Introduction

Endoscopic full-thickness resection (EFTR) with the full-thickness resection device (FTRD) has become the standard technique for selected non-lifting colorectal adenoma but tumor size is the major limitation. However, large lesions might be approached in combination with endoscopic mucosal resection (EMR). Herein, we report the largest single-center experience to date of combined EMR/EFTR (Hybrid-EFTR) in patients with large (≥ 25 mm) non-lifting colorectal adenoma not amenable to EMR or EFTR alone.

Aims & Methods

This is a single-center retrospective analysis of consecutive patients who underwent Hybrid-EFTR of large (≥ 25 mm) non-lifting colorectal adenoma. Outcomes of technical success (successful advancement of the FTRD with consecutive successful clip deployment and snare resection), macroscopic complete resection, adverse events and endoscopic follow-up were evaluated.

Results

75 patients with non-lifting colorectal adenoma were included. Mean lesion size was 36.5 mm (range 25-60 mm) and 66.6 % were located in the right-sided colon. Technical success was 100 % with macroscopic complete resection in 97.3 %. Mean procedure time was 83.6 minutes. Adverse events occurred in 6.7 % leading to surgical therapy in 1.3 %. Histology revealed T1 carcinoma in 16 %. Endoscopic follow-up was available in 93.3 % (mean follow-up time: 8.1 months, range 3-36 months) and showed no signs of residual or recurrent adenoma in 88.6 %. Recurrency (11.4 %) was treated endoscopically.

Conclusion

Hybrid-EFTR is safe and effective for advanced colorectal adenoma which cannot be approached by EMR or EFTR alone. Hybrid-EFTR expands the indication of EFTR substantially in selected patients.

Disclosure

BM received fees for research activities and lecture fees from Ovesco Endoscopy AG.
KC received fees for FTRD training courses and lecture fees from Ovesco Endoscopy AG.
IE, NS and AW have no disclosures to report.

Introduction

Endoscopic full-thickness resection (EFTR) is emerging as an effective and safe technique for difficult colorectal lesions, offering a valid alternative to surgery for “no-lifting” lesions, commonly performed during hospitalization. The recent outbreak of COVID-19 compelled endoscopic units to admit only patients for urgent endoscopic procedures, postponing hospitalization for elective non-life-saving procedures such as EFTR. Moreover, there has been growing experience supporting the safety and effectiveness of EFTR. We aim to retrospectively evaluate the safety and feasibility of non-exposed EFTR as an outpatient procedure in the main Italian centers.

Aims & Methods

We conducted a nationwide multicentre retrospective study, including 11 centers with demonstrated >5 years of expertise in non-exposed EFTR. The study is conceived as a collection of all consecutive cases of non-exposed colorectal EFTR for lesions <30 mm with “no lifting sign” or located in difficult anatomic locations, performed since 2018 in outpatient or hospital settings. “Hospital setting” is a hospital admission for clinical monitoring, including at least a one-night stay. “Outpatient setting” is defined as clinical monitoring that does not require the patient to stay overnight. The primary outcome was to compare the safety (defined as any adverse event rate) of EFTR between the hospital and outpatient groups. The Adverse Events (AEs) were classified as follows: mild (not requiring medical or endoscopic intervention), moderate (requiring medical or endoscopic intervention), and severe (requiring surgical therapy and/or potentially life-threatening.). Secondary outcomes were clinical success (histologically confirmed full-thickness R0 resection), technical success (ability to reach the target lesion), and recurrence rate at 12 months.

