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Tu1455 Cap-Assisted Endoscopic Mucosal Resection (C-EMR) Is Effective and Safe for Removal of Very Flat Right Colonic Polyps
Abstracts
no significant difference in two groups (with and without delayed bleeding) in mean lesion size (31.0 mm and 35.4 mm; p⫽0.16), growth pattern (the rate of laterally spreading tumors, 92% and 81%; p⫽0.27) and mean procedure time (88.7 min and 83.5 min; p⫽0.6). As for lesion locations, the rate of the lesions located in rectum with delayed bleeding (20/25; 80%) was significant higher (p⫽0.0003) than that without delayed bleeding (150/352; 42.6%). The rate of lesions with severe fibrosis (F2) with bleeding (12/25; 48%) was significant higher (p⫽0.022) than that without bleeding (88/352; 25%). Conclusions: This study demonstrated that the risk factors for delayed bleeding after ESD for colorectal neoplasms were lesion location and the degree of submucosal fibrosis.
Tu1453 The Effect of Preoperative Biopsy on Colorectal Endoscopic Submucosal Dissection Fumisato Sasaki*, Shuji Kanmura, Keita Funakawa, Hiroshi Fujita, Masatsugu Numata, Akio IDO, Hirohito Tsubouchi Department of Digestive Disease and Life-style Related Disease, Kagoshima University School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan Background and Aims: Endoscopic submucosal dissection (ESD) is increasingly used to resect early colorectal neoplasms despite the technical difficulties associated with this procedure. Colonoscopic biopsies performed for diagnostic purposes may lead to scar and ulcer formation. Since the effects of the diagnostic biopsy prior to colorectal ESD have not been reported, the aim of this study was to investigate the relationship between post-biopsy scarring and the difficulty level of colorectal ESD. Methods: This study included 87 lesions in 85 patients with colorectal adenoma or adenocarcinoma who underwent colorectal ESD from January 2009 through August 2012 at our institution. There were 7 protruding lesions, 1 type 0-IIc lesion and 79 laterally spreading tumors (LSTs) on the morphologically-based classification of colon neoplasms in this study. LSTs were classified as granular (LST-G) or non-granular (LST-NG) and further divided into LST-G-H (homogenous; 14 lesions) and LST-G-M (nodular mixed; 35 lesions) or LST-NG-F (flat elevated; 10 lesions) and LST-NG-PD (pseudodepressed; 20 lesions) types. We retrospectively analyzed the procedure duration, degree of submucosal fibrosis, and perforation rate with or without preoperative biopsy. Results: (1) Preoperative biopsy before colorectal ESD was performed 68% (59/87), and two or more biopsies were performed in 5 patients. (2) The rate of biopsy for protruding lesions and LST-G-M were higher than for other groups. (3) Mild submucosal fibrosis was more common in the biopsy group. There was a no significant trend towards longer procedure time in the biopsy group (139⫾90 min vs.103⫾58 min, p⫽0.07). (4) There were 3 cases of perforation, all occurring in biopsied patients, of which 2 had severe submucosal fibrosis at the biopsy site. Conclusions: Preoperative biopsy may lead to severe submucosal fibrosis. Unnecessary biopsies should be avoided in order to prevent severe submucosal fibrosis on colorectal ESD.
