Endoscopic mucosal resection in the colon: A practical guide

doi:10.1016/j.tgie.2011.01.002

Techniques in Gastrointestinal Endoscopy

Volume 13, Issue 1, January 2011, Pages 35-49

https://doi.org/10.1016/j.tgie.2011.01.002 Get rights and content

Endoscopic mucosal resection (EMR) is an important therapy for large sessile lesions and advanced mucosal neoplasia of the colon. Careful pre-resection assessment against established classification systems including Paris and lesion granularity is mandatory to formulate a treatment plan, predict technical success and stratify for the risk of invasive disease. Lesions at high risk for invasive disease are best removed en bloc and this finding may dictate a change in the therapeutic strategy. Meticulous technique is crucial to maximise procedural success. This chapter will provide a comprehensive step by step approach to colonic EMR including equipment selection, lesion assessment, endoscopic technique, post procedural care and early detection and management of complications.

Section snippets

Lesion assessment and indications

EMR is indicated for sessile colonic lesions >10 mm in maximum dimension that are being considered for endoscopic treatment. Smaller or pedunculated lesions can generally be safely removed with a conventional snare technique. All sessile lesions should be carefully characterized and assessed for the risk of submucosal invasion (SMI) before excision. If a significant risk for SMI exists, then this may suggest a change in the endoscopic treatment strategy or the need for surgery. En bloc

Snares

Snare selection is to some extent an individual choice, but stiff type snares have clear advantages for tissue capture. We prefer a snare with a serrated wire to facilitate entrapment of normal tissue at the margin of the lesion. A range of sizes and configurations is required, including oval, round, and hexagonal from 10 to 20 mm for flat lesions. For large pedunculated and bulky exophytic lesions, large snares of 3 × 4-6 cm, oval or hexagonal, are necessary. The 20-mm spiral snare is our

General principles

The goal of endoscopic resection is to remove the entire lesion in as few pieces as is safely possible. For lesions of maximum dimension 20-25 mm in the right colon and 25-30 mm in the left colon (particularly rectum), en bloc or Ro resection should be considered, but may not always be technically possible. In the colon a Ro excision should be consistently achievable for lesions <20 mm in maximum dimension. En bloc resection has many proven and theoretic advantages, including more accurate

Complications and management

The most serious complications are nonspecific postprocedural pain, serositis, delayed bleeding, and perforation. Identification of high-risk patients, early recognition of complications, and aggressive management ameliorate their frequency and severity.

Conclusions

EMR is the primary endoscopic therapy in the management of large LSTs and sessile lesions in the colon. Evidence-based lesion-specific endoscopic treatment algorithms are required. Postprocedural care, procedure duration, and endoscopic complications are major considerations in the West that influence the approach and favor, for example, EMR over ESD. Among typical referral cases seen at tertiary centers in the West, nongranular lesions are uncommon and absolute indications for en bloc

References (54)

M.P. Swan et al.
Large refractory colonic polyps: is it time to change our practice?A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos)
Gastrointest Endosc
(2009)
J.E. Onken et al.
Treatment patterns and costs associated with sessile colorectal polyps
Am J Gastroenterol
(2002)
A. Moss et al.
Lesion morphology, Paris classification and pit pattern but not size predict and stratify risk of submucosal invasive adenocarcinoma within laterally spreading tumours (LSTs) and large sessile colonic polyps in a multicenter setting: results of the Australian Colonic Endoscopic mucosal resection (ACE) study
Gastrointest Endosc
(2010)
D.K. Rex
Narrow-band imaging without optical magnification for histologic analysis of colorectal polyps
Gastroenterology
(2009)
H. Kanao et al.
Narrow-band imaging magnification predicts the histology and invasion depth of colorectal tumors
Gastrointest Endosc
(2009)
M.J. Bourke
Mucosal resection in the upper GI tract
Tech Gastrointest Endosc
(2010)
A. Moss et al.
Succinylated gelatin substantially increases en bloc resection size in colonic EMR: a randomized blinded trial in a porcine model
Gastrointest Endosc
(2010)
S. Alexander et al.
EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long term outcome
Gastrointest Endosc
(2009)
S. Tanaka et al.
Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization
Gastrointest Endosc
(2007)
M. Fujishiro et al.
Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases
Clin Gastroenterol Hepatol
(2007)

Y. Saito et al.

Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video)

Gastrointest Endosc

(2007)

E. Coman et al.

Fat necrosis and inflammatory pseudotumor due to endoscopic tattooing of the colon with India ink

Gastrointest Endosc

(1991)

A. Sawaki et al.

A two-step method for marking polypectomy sites in the colon and rectum

Gastrointest Endosc

(2003)

M. Conio et al.

EMR of large sessile colorectal polyps

Gastrointest Endosc

(2004)

D.K. Rex

Have we defined best colonoscopic polypectomy practice in the United States?

