Endoscopic mucosal resection (EMR) is a safe, effective, and surgery-sparing technique
for removing large colorectal lesions [1]. Although piecemeal EMR is recommended for polyps > 20 mm in size, it remains a
suboptimal technique for complete lesion resection, with high rates of residual polyp
and recurrence rates reaching 15 % [2]. Hybrid argon plasma coagulation (hAPC) is a novel approach allowing ablation of
resection margins and surface after EMR. hAPC combines waterjet injection and argon
plasma coagulation (APC) in a single device. On-demand, repeatable saline cushioning
without instrument exchange reduces thermal ablative insult to deep tissue structures,
allowing for effective destruction of micro-remnants with reduced risk of perforation.
High technical success and low recurrence rates (0 %) were shown in a pilot study
using EMR in combination with hAPC [3]. A prospective international multicenter study showed that the local recurrence
rate was only 2.2 % when using hAPC after EMR [4]. One recent meta-analysis found the local recurrence rate to be 3.3 % after hot
EMR and margin ablation at 12-month follow-up [5].
We present a step-by-step video tutorial demonstrating how hAPC-assisted EMR is performed
while providing technical tips to achieve optimal ablation results ([Video 1]).
Video 1 Video tutorial demonstrating how to perform hybrid argon plasma coagulation-assisted
endoscopic mucosal resection in different clinical examples.
hAPC-assisted EMR is done after standard initial assessment of polyp morphology and
submucosal invasion. The polyp is removed in piecemeal fashion using a combination
of an electrosurgical snare, cold snare, and forceps avulsion techniques ([Fig. 1]). Following complete resection of the entire visible polyp, the base and margins
of the submucosal defect are then lifted using the waterjet function of the hAPC probe
and thermal ablation is performed. EMR margin ablation is performed with combinations
alternating between 25–40 W pulsed-APC and precise-APC Effect 8–10 (11–21 W), with
both modes using a flow of 0.8 L/min. Vessels can be prophylactically ablated; however,
the clinical benefit of this is unclear at present.
Fig. 1 The hybrid argon plasma coagulation (hAPC)-assisted endoscopic mucosal resection
(EMR) technique for removal of colon polyps. a EMR is performed. b The resection area post-EMR. c Needless waterjet injection for margin and base lifting prior to hAPC. d Thermal ablation using hAPC.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online. Processing charges apply, discounts and
wavers acc. to HINARI are available.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
Citation Format
Endoscopy 2023; 54 (S01); E229–E230, DOI: 10.1055/a-1966-0441.