Tu1454 Is ESD Necessary for All Colorectal Tumors? -Comparison About Clinical Outcome of Colorectal EMR/ESD Takemasa Sato*, Masakatsu Fukuzawa, Masaya Nonaka, Takuji Gotoda, Fuminori Moriyasu Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan Background: Colorectal ESD is now covered by Japanese health insurance for the treatment of “early colorectal cancers or adenomas with a maximum diameter of 2 to 5 cm”. Aim: Evaluate the validity of the indication for colorectal ESD by comparing the clinical outcomes of EMR and ESD. Subjects & Methods: Between June 2007 and August 2012 a total of 552 lesions that were 2 cm or larger were treated with EMR (348) or ESD (189). We compared the short-term outcomes between EMR and ESD in terms of procedure time, rate of en-bloc resection, complications and tumor macroscopic type, diameter and location,. In the patients followed for 3 months or longer, we compared the tumor recurrence rates between 256 EMR-treated lesions and 135 treated with ESD. ESD was indicated for the following lesions in accordance with the Working Group of ESD Standardization for Colorectal Tumors in Japan: LST-NG lesions 2cm or larger in diameter, intra-mucosal carcinoma with non-lifting sign positive, LST-G lesions with large nodules, elevated lesions that were difficult for en bloc resection with the use of a conventional snare, and remnant or recurrent lesions. Results: EMR (en bloc/piecemeal; 228/120)Is,Isp/IIa,IIc/LST-NG/LST-G/remnant: 98/65/51/133/1. The mean tumor diameter was 25.2 mm (range, 20 -50). C-T/DS/R: 163/89/96. Complete en-bloc resection rate was 56.3%. Complications were postoperative bleeding in 6 cases (2%) and perforation in 1 (0.3%). The mean procedure time was 13 minutes. Histopathological diagnoses were adenoma in 70% and cancer in 30%. Tumor recurrence was seen in 12 cases (4.7%). All of these cases could be successfully managed by additional endoscopic treatment. ESD (189)Is,Isp/IIa,IIc/LST-NG/LST-G/remnant: 13/10/80/85/1. The mean tumor diameter was 31.7 mm (range, 20 -50). C-T/D-S/R: 97/31/61. Complete en- bloc
resection rate was 87.3%. Complications were bleeding in 2 cases (1%) and perforation in 5 (2.6%), but these cases could be managed with conservative therapy. The mean procedure time was 108 minutes. Histopathological diagnoses of adenoma and cancer were made in 17% and 83%, respectively. Tumor recurrence was seen in 3 cases (2.2%), all of which could be endoscopically managed. Conclusions: In 2-5 cm lesions, the majority of those treated with EMR were adenoma and recurrent remnant cases could be managed with additional endoscopic therapy. In contrast, most of those treated with ESD were cancer cases, necessitating en-bloc resection and detailed pathological diagnosis, so those lesions were considered proper indications for ESD. It should be considered inappropriate to conduct ESD for the treatment of every 2 cm or larger adenoma or cancer because the procedure time is longer and complications occur more frequently.
Tu1455 Cap-Assisted Endoscopic Mucosal Resection (C-EMR) Is Effective and Safe for Removal of Very Flat Right Colonic Polyps Simon K. Lo*1, Laith H. Jamil1, Brian R. Boulay2 1 Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA; 2 Gastroenterology, University of Illinois, Chicago, IL C-EMR is commonly believed to be risky for removal of flat polyps in the colon. This notion was challenged by Conio et al (Dis Colon Rectum 2010); however, that report had mostly thick granular or sessile lesions in the left colon. Aim: To evaluate the safety and efficacy of C-EMR for treatment of the very flat colonic lesions. Methods: All EMRs of flat polyps performed by a single endoscopist from 2007-2012 were reviewed. Flat polyps with a favorable appearance (raised edge, easy lift, good orientation and thick tissue) for easy resection were treated with the freehand snare (FHS) technique by injecting a saline-epinephrine-Indigo carmine fluid and removing with a spiral snare. When easy removal was in doubt, an EMR cap and crescent snare was used for en bloc or piecemeal resection of a fluid-lifted lesion. The primary method was switched from FHS to C-EMR or vise versa when difficulty was encountered. Adjunctive maneuvers for ablation of residual tissue (argon plasma, hot or cold forceps, grasp-n-cut) were recorded. Results: 170 patients had 183 EMR procedures (35 FHS, 145 C-EMR, 3 band ligation) for flat colorectal lesions. Size of polyps: 2.47⫾1.0 cm (mean length) x 1.88⫾0.9 cm (mean width). 60.7% were non-granular lateral spreading lesions and 51% were deemed very flat (minimal edge with thin profile) by the endoscopist. There were 184 resected lesions: 51.6% right colon (37 cecum, 6 IC valve, 52 ascending), 28.2% mid-colon (24 hepatic flexure, 28 transverse), 19% left colon (8 splenic flexure, 13 descending, 6 sigmoid, 8 rectum). Cases that started with FHS were more likely to need to switch to C-EMR for completion than the reverse (6/35 FHS to C-EMR vs. 3/145 C-EMR to FHS, p⫽0.002, Fisher’s exact test). FHS (37.1%) also required more supplemental ablative maneuvers than C-EMR (17.2%) (25/145 vs. 13/35, p⫽0.019). 