Results

One hundred-sixty-eight patients, 94 (55%) hospital setting, and 74 (45%) outpatient setting were included in the analysis. The two study groups were comparable for gender (male 59.6% vs 54.1%, p=0.47) and age (71.4±12.1 vs 68.4±11.1, p=0.1). There were no statistically significant differences among the groups for antiplatelet/coagulant therapy, lesion location, morphology, and size. No statistically significant differences in terms of mild AEs (2.1% vs 5.4%, p=0.41), moderate AEs (9.6% vs 9.5%, p= 0.98), and severe AEs (6.4% vs 1.4% p= 0.14) rate, technical success (96.8% vs 100%, p= 0.26), R0 resection rate (89.3% vs 87.8%, p= 0.78), technical difficulties (19.2% vs 27%, p= 0.23) and recurrence rate at 12 months (7.5% vs 4.2%, p=0.52) were observed between the two groups.

Conclusion

EFTR performed in an outpatient setting is safe and feasible with similar AEs and success rate to EFTR performed in a hospital setting. Thus, strict self-observation with the possibility to access directly to the endoscopic service allows adequate and cost-effective management for the post-EFTR AEs. Prospective studies are needed to confirm these results and demonstrate the safety and effectiveness of EFTR in this setting.

References

1. Gibiino G, Binda C, Papparella LG, Spada C, Andrisani G, Di Matteo FM, et al. Technical failure during colorectal endoscopic full-thickness resection: the "through thick and thin" study. Endoscopy. 2024;56(11):831-9.
2. Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut. 2018;67(7):1280-9.

Introduction

Piecemeal endoscopic mucosal resection (pEMR) is the preferred treatment for large non-pedunculated colorectal polyps (LNPCPs)[1,2]. A major limitation of pEMR is residual or recurrent adenoma (RRA), which was reported to in 15%-30% of cases at first surveillance colonoscopy (SC1)[3], performed 3-6 months after the index procedure, but is reduced to the range of 3%-5% by applying ablative measures to the post-EMR resection margin[4].

Aims & Methods

This study aimed to evaluate the effects of late SC1 on RRA.
This is an analysis of a prospectively collected cohort of adult patients referred for pEMR at two academic centers in Israel, from 2016 to 2023. We included all patients who underwent pEMR of LNCPCs and completed SC1.
We compared outcomes between patients who completed early SC1 at 3-6 months following the index procedure with patients who completed late SC1 later than 6 months. All procedures and surveillance colonoscopies were performed by experienced endoscopists trained in pEMR using high-definition scopes. EMR was followed by thermal ablation of the entire mucosal defect margin with snare soft tip coagulation, as previously described[4].
Scar evaluation at SC1 was performed with high-definition white light and chromoendoscopy. Our primary endpoint was RRA at SC1.
Analyses were performed per lesion. We compared baseline parameters and outcome rates between groups, and performed multivariate analysis to assess the adjusted association of months to SC1 with RRA.

Results

We analyzed 516 lesions that underwent index pEMR resection and subsequent SC1. Baseline parameters and recurrence rates are presented in Table 1. The early SC1 group (n=371) underwent SC1 at a mean of 5.1 months versus a mean of 11.1 months in the late SC1 group (p<0.01; Table 1). Polyp size in the early SC1 group was significantly larger than that in the late SC1 group (mean size 35.9 mm [SD 13.9] vs. 32.1 mm [SD 12.4], p<0.01; Table 1). The distribution of lesion location, granularity differed between the groups (Table 1). However, there were no significant differences in lesion Paris classification or rates of high grade dysplasia (Table 1).
We found no statistically significant difference in the rate of recurrence at SC1 between the two groups (6.3% in the standard group versus 4.8% in the delayed group, p=0.64). Additionally, a sub-analysis comparing the early SC1 group to patients with very late SC1 (>12 months – mean time to SC1 17.9 (SD [5.4] months) and did not reveal significant difference in recurrence at SC1 (6.2% in the early SC1 vs 6.3% in the very late group, p=1).
Multivariate analysis, adjusted for lesion size, location, and high-grade dysplasia, showed that time to SC1 was not significantly associated with RRA (odds ratio 1.05, 95% confidence interval 0.98-1.13).

TABLE 1. Comparison of baseline variables and outcome between the early and late SC1.

