Endoscopic Mucosal Resection for Colonic Mucosal Neoplasia and Evaluation of Long-Term Recurrence

A Single-Center Experience of 500 Cases

Saeed Ali, MD; Neelam Khetpal, MD; Evgeny Idrisov, MD; Asad Ur Rahman, MD; Sameen Khalid, MD; Yuan Du, MS; Udayakumar Navaneethan, MD; Shyam Varadarajulu, MD; Robert Hawes, MD; Muhammad Khalid Hasan, MD

Disclosures

South Med J. 2021;114(4):199-206. 

In This Article

Abstract and Introduction

Abstract

Objectives: Endoscopic mucosal resection (EMR) is an alternative to surgery for the treatment of large laterally spreading lesions. Residual or recurrent adenoma is a major limitation. This study aimed to quantify early and late recurrences and to assess its associated risk factors.

Methods: The study was a single-center, multiendoscopist, longitudinal study conducted between January 1, 2013 and April 26, 2017. A total of 480 patients with 500 polyps who underwent an endoscopic resection were included. Surveillance colonoscopy (SC) was performed at 4 to 6 months (SC1) and 16 to 18 months (SC2).

Results: At SC1, early recurrence was noted in 77 of 354 (21.8%) lesions; 76 (98.7%) were treated endoscopically. The remaining 277 of 354 (78.2%) lesions had no recurrence at SC1; only 41 lesions (15%) were followed up at SC2. Recurrence at SC2 was found in 4 lesions (9.8%), all of which were treated endoscopically. Lesion size >40 mm was associated with recurrence. Recurrence at both SC1 and SC2 was successfully treated endoscopically in 78 of 81 lesions (96.3%).

Conclusions: EMR is an effective, minimally invasive technique for the treatment of large laterally spreading lesions. Although recurrence is a concern, its risk is low (21.8% on SC1 and 9.8% on SC2) and was managed endoscopically in 96.3% cases on follow-up endoscopy.

Introduction

Colonoscopy with polypectomy reduces colon cancer incidence and cancer-related mortality.[1–4] The majority of colonic polyps are small or pedunculated and can be easily resected.[5] In contrast, sessile and nonpolypoid adenomas, known as laterally spreading lesions (LSLs), have a stronger association with carcinoma and are being increasingly detected as a result of advancements in technology.[6] The endoscopic resection of LSLs is challenging, and thus they have been mostly managed surgically.[7–9] Surgery has an inherent risk of significant morbidity, mortality, and cost, especially in older patients with comorbid illnesses.[10]

Endoscopic mucosal resection (EMR) is a minimally invasive endoscopic technique for the removal of large LSLs.[11] When performed by an experienced endoscopist, it is a safe and effective alternative to surgery and is considered by many as a potential first-line therapy. It is efficient, consumes fewer hospital beds, and is associated with fewer adverse events as compared with surgery or endoscopic submucosal dissection (ESD).[8,9,11–18] ESD, which originally was developed for the resection of early gastric cancer,[19] is another technique used for the removal of large colonic LSLs.[20] It provides a high en-bloc resection rate and is less invasive than surgical resection.[21] The disadvantages of ESD over EMR include the substantially increased procedure time, it is technically more challenging, additional endoscopic training is required, and that it is associated with multiday hospital admission.[14,20,22]

The acceptance of EMR may have been limited by concerns over its associated high rates of residual or recurrent adenoma (RRA) and an unfounded perceived higher risk of complications.[23,24] Recent improvements in endoscope resolution have facilitated the accurate definition of lesion margins, however, thus allowing greater confidence regarding the completeness of EMR with potentially lower recurrence rates.[24] The current guidelines recommend a first surveillance colonoscopy (SC1) at 4 to 6 months and a second SC (SC2) at a subsequent interval after piecemeal EMR.[25–27]

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