86 (9 freehand, 77 C-EMR) pts had at least 1 follow up endoscopy; 11% (1/9) of FHS and 5.3% (5/77) of C-EMR had residual/recurrent lesions (p⫽0.50). Only 50% of the 6 biopsy-proven residual lesions had been noted to be incomplete removal at the original procedures. Complications: 2.9% of FHS (1 post-polypectomy syndrome) versus 9.7% of C-EMR (1 delayed perforation, 2 intra-procedure perforations, 1 postpolypectomy syndrome, 3 delayed bleeding, 7 hospitalizations for transient pain) (p⫽0.31). Excluding pain observations, complications for C-EMR was 4.8%. Conclusions: C-EMR can be done effectively on very thin lesions and in the right colon, with only 5.3% chance of finding a residual lesion on follow up. It is reasonably safe, but a 2% perforation rate is a small concern. Even though our own treatment strategy had allowed FHS to resect technically easier cases, our C-EMR procedures actually required significantly less supplemental ablative maneuvers without leaving more residual lesions or causing more complications. Supplemental maneuvers, residual lesions, and complications between free hand snare and cap assisted endoscopic mucosal resection
Procedures (n) Supplemental maneuvers: -Argon plasma -Hot forceps -Cold forceps -Grasp-n-cut -Switch EMR method Residual lesion on FU Complications
FHS technique
C-EMR technique
35 13 (37%) 2 4 1 0 6 to C-EMR 1/9 (11%) 2.9%
145 25 (17.2%) 4 17 0 1 3 to FHS 5/77 (5.3%) 9.7% (4.8% minus observations)
P value 0.019
0.002 0.5 0.31
FHS Free hand snare endoscopic mucosal resection C-EMR Cap assisted endoscopic mucosal resection
AB546 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
no significant difference in two groups (with and without delayed bleeding) in mean lesion size (31.0 mm and 35.4 mm; p⫽0.16), growth pattern (the rate of laterally spreading tumors, 92% and 81%; p⫽0.27) and mean procedure time (88.7 min and 83.5 min; p⫽0.6). As for lesion locations, the rate of the lesions located in rectum with delayed bleeding (20/25; 80%) was significant higher (p⫽0.0003) than that without delayed bleeding (150/352; 42.6%). The rate of lesions with severe fibrosis (F2) with bleeding (12/25; 48%) was significant higher (p⫽0.022) than that without bleeding (88/352; 25%). Conclusions: This study demonstrated that the risk factors for delayed bleeding after ESD for colorectal neoplasms were lesion location and the degree of submucosal fibrosis.
Tu1453 The Effect of Preoperative Biopsy on Colorectal Endoscopic Submucosal Dissection Fumisato Sasaki*, Shuji Kanmura, Keita Funakawa, Hiroshi Fujita, Masatsugu Numata, Akio IDO, Hirohito Tsubouchi Department of Digestive Disease and Life-style Related Disease, Kagoshima University School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan Background and Aims: Endoscopic submucosal dissection (ESD) is increasingly used to resect early colorectal neoplasms despite the technical difficulties associated with this procedure. Colonoscopic biopsies performed for diagnostic purposes may lead to scar and ulcer formation. Since the effects of the diagnostic biopsy prior to colorectal ESD have not been reported, the aim of this study was to investigate the relationship between post-biopsy scarring and the difficulty level of colorectal ESD. Methods: This study included 87 lesions in 85 patients with colorectal adenoma or adenocarcinoma who underwent colorectal ESD from January 2009 through August 2012 at our institution. There were 7 protruding lesions, 1 type 0-IIc lesion and 79 laterally spreading tumors (LSTs) on the morphologically-based classification of colon neoplasms in this study. LSTs were classified as granular (LST-G) or non-granular (LST-NG) and further divided into LST-G-H (homogenous; 14 lesions) and LST-G-M (nodular mixed; 35 lesions) or LST-NG-F (flat elevated; 10 lesions) and LST-NG-PD (pseudodepressed; 20 lesions) types. We retrospectively analyzed the procedure duration, degree of submucosal fibrosis, and perforation rate with or without preoperative biopsy. Results: (1) Preoperative biopsy before colorectal ESD was performed 68% (59/87), and two or more biopsies were performed in 5 patients. (2) The rate of biopsy for protruding lesions and LST-G-M were higher than for other groups. (3) Mild submucosal fibrosis was more common in the biopsy group. There was a no significant trend towards longer procedure time in the biopsy group (139⫾90 min vs.103⫾58 min, p⫽0.07). (4) There were 3 cases of perforation, all occurring in biopsied patients, of which 2 had severe submucosal fibrosis at the biopsy site. Conclusions: Preoperative biopsy may lead to severe submucosal fibrosis. Unnecessary biopsies should be avoided in order to prevent severe submucosal fibrosis on colorectal ESD.