Conclusion

Late SC1 is not associated with an increased RRA. Hence, we suggest that high-quality pEMR with margin ablation may alleviate the need for early SC1, thereby reducing healthcare and patient burdens. Further interventional studies are required.

References

[1] Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270–297. doi:10.1055/S-0043-102569/ID/JR15335-1/BIB
[2] Shaukat A, Kaltenbach T, Dominitz JA, et al. Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 159: 1916-1934.e2. doi:10.1053/j.gastro.2020.08.050
[3] 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. doi:10.1055/S-0034-1364970/ID/JR910-7/BIB
[4] 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.e3. doi:10.1053/j.gastro.2018.10.003

Disclosure

The authors report no conflict of interests

Introduction

Large non-pedunculated colorectal polyps (LNPCP's) are significant precursors of colorectal cancer, commonly treated by piecemeal endoscopic mucosal resection (pEMR). When histology reveals a focus of adenocarcinoma invading the sub-mucosa, the resection is often considered non curative and salvage surgery is performed. Recent evidence shows that the risk of residual cancer in the bowel wall or lymph nodes of the surgical specimen are uncommon and that in some cases surgery may be avoided even when a focus of invasive cancer is found in the EMR specimen.

Aims & Methods

This is a retrospective observational study aimed to evaluate the prevalence, characteristics, and outcomes of covert carcinoma in LNPCPs resected by EMR in a two academic centers.
Data was collected from a prospective cohort of LNPCPs at two academic centers in Israel. We collected patient, lesion and procedural characteristics prospectively.
EMR was performed by 3 experienced endoscopist with dedicated EMR training. Piecemeal EMR was performed after endoscopic assessment for polyps that were deemed not to have sub-mucosal invasion according to accepted classification systems. Lesions suspected to containing invasive cancer were referred to surgery without endoscopic resection were excluded from the analysis.
For lesions containing invasive carcinoma, data was collected on Kikuchi classification, presence of tumor budding and lymphovascular invasion, grade of tumor differentiation, and status of the deep margin. Surgical data included presence of residual carcinoma in the surgical specimen, grading, margin involvement, and lymph node involvement.

Results

We analyzed 546 LNPCPs referred for resection at the two centers. We identified 27 cases of covert carcinoma, accounting for 4.9% of all LNPCPS resected by piecemeal EMR. A multidisciplinary tumor board deemed resection curative in 7 cases, and 18 patients were refferd for surgical resection. One patient refused surgery, and One patient was lost to follow up.
None of the surgical specimens had lymph node metastasis. In one case residual carcinoma was found in the bowel wall of the surgical specimen. No recurrence of colorectal cancer, presence of metastasis on imaging or elevation of CEA was documented for any of the patients during follow up of two year.

Conclusion

In conclusion, our study shows that covert carcinoma is relatively rare when EMR is performed in a high-volume center by expert endoscopists. In addition, the data suggests that even in these cases, the risk of metastatic disease is probably very low.

References

1. Kudo S ei, Lambert R, Allen JI, Fujii H, Fujii T, Kashida H, et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc. 2008 Oct;68(4 SUPPL.).
2. Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau JM, Paspatis G, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Vol. 49, Endoscopy. Georg Thieme Verlag; 2017. p. 270–97.
3. Lopez A, Bouvier AM, Jooste V, Cottet V, Romain G, Faivre J, et al. Outcomes following polypectomy for malignant colorectal polyps are similar to those following surgery in the general population. Gut. 2019 Jan 1;68(1):111–7.
4. Choi YS, Kim WS, Hwang SW, Park SH, Yang DH, Ye BD, et al. Clinical outcomes of submucosal colorectal cancer diagnosed after endoscopic resection: A focus on the need for surgery. Intest Res. 2020 Jan 1;18(1):96–106.
5. Gibson DJ, Sidhu M, Zanati S, Tate DJ, Mangira D, Moss A, et al. Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer. Gut. 2022 Mar 7;

Disclosure

Conflicts of interest: None. Financial disclosures: None.