Clin Gastroenterol Hepatol

(2007)

M.P. Swan et al.

The Target sign: an endoscopic marker for the resection of the muscularis propria during colonic endoscopic mucosal resection

Gastrointest Endosc

(2011)

A.J. Hui et al.

Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases

Gastrointest Endosc

(2004)

G. Eisen et al.

Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures

Gastrointest Endosc

(2002)

T. Kaltenbach et al.

Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions > or =1 cm (with video)

Gastrointest Endosc

(2007)

H. Neuhaus et al.

Randomized controlled study of EMR versus endoscopic submucosal dissection with a water-jet hybrid-knife of esophageal lesions in a porcine model

Gastrointest Endosc

(2009)

H. Neuhaus et al.

Endoscopic submucosal resection (ESD) of early Barrett's neoplasia (EBN) with a water-jet hybrid knife (ESDH): first prospective clinical trial

Gastrointest Endosc

(2010)

S.J. Winawer et al.

Prevention of colorectal cancer by colonoscopic polypectomyThe National Polyp Study Workgroup

N Engl J Med

(1993)

I. Dove-Edwin et al.

Prevention of colorectal cancer by colonoscopic surveillance in individuals with a family history of colorectal cancer: 16 year, prospective, follow-up study

BMJ

(2005)

A. Zauber et al.

Effect of initial polypectomy versus surveillance polypectomy on colorectal cancer mortality reduction: microsimulation modelling of the national polyp study

Am J Gastroenterol

(2007)

J.E. Waye

Polypectomy: basic principles

T. Voloyiannis et al.

Management of the difficult colon polyp referred for resection: resect or rescope?

Dis Colon Rectum

(2008)

S. Manfredi et al.

Colonoscopy results of a French regional FOBT-based colorectal cancer screening program with high compliance

Endoscopy

(2008)

Cited by (54)

