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Endoscopy
DOI: 10.1055/a-2535-7559
Original article

Impact of margin thermal ablation after cold-forceps avulsion with snare-tip soft coagulation for nonlifting large nonpedunculated colorectal polyps

Francesco Vito Mandarino 
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
Timothy O'Sullivan
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
,
Julia L. Gauci 
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
Clarence Kerrison
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
,
Anthony Whitfield
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
,
Brian Lam
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
Varan Perananthan
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
Sunil Gupta 
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
,
Oliver Cronin
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
,
Renato Medas
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
David J. Tate 
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
Eric Y. Lee
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
,
Nicholas G. Burgess
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
,
Michael J. Bourke
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia (Ringgold ID: RIN8539)
2   The University of Sydney Westmead Clinical School, Sydney, Australia (Ringgold ID: RIN216997)
› Institutsangaben Clinical Trial: Registration number (trial ID): NCT01368289, Trial registry: Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/), Type of Study: Prospective
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Abstract

Background

Nonlifting large nonpedunculated colorectal polyps (NL-LNPCPs) account for 15% of LNPCPs and are effectively managed by endoscopic mucosal resection (EMR) with adjunctive cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST). Recurrence rates >10% at surveillance colonoscopy are however a significant limitation. We aimed to compare the outcomes of CAST plus margin thermal ablation (MTA) versus CAST alone for NL-LNPCPs.

Methods

Prospective observational data on consecutive patients with NL-LNPCPs treated by EMR and CAST at a single tertiary center were retrospectively evaluated. Two cohorts were established: the pre-MTA period (January 2012–June 2017) and the MTA period (July 2017–October 2023). The primary outcome was the residual/recurrent adenoma (RRA) rate at first surveillance colonoscopy (SC1). Secondary outcomes included the RRA rate at SC2 and adverse events.

Results

Over 142 months, 300 patients underwent EMR and CAST for LNPCP: 103 lesions pre-MTA and 197 with MTA. At SC1 and SC2, recurrence was lower in the MTA cohort compared with the pre-MTA cohort (5.0% vs. 18.8% and 0.8% vs. 10.0%, respectively; both P<0.001). Adverse events were similar between the two cohorts for deep mural injury types III–V (pre-MTA 2.9% vs. MTA 5.6%; P=0.29) and delayed bleeding (pre-MTA 8.7% vs. MTA 7.1%; P=0.49). On multivariate analysis, MTA was the only variable independently associated with a reduced likelihood of recurrence (odds ratio 0.20, 95%CI 0.07–0.54; P=0.001).

Conclusions

For NL-LNPCPs, MTA in combination with CAST is safe and effective and reduces recurrence at SC1 in comparison with CAST alone.

