Endoscopic resection outcomes and predictors of failed en bloc endoscopic mucosal resection of colorectal polyps ≤ 20 mm among advanced endoscopy trainees

William W. King; Peter V. Draganov; Andrew Y. Wang; Dushant Uppal; Amir Rumman; Nikhil A. Kumta; Christopher J. DiMaio; Arvind J. Trindade; Divyesh V. Sejpal; Lionel S. D’Souza; Juan C. Bucobo; Victoria Gomez; Michael B. Wallace; Heiko Pohl; Dennis Yang

doi:10.1055/a-1578-1965

Endoscopy International Open, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(11): E1820-E1826
DOI: 10.1055/a-1578-1965

Original article

Endoscopic resection outcomes and predictors of failed en bloc endoscopic mucosal resection of colorectal polyps ≤ 20 mm among advanced endoscopy trainees

William W. King

¹Department of Medicine, University of Florida, Gainesville, Florida, United States

,

Peter V. Draganov

²Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States

,

Andrew Y. Wang

³Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States

,

Dushant Uppal

³Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States

,

Amir Rumman

³Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States

,

Nikhil A. Kumta

⁴Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Christopher J. DiMaio

⁴Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Arvind J. Trindade

⁵Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, United States

,

Divyesh V. Sejpal

⁵Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, United States

,

Lionel S. D’Souza

⁶Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, United States

,

Juan C. Bucobo

⁶Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, United States

,

Victoria Gomez

⁷Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, United States

,

Michael B. Wallace

⁸Division of Gastroenterology and Hepatology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates

,

Heiko Pohl

⁹Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Gastroenterology, Veterans Administration Medical Center, White River Junction, Vermont

,

Dennis Yang

²Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States

› Institutsangaben

Abstract

Background and study aims En bloc endoscopic mucosal resection (EMR) is preferred over piecemeal resection for polyps ≤ 20 mm. Data on colorectal EMR training are limited. We aimed to evaluate the en bloc EMR rate of polyps ≤ 20 mm among advanced endoscopy trainees and to identify predictors of failed en bloc EMR.

Methods This was a multicenter prospective study evaluating trainee performance in EMR during advanced endoscopy fellowship. A logistic regression model was used to identify the number of procedures and lesion cut-off size associated with an en bloc EMR rate of ≥ 80 %. Multivariate analysis was performed to identify predictors of failed en bloc EMR.

Results Six trainees from six centers performed 189 colorectal EMRs, of which 104 (55 %) were for polyps ≤ 20 mm. Of these, 57.7 % (60/104) were resected en bloc. Trainees with ≥ 30 EMRs (OR 6.80; 95 % CI: 2.80–16.50; P = 0.00001) and lesions ≤ 17 mm (OR 4.56;95 CI:1.23–16.88; P = 0.02) were more likely to be associated with an en bloc EMR rate of ≥ 80 %. Independent predictors of failed en bloc EMR on multivariate analysis included: larger polyp size (OR:6.83;95 % CI:2.55–18.4; P = 0.0001), right colon location (OR:7.15; 95 % CI:1.31–38.9; P = 0.02), increased procedural difficulty (OR 2.99; 95 % CI:1.13–7.91; P = 0.03), and having performed < 30 EMRs (OR: 4.87; 95 %CI: 1.05–22.61; P = 0.04).

Conclusions In this pilot study, we demonstrated that a relatively low proportion of trainees achieved en bloc EMR for polyps ≤ 20 mm and identified procedure volume and lesion size thresholds for successful en bloc EMR and independent predictors for failed en bloc resection. These preliminary results support the need for future efforts to define EMR procedure competence thresholds during training.

Volltext

Referenzen

References
1 Zauber AG, Winawer SJ, O’Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
2 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
3 Pabby A, Schoen RE, Weissfeld J. et al. Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary Polyp Prevention Trial. Gastrointest Endsoc 2005; 61: 385-391
4 Robertson D, Lieberman D, Winawer SJ. et al. Interval cancer after total colonoscopy: results from a pooled analysis of eight studies. Gastroenterology 2008; 134: 111-112
5 Yang D, Othman M, Draganov PV. Endoscopic mucosal resection vs endoscopic submucosal dissection for Barrett’s Esophagus and Colorectal Neoplasia. Clin Gastroenterol Hepatol 2019; 17: 1019-1028
6 Belderbos TDG, Leenders M, Moons LMG. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-400
7 Klein A, Bourke MJ. How to perform high-quality endoscopic mucosal resection during colonoscopy. Gastroenterology 2017; 152: 466-471
8 Djinbachian R, Iratni R, Durand M. et al. Rate of incomplete resection of 1- to 20-mm Colorectal polyps: a systematic review and meta-analysis. Gastroenterology 2020; 159: 904-914
9 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy – results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80
10 Chen CA, Ho CH, Hsieh PH. Evaluation of factors associated with en bloc colonic underwater endoscopic mucosal resection. Adv Dig Med; 2020: 1-8
11 Kahi CJ, Rex DK. Why we should CARE about polypectomy technique. Gastroenterology 2013; 144: 16-18
12 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions – recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91: 486-519
13 Yang D, Perbtani YB, Wang Y. et al. Evaluating learning curves and competence in colorectal EMR among advanced endoscopy fellows: a pilot multicenter prospective trial using cumulative sum analysis. Gastrointest Endosc 2021; 93: 682-690.e4
14 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
15 Robertson DJ, Lieberman DA, Winawer SJ. et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014; 63: 949-956
16 Choi JM, Lee C, Park JH. et al. Complete resection of colorectal adenomas: what are the important factors in fellow training?. Dig Dis Sci 2015; 60: 1579-1588
17 Bhurwal A, Bartel MJ, Heckman MG. et al. Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia. Gastrointest Endosc 2016; 84: 959-968
18 Hassan C, Rutter M, Repici A. En bloc resection for 10-20 mm polyps to reduce post colonoscopy cancer and surveillance. Gastroenterology 2019; 17: 2173-2175
19 Liang J, Kalady MF, Appau K. et al. Serrated polyp detection rate during screening colonoscopy. Colorectal Dis 2012; 14: 1323-1327
20 Lee SP, Sung I, Kim JH. et al. Risk Factors for Incomplete Polyp Resection during Colonoscopic Polypectomy. Gut Liver 2015; 9: 66-72
21 Yang D, Wagh MS, Draganov PV. The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging. Gastrointest Endosc 2020; 92: 1016-1025
22 Binmoeller KF. Underwater EMR without submucosal injection: is less more?. Gastrointest Endosc 2019; 89; 1117-1119
23 Klein A, Tate DJ, Jayasekeran V. et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology 2019; 156: 604-613
24 Yamashina T, Uedo N, Akasak T. et al. Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology 2019; 157: 451-461