The Surface Morphology of Large Nonpedunculated Colonic Polyps Predicts Synchronous Large Lesions
2023, Clinical Gastroenterology and Hepatology
Large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may have synchronous LNPCPs in up to 18% of cases. The nature of this relationship has not been investigated. We aimed to examine the relationship between individual LNPCP characteristics and synchronous colonic LNPCPs.
Consecutive patients referred for resection of LNPCPs over 130 months until March 2022 were enrolled. Serrated lesions and mixed granularity LNPCPs were excluded from analysis. Patients with multiple LNPCPs resected were identified, and the largest was labelled as dominant. The primary outcome was the identification of individual lesion characteristics associated with the presence of synchronous LNPCPs.
There were 3149 of 3381 patients (93.1%) who had a single LNPCP. In 232 (6.9%) a synchronous lesion was detected. Solitary lesions had a median size of 35 mm with a predominant Paris 0-IIa morphology (42.9%) and right colon location (59.5%). In patients with ≥2 LNPCPs, the dominant lesion had a median size of 40 mm, Paris 0-IIa (47.6%) morphology, and right colon location (65.9%). In this group, 35.8% of dominant LNPCPs were non-granular compared with 18.7% in the solitary LNPCP cohort. Non-granular (NG)-LNPCPs were more likely to demonstrate synchronous disease, with left colon NG-LNPCPs demonstrating greater risk (odds ratio, 4.78; 95% confidence interval, 2.95–7.73) than right colon NG-LNPCPs (odds ratio, 1.99; 95% confidence interval, 1.39–2.86).
We found that 6.9% of LNPCPs have synchronous disease, with NG-LNPCPs demonstrating a greater than 4-fold increased risk. With post-colonoscopy interval cancers exceeding 5%, endoscopists must be cognizant of an individual’s LNPCP phenotype when examining the colon at both index procedure and surveillance. ClinicalTrials.gov, NCT01368289; NCT02000141; NCT02198729.
Impact of including epinephrine in the submucosal injectate for colorectal EMR on postprocedural pain: a randomized controlled trial
2022, Gastrointestinal Endoscopy
EMR is first-line therapy for colorectal laterally spreading lesions. Some colonoscopists include epinephrine in the submucosal injectate, which we observed increased postprocedure discomfort. Our aim was to determine whether inclusion of epinephrine in the submucosal injectate increases postprocedure pain after EMR.
We performed a randomized, controlled, double-blind trial comparing epinephrine in submucosal injectate versus injectate alone for abdominal pain at 30 and 60 minutes after EMR.
Mean polyp diameter in both arms was >40 mm. There were no differences in procedure times or amounts of fluid injected. Mean pain was higher on a visual analog scale in the epinephrine group at 30 minutes (47 vs 14, P = .022) and at 60 minutes (44 vs 13, P = .035). Recovery room stay was longer in the epinephrine group (68 vs 53 minutes, P = .034).
Epinephrine in the submucosal injectate for EMR increases postprocedural pain, which could cause diagnostic confusion and prolong observation time in the recovery area. (Clinical trial registration number: NCT04065451.)
Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video)
2020, Gastrointestinal Endoscopy
Conventional EMR using a hot snare is the standard of care for resection of large (≥20 mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly because of electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). This study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized ≥20 mm.
All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps ≥20 mm over a 2-year period, from January 2016 to December 2017, were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records.
CSP-EMR was performed on 204 polyps sized ≥20 mm in 186 patients (men, 33.8%; median age, 68 years). SC1 for 164 polyps (80.4%) at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% confidence interval, 3%-11%). SC2 for 113 polyps (72.9%) at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% confidence interval, .9%-8.5%) after a normal SC1. Intraprocedural bleeding was successfully treated in 4 patients (2.2%), whereas 7 patients (3.8%) experienced self-limited clinically significant post-EMR bleeding and 1 patient (.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events.
CSP-EMR of sessile colonic polyps ≥20 mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR and to further determine the polyp morphologies that are best suited for CSP-EMR.
Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions
2020, Gastrointestinal Endoscopy
The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models.
A multicenter cohort study was performed in patients with nonpedunculated lesions ≥20 mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies.
DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets.
The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT 03050333.)
How to Perform Wide-Field Endoscopic Mucosal Resection and Follow-up Examinations
2019, Gastrointestinal Endoscopy Clinics of North America
Citation Excerpt :
In a randomized trial it proved superior to normal saline, with significantly lower injections, fewer resections, and shorter procedure time.18 Inert dye (preferably indigo carmine) stains the submucosa and therefore provides helpful guidance for resection within the correct tissue plane; if the deeper nonstaining muscularis propria is entered, an obvious disruption of the stained tissue plane is noted.10 The dye also defines the extent of the fluid cushion and the margin of the lesion, which is advantageous in subtle lesions.
Duodenal and Papillary Adenomas
2019, Clinical Gastrointestinal Endoscopy
Duodenal polyps are uncommon. They can be found in 0.3%–4.6% of patients undergoing upper gastrointestinal endoscopy, and are usually an incidental finding. Adenomas account for approximately 7% of all duodenal polyps. They are most commonly found in the second part of the duodenum, and are usually solitary, flat, sessile lesions. Duodenal adenomas can be classified as papillary adenomas (PAs), when primarily involving the papilla Vateri, or duodenal adenomas (DAs), when there is no involvement of the papilla. These adenomas can be further classified as sporadic papillary adenomas (SPAs) or sporadic duodenal adenomas (SDAs), i.e., those not associated with genetic polyposis syndromes, or as those related to familial adenomatous polyposis (FAP). It is estimated that 40% of duodenal adenomas are sporadic and 60% are related to FAP. Endoscopic resection (ER) of DA and PA is quickly becoming the treatment of choice for noninvasive lesions, even when they are very extensive. Although no systematic comparative data exist, due to the lower risks of morbidity, mortality, and long-term digestive dysfunction, ER is considered preferable to surgery. ER in the duodenum requires a diverse range of endoscopic skills. These include proficiency in advanced endoscopic resection techniques, experience with pancreaticobiliary endoscopy, and the ability to identify and manage complications. These procedures should be performed by experienced endoscopists practicing in tertiary referral centers with access to surgical and interventional radiology support. A structured approach to lesion assessment, the technical aspects of resection, and postresection surveillance is required.

View all citing articles on Scopus

View full text

Endoscopic mucosal resection in the colon: A practical guide

Section snippets

Lesion assessment and indications

Snares

General principles

Complications and management

Conclusions

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Tech Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Prevention of colorectal cancer by colonoscopic polypectomyThe National Polyp Study Workgroup

N Engl J Med

Prevention of colorectal cancer by colonoscopic surveillance in individuals with a family history of colorectal cancer: 16 year, prospective, follow-up study

BMJ

Effect of initial polypectomy versus surveillance polypectomy on colorectal cancer mortality reduction: microsimulation modelling of the national polyp study

Am J Gastroenterol

Polypectomy: basic principles

Management of the difficult colon polyp referred for resection: resect or rescope?

Dis Colon Rectum

Colonoscopy results of a French regional FOBT-based colorectal cancer screening program with high compliance

Endoscopy