Supplementary Material



Publikationsverlauf

Eingereicht: 30. Juni 2024

Angenommen nach Revision: 07. Februar 2025

Accepted Manuscript online:
07. Februar 2025

Artikel online veröffentlicht:
21. März 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Ferlitsch M, Hassan C, Bisschops R. et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024. Endoscopy 2024; 56: 516-545
    Thieme ConnectPubMedSuche in Google Scholar
  • 2 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions - Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158: 1095-1129
    CrossrefPubMedSuche in Google Scholar
  • 3 Tate DJ, Desomer L, Awadie H. et al. EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointest Endosc 2018; 87: 1279-1288 e2
    CrossrefPubMedSuche in Google Scholar
  • 4 Nanda KS, Tutticci N, Burgess NG. et al. Endoscopic mucosal resection of laterally spreading lesions involving the ileocecal valve: technique, risk factors for failure, and outcomes. Endoscopy 2015; 47: 710-718
    Thieme ConnectPubMedSuche in Google Scholar
  • 5 Shahidi N, Sidhu M, Vosko S. et al. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69: 673-680
    CrossrefPubMedSuche in Google Scholar
  • 6 Tutticci N, Klein A, Sonson R. et al. Endoscopic resection of subtotal or completely circumferential laterally spreading colonic adenomas: technique, caveats, and outcomes. Endoscopy 2016; 48: 465-471
    Thieme ConnectPubMedSuche in Google Scholar
  • 7 Mandarino FV, Danese S, Uraoka T. et al. Precision endoscopy in colorectal polyps' characterization and planning of endoscopic therapy. Dig Endosc 2024; 36: 761-777
    CrossrefPubMedSuche in Google Scholar
  • 8 Bahin FF, Heitman SJ, Rasouli KN. et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67: 1965-1973
    CrossrefPubMedSuche in Google Scholar
  • 9 Ahlenstiel G, Hourigan LF, Brown G. et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80: 668-676
    CrossrefPubMedSuche in Google Scholar
  • 10 Jayanna M, Burgess NG, Singh R. et al. Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions. Clin Gastroenterol Hepatol 2016; 14: 271-278 e82
    CrossrefPubMedSuche in Google Scholar
  • 11 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
    CrossrefPubMedSuche in Google Scholar
  • 12 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65: 806-820
    CrossrefPubMedSuche in Google Scholar
  • 13 Sidhu M, Shahidi N, Gupta S. et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology 2021; 161: 163-170 e3
    CrossrefPubMedSuche in Google Scholar
  • 14 Rex DK, Haber GB, Khashab M. et al. Snare tip soft coagulation vs argon plasma coagulation vs no margin treatment after large nonpedunculated colorectal polyp resection: a randomized trial. Clin Gastroenterol Hepatol 2024; 22: 552-561 e4
    CrossrefPubMedSuche in Google Scholar
  • 15 Abu Arisha M, Scapa E, Wishahi E. et al. Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice. Gastrointest Endosc 2023; 97: 559-567
    CrossrefPubMedSuche in Google Scholar
  • 16 Tate DJ, Bahin FF, Desomer L. et al. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions. Endoscopy 2018; 50: 52-62
    PubMedSuche in Google Scholar
  • 17 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344-349
    CrossrefPubMedSuche in Google Scholar
  • 18 van Hattem WA, Shahidi N, Vosko S. et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70: 1691-1697
    CrossrefPubMedSuche in Google Scholar
  • 19 Veitch AM, Vanbiervliet G, Gershlick AH. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines [published correction appears in Endoscopy 2016; 48: c1]. Endoscopy 2016; 48: 385-402
    Thieme ConnectPubMedSuche in Google Scholar
  • 20 Veitch AM, Radaelli F, Alikhan R. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53: 947-969
    Thieme ConnectPubMedSuche in Google Scholar
  • 21 Klein A, Bourke MJ. How to perform high-quality endoscopic mucosal resection during colonoscopy. Gastroenterology 2017; 152: 466-471
    CrossrefPubMedSuche in Google Scholar
  • 22 Burgess NG, Bassan MS, McLeod D. et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2017; 66: 1779-1789
    CrossrefPubMedSuche in Google Scholar
  • 23 Desomer L, Tutticci N, Tate DJ. et al. A standardized imaging protocol is accurate in detecting recurrence after EMR. Gastrointest Endosc 2017; 85: 518-526
    CrossrefPubMedSuche in Google Scholar
  • 24 Vosko S, Gupta S, Shahidi N. et al. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 94: 959-968 e2
    CrossrefPubMedSuche in Google Scholar
  • 25 O'Sullivan T, Mandarino FV, Gauci JL. et al. Impact of margin thermal ablation after endoscopic mucosal resection of large (≥20 mm) non-pedunculated colonic polyps on long-term recurrence. Gut 2024; 74: 67-74
    CrossrefPubMedSuche in Google Scholar
  • 26 Gauci J, Mandarino FV, Kerrison C. et al. Margin thermal ablation eliminates size as a risk factor for recurrence after piecemeal endoscopic mucosal resection. Gut 2025; 2025
    CrossrefPubMedSuche in Google Scholar
  • 27 Shahidi N, Vosko S, Gupta S. et al. Previously attempted large nonpedunculated colorectal polyps are effectively managed by endoscopic mucosal resection. Am J Gastroenterol 2021; 116: 958-966
    CrossrefPubMedSuche in Google Scholar
  • 28 Gupta S, Sidhu M, Shahidi N. et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial [published correction appears in Lancet Gastroenterol Hepatol 2022; 7: e2]. Lancet Gastroenterol Hepatol 2022; 7: 152-160
    CrossrefPubMedSuche in Google Scholar