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Thermal ablation after endoscopic mucosal resection of large colorectal polyps: not only the margins, but also the base?
  1. Roupen Djinbachian1,
  2. Heiko Pohl2,
  3. Douglas K Rex3,
  4. John M Levenick4,
  5. Douglas K Pleskow5,
  6. Michael B Wallace6,
  7. Mouen Khashab7,
  8. Ajaypal Singh8,
  9. Joshua Melson9,
  10. Dennis Yang10,
  11. Aleksandar Gavrić11,
  12. Daniel von Renteln12
  1. 1 Centre de recherche du CHUM, Montreal, Québec, Canada
  2. 2 Gastroenterology and Hepatology, White River Junction VA Medical Center, White River Junction, Vermont, USA
  3. 3 Indiana University School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA
  4. 4 Gastroenterology and Hepatology, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
  5. 5 Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  6. 6 Mayo Clinic Jacksonville, Jacksonville, Florida, USA
  7. 7 Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
  8. 8 Rush University Medical Center, Chicago, Illinois, USA
  9. 9 University of Arizona Medical Center-Banner Health, Tucson, Arizona, USA
  10. 10 Center for Interventional Endoscopy, Orlando, Florida, USA
  11. 11 Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
  12. 12 Medicine, Centre Hospitalier de L'Universite de Montreal, Montreal, Québec, Canada
  1. Correspondence to Dr Daniel von Renteln, Medicine, Centre Hospitalier de L'Universite de Montreal, Montreal, Canada; danielrenteln{at}gmail.com

http://dx.doi.org/10.1136/gutjnl-2023-331057

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    Thermal ablation of resection margins has been shown to reduce recurrence after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps, however, to a variable extent. In addition, residual or recurrent adenoma (RRA) may also arise from remnants in the resection base. We present a combined technique of margin and base ablation using submucosal injection followed by low energy argon beamer coagulation: Of 113 cases treated this way, RRA was found in one case only (0.9%). These data from multicentre registries were significantly lower compared with cases with margin ablation only (n=170; RRA rate 8.8%) or cases without (n=144; RRA rate 23.4%) in the same databases. This difference persisted when analysing only large lesions ≥40 mm (2.4 vs 12.5 vs 28.1%; overall n=137). Bleeding and perforation rates were similar across all groups.

    In more details

    Significant efforts have been expended to reduce RRAs after EMR. Thermal margin ablation using snare tip soft coagulation (STSC) has recently emerged as a potential solution to the high RRAs with very low recurrence (<5%) observed in one group, but variable and less significant reductions (9%–13%) in other studies, limiting the generalisability of the results in the initial experience.1–5 Next to the margins the resection surface can be a potential nidus for recurrence, explaining the high recurrence rates especially found in >4 cm large non-pedunculated colonic polyps (LNPCPs) undergoing EMR with margin ablation.4 We hypothesised that double ablation (ablation of the margin and base) could potentially result in lower recurrence rates compared with single (margin only) ablation. We, therefore, compared recurrence rates after EMR with double, single and no ablation within prospectively collected data from three multicentred registries (NCT04220905, NCT04015765, NCT04117100).

    EMR in all cases was performed according to current standards of care using piece-meal hot snare resection. In the single ablation group, cases that …

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    Footnotes

    • Contributors RD and DvR drafted the manuscript, collected data and critically revised the manuscript for important intellectual content. RD performed statistical analysis. DvR was responsible for study concept and design. All authors collected the data. All authors critically revised the manuscript for important intellectual content. All authors approved the final version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests DKR has received research funding from ERBE Elektromedizin, Ventage, Pendopharm, Fujifilm, Satisfai Health and Pentax, and has received consultant or speaker fees from Boston Scientific, ERBE Elektromedizin and Pendopharm. DKR is a consultant to: Olympus Corporation, Boston Scientific, Aries Pharmaceutical, Braintree Laboratories, Lumendi, Norgine, Endokey, GI Supply, Medtronic, Acacia Pharmaceuticals; has received research support from: EndoAid, Olympus Corporation, Medivators, Erbe USA, Braintree Laboratories; and is a shareholder in Satisfai Health

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.