscopic mucosal resection for non-pedunculated colorectal lesions: a randomized clinical trial. Gastrointest Endosc 2023; 97: 549-558
    CrossrefPubMedSearch in Google Scholar
  • 32 Hamerski C, Samarasena J, Lee DP. et al. Underwater versus conventional endoscopic mucosal resection for the treatment of colorectal laterally spreading tumors: results from an international, multicenter, randomized controlled trial: 125. Am J Gastroenterol 2019; 114: S75
    CrossrefPubMedSearch in Google Scholar
  • 33 Rodríguez Sánchez J, Alvarez-Gonzalez MA, Pellisé M. et al. Underwater versus conventional EMR of large nonpedunculated colorectal lesions: a multicenter randomized controlled trial. Gastrointest Endosc 2023; 5: 941-951.e2
    CrossrefPubMedSearch in Google Scholar
  • 34 Mohan BP, Adler DG. Heterogeneity in systematic review and meta-analysis: how to read between the numbers. Gastrointest Endosc 2019; 89: 902-903
    CrossrefPubMedSearch in Google Scholar
  • 35 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
    CrossrefPubMedSearch in Google Scholar
  • 36 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
    CrossrefPubMedSearch in Google Scholar
  • 37 Leung FW, Leung JW, Mann SK. et al. The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy. Endoscopy 2011; 43: 816-821
    Thieme ConnectPubMedSearch in Google Scholar
  • 38 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
    CrossrefPubMedSearch in Google Scholar
  • 39 Keihanian T, Othman MO. Colorectal endoscopic submucosal dissection: an update on best practice. Clin Exp Gastroenterol 2021; 14: 317-330
    Search in Google Scholar
  • 40 Draganov PV, Wang AY, Othman MO. et al. AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States. Clin Gastroenterol Hepatol 2019; 17: 16-25.e11
    Search in Google Scholar
  • 41 Mann R, Gajendran M, Umapathy C. et al. Endoscopic management of complex colorectal polyps: current insights and future trends. Front Med (Lausanne) 2021; 8: 728704
    CrossrefPubMedSearch in Google Scholar
  • 42 Robertson DJ, Greenberg ER, Beach M. et al. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005; 129: 34-41
    CrossrefPubMedSearch in Google Scholar
  • 43 Lieberman DA, Rex DK, Winawer SJ. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
    Search in Google Scholar
  • 44 Pohl H, Robertson DJ. Colorectal cancers detected after colonoscopy frequently result from missed lesions. Clin Gastroenterol Hepatol 2010; 8: 858-864
    CrossrefPubMedSearch in Google Scholar
  • 45 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80.e71
    Search in Google Scholar
  • 46 Parihar V, Sopena-Falco J, Leung E. et al. R0 resection margin, a new quality measure in the era of national bowel screening?. Ir Med J 2020; 113: 7
    PubMedSearch in Google Scholar
  • 47 Sánchez JR, Ugarte DC, Koeklin H. et al. Efficacy of underwater endoscopic mucosal resection for the treatment of large complex colorectal lesions: a randomized and multicenter control trial. Endoscopy 2020; 52: OP324
    PubMedSearch in Google Scholar
  • 48 Lenz L, Di Sena V, Nakao FS. et al. Comparative results of gastric submucosal injection with hydroxypropyl methylcellulose, carboxymethylcellulose and normal saline solution in a porcine model. Arq Gastroenterol 2010; 47: 184-187
    CrossrefPubMedSearch in Google Scholar
  • 49 van Hattem WA, Shahidi N, Vosko S. et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70: 1691-1697
    CrossrefPubMedSearch in Google Scholar