Tu1454 Is ESD Necessary for All Colorectal Tumors? -Comparison About Clinical Outcome of Colorectal EMR/ESD Takemasa Sato*, Masakatsu Fukuzawa, Masaya Nonaka, Takuji Gotoda, Fuminori Moriyasu Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan Background: Colorectal ESD is now covered by Japanese health insurance for the treatment of “early colorectal cancers or adenomas with a maximum diameter of 2 to 5 cm”. Aim: Evaluate the validity of the indication for colorectal ESD by comparing the clinical outcomes of EMR and ESD. Subjects & Methods: Between June 2007 and August 2012 a total of 552 lesions that were 2 cm or larger were treated with EMR (348) or ESD (189). We compared the short-term outcomes between EMR and ESD in terms of procedure time, rate of en-bloc resection, complications and tumor macroscopic type, diameter and location,. In the patients followed for 3 months or longer, we compared the tumor recurrence rates between 256 EMR-treated lesions and 135 treated with ESD. ESD was indicated for the following lesions in accordance with the Working Group of ESD Standardization for Colorectal Tumors in Japan: LST-NG lesions 2cm or larger in diameter, intra-mucosal carcinoma with non-lifting sign positive, LST-G lesions with large nodules, elevated lesions that were difficult for en bloc resection with the use of a conventional snare, and remnant or recurrent lesions. Results: EMR (en bloc/piecemeal; 228/120)Is,Isp/IIa,IIc/LST-NG/LST-G/remnant: 98/65/51/133/1. The mean tumor diameter was 25.2 mm (range, 20 -50). C-T/DS/R: 163/89/96. Complete en-bloc resection rate was 56.3%. Complications were postoperative bleeding in 6 cases (2%) and perforation in 1 (0.3%). The mean procedure time was 13 minutes. Histopathological diagnoses were adenoma in 70% and cancer in 30%. Tumor recurrence was seen in 12 cases (4.7%). All of these cases could be successfully managed by additional endoscopic treatment. ESD (189)Is,Isp/IIa,IIc/LST-NG/LST-G/remnant: 13/10/80/85/1. The mean tumor diameter was 31.7 mm (range, 20 -50). C-T/D-S/R: 97/31/61. Complete en- bloc
resection rate was 87.3%. Complications were bleeding in 2 cases (1%) and perforation in 5 (2.6%), but these cases could be managed with conservative therapy. The mean procedure time was 108 minutes. Histopathological diagnoses of adenoma and cancer were made in 17% and 83%, respectively. Tumor recurrence was seen in 3 cases (2.2%), all of which could be endoscopically managed. Conclusions: In 2-5 cm lesions, the majority of those treated with EMR were adenoma and recurrent remnant cases could be managed with additional endoscopic therapy. In contrast, most of those treated with ESD were cancer cases, necessitating en-bloc resection and detailed pathological diagnosis, so those lesions were considered proper indications for ESD. It should be considered inappropriate to conduct ESD for the treatment of every 2 cm or larger adenoma or cancer because the procedure time is longer and complications occur more frequently.
Tu1455 Cap-Assisted Endoscopic Mucosal Resection (C-EMR) Is Effective and Safe for Removal of Very Flat Right Colonic Polyps Simon K. Lo*1, Laith H. Jamil1, Brian R. Boulay2 1 Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA; 2 Gastroenterology, University of Illinois, Chicago, IL C-EMR is commonly believed to be risky for removal of flat polyps in the colon. This notion was challenged by Conio et al (Dis Colon Rectum 2010); however, that report had mostly thick granular or sessile lesions in the left colon. Aim: To evaluate the safety and efficacy of C-EMR for treatment of the very flat colonic lesions. Methods: All EMRs of flat polyps performed by a single endoscopist from 2007-2012 were reviewed. Flat polyps with a favorable appearance (raised edge, easy lift, good orientation and thick tissue) for easy resection were treated with the freehand snare (FHS) technique by injecting a saline-epinephrine-Indigo carmine fluid and removing with a spiral snare. When easy removal was in doubt, an EMR cap and crescent snare was used for en bloc or piecemeal resection of a fluid-lifted lesion. The primary method was switched from FHS to C-EMR or vise versa when difficulty was encountered. Adjunctive maneuvers for ablation of residual tissue (argon plasma, hot or cold forceps, grasp-n-cut) were recorded. Results: 170 patients had 183 EMR procedures (35 FHS, 145 C-EMR, 3 band ligation) for flat colorectal lesions. Size of polyps: 2.47⫾1.0 cm (mean length) x 1.88⫾0.9 cm (mean width). 60.7% were non-granular lateral spreading lesions and 51% were deemed very flat (minimal edge with thin profile) by the endoscopist. There were 184 resected lesions: 51.6% right colon (37 cecum, 6 IC valve, 52 ascending), 28.2% mid-colon (24 hepatic flexure, 28 transverse), 19% left colon (8 splenic flexure, 13 descending, 6 sigmoid, 8 rectum). Cases that started with FHS were more likely to need to switch to C-EMR for completion than the reverse (6/35 FHS to C-EMR vs. 3/145 C-EMR to FHS, p⫽0.002, Fisher’s exact test). FHS (37.1%) also required more supplemental ablative maneuvers than C-EMR (17.2%) (25/145 vs. 13/35, p⫽0.019). 86 (9 freehand, 77 C-EMR) pts had at least 1 follow up endoscopy; 11% (1/9) of FHS and 5.3% (5/77) of C-EMR had residual/recurrent lesions (p⫽0.50). Only 50% of the 6 biopsy-proven residual lesions had been noted to be incomplete removal at the original procedures. Complications: 2.9% of FHS (1 post-polypectomy syndrome) versus 9.7% of C-EMR (1 delayed perforation, 2 intra-procedure perforations, 1 postpolypectomy syndrome, 3 delayed bleeding, 7 hospitalizations for transient pain) (p⫽0.31). Excluding pain observations, complications for C-EMR was 4.8%. Conclusions: C-EMR can be done effectively on very thin lesions and in the right colon, with only 5.3% chance of finding a residual lesion on follow up. It is reasonably safe, but a 2% perforation rate is a small concern. Even though our own treatment strategy had allowed FHS to resect technically easier cases, our C-EMR procedures actually required significantly less supplemental ablative maneuvers without leaving more residual lesions or causing more complications. Supplemental maneuvers, residual lesions, and complications between free hand snare and cap assisted endoscopic mucosal resection
Procedures (n) Supplemental maneuvers: -Argon plasma -Hot forceps -Cold forceps -Grasp-n-cut -Switch EMR method Residual lesion on FU Complications
FHS technique
C-EMR technique
35 13 (37%) 2 4 1 0 6 to C-EMR 1/9 (11%) 2.9%
145 25 (17.2%) 4 17 0 1 3 to FHS 5/77 (5.3%) 9.7% (4.8% minus observations)
P value 0.019
0.002 0.5 0.31
FHS Free hand snare endoscopic mucosal resection C-EMR Cap assisted endoscopic mucosal resection
AB546 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org