Year 2023 / Volume 115 / Number 5
Original
Underwater versus conventional endoscopic mucosal resection for sessile colorectal polyps: an updated systematic review and meta-analysis

225-233

DOI: 10.17235/reed.2022.8956/2022

Sridhar Sundaram, Vishal Seth, Vaneet Jearth, Suprabhat Giri,

Abstract
Background: underwater endoscopic mucosal resection (uEMR) without submucosal injection for sessile colorectal polyps was introduced as a new replacement for conventional EMR (cEMR). However, the optimal resection strategy remains a topic of debate. Hence, this meta-analysis was performed to compare the efficacy and safety of uEMR and cEMR in patients with sessile colorectal polyps. Methods: a comprehensive search of the literature from 2000 till January 2022 was performed from Medline, CENTRAL and Embase for randomized controlled trials (RCTs) comparing cEMR vs uEMR for colorectal polyps. The evaluated outcomes included en bloc resection, R0 resection, procedure time, overall bleeding and recurrence. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a random effect model. Results: six studies were included, out of which four were full-text articles and two were conference abstracts. En bloc resection (RR 1.26, 95 % CI: 1.00-1.60), R0 resection (RR 1.10, 95 % CI: 0.96-1.26), overall bleeding (RR 0.85, 95 % CI: 0.54-1.34) and recurrence rate (RR 0.75, 95 % CI: 0.45-1.27) were comparable between uEMR and cEMR. However, uEMR was associated with a shorter procedure time (mean difference [MD] -1.55 minutes, 95 % CI: -2.71 to -0.39). According to the subgroup analysis, uEMR led to a higher rate of en bloc resection (RR 1.41, 95 % CI: 1.07-1.86) and R0 resection (RR 1.19, 95 % CI: 1.01-1.41) for polyps ≥ 10 mm in size. Conclusion: both uEMR and cEMR have a comparable safety and efficacy. For polyps larger than 10 mm, uEMR may have an advantage over cEMR and should be the topic for future studies.
Lay Summary
Endoscopic mucosal resection is a minimally invasive alternative to surgery for removing polyps from the colon. The conventional EMR (cEMR) involves injection of a lifting agent under the polyp followed by cutting, compared to underwater endoscopic mucosal resection (uEMR) in which cutting is done underwater, without injection. Hence, this meta-analysis was conducted to compare the efficacy and safety of uEMR and cEMR in patients with sessile colorectal polyps. There was no difference between the two techniques concerning the removal of the entirety of a tumor without violating its capsule and microscopically margin-negative resection. Also, the overall rate of bleeding and recurrence of polyp were comparable between the groups. However, uEMR was associated with a shorter procedural duration. On subgroup analysis of polyps with size ≥ 10 mm, uEMR was better in terms of removal of the entirety of a tumor without violating its capsule and microscopically negative resection margin. To conclude, both uEMR and cEMR have comparable safety and efficacy. For polyps larger than 10 mm, uEMR may have an advantage over cEMR and should be the topic for future studies.
Share Button
New comment
Comments
No comments for this article
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. 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(3):270-297.
3. Repici A, Pellicano R, Strangio G, et al. Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes. Dis Colon Rectum. 2009;52(8):1502-1515.
4. Knabe M, Pohl J, Gerges C, et al. Standardized long-term follow-up after endoscopic resection of large, nonpedunculated colorectal lesions: a prospective two-center study. Am J Gastroenterol. 2014;109:183–189.
5. Moss A, Williams S J, 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.
6. Binmoeller K F, Weilert F, Shah J, et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video) Gastrointest Endosc. 2012;75:1086–1091.
7. Spadaccini M, Fuccio L, Lamonaca L, et al. Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video). Gastrointest Endosc. 2019;89(6):1109-1116.e4
8. Yamashina T, Hanaoka N, Setoyama T, et al. Efficacy of Underwater Endoscopic Mucosal Resection for Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis. Cureus. 2021;13(8):e17261
9. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.
10. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.
11. Hamerski CM, Wang AY, Amato A, et al. Injection-assisted versus underwater endoscopic mucosal resection without injection for the treatment of colorectal laterally spreading tumors: interim analysis of an international multicenter randomized controlled trial. Gastrointest Endosc. 2018, 87:AB55-6.
12. Yamashina T, Uedo N, Akasaka T, et al. Comparison of Underwater vs Conventional Endoscopic Mucosal Resection of Intermediate-Size Colorectal Polyps. Gastroenterology. 2019;157:451-461.e2.
13. Yen AW, Leung JW, Wilson MD, et al. Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video). Gastrointest Endosc. 2020;91:643-654.e2.
14. Zhang Z, Xia Y, Cui H, et al. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial : (UEMR vs. CEMR for small size non-pedunculated colorectal polyps). BMC Gastroenterol. 2020;20:311.
15. Spanish Group of Endoscopic Mucosal Resection (Spanish Society of Gastrointestinal Endoscopy) Sánchez JR, Ugarte DC, Koeklin HIU, et al. Efficacy of underwater endoscopic mucosal resection for the treatment of large complex colorectal lesions: a randomized and multicenter control trial. Endoscopy.2020;52:S111.
16. Nagl S, Ebigbo A, Goelder SK, et al. Underwater vs Conventional Endoscopic Mucosal Resection of Large Sessile or Flat Colorectal Polyps: A Prospective Randomized Controlled Trial. Gastroenterology. 2021;161:1460-1474.e1.
17. Deyhle P, Largiadèr F, Jenny S, et al. A Method for Endoscopic Electroresection of Sessile Colonic Polyps. Endoscopy 1973; 5: 38-40 [DOI: 10.1055/s-0028-1098209.
18. Yokota T, Sugihara K, Yoshida S. Endoscopic mucosal resection for colorectal neoplastic lesions. Dis Colon Rectum 1994; 37: 1108-1111.
19. Tadepalli US, Feihel D, Miller KM, et al. A morphologic analysis of sessile serrated polyps observed during routine colonoscopy.1016 (with video). Gastrointest Endosc 2011; 74:1360-1368.
20. Oka S, Tanaka S, Saito Y, et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 2015;110: 697–7073.
21. Li P, Ma B, Gong S, et al. Underwater endoscopic mucosal resection for colorectal lesions: a metaanalysis. Surg Endosc. 2021, 35:3003-13.
22. Ni DQ, Lu YP, Liu XQ, et al. Underwater vs conventional endoscopic mucosal resection in treatment of colorectal polyps: a meta-analysis. World J Clin Cases. 2020, 8:4826-37.
23. Choi AY, Moosvi Z, Shah S, et al. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc. 2021,93:378-89.
24. Kamal F, Khan MA, Lee-Smith W, et al.: Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis. Endosc Int Open. 2020, 8:E1264-72.
25. Binmoeller KF, Hamerski CM, Shah JN, et al. Underwater EMRof adenomas of the appendiceal orifice (with video). Gastrointest Endosc 2016; 83: 638–642.
26. Levy I, Hamerski CM, Nett AS, et al. Su1618 underwater endoscopic mucosal resection (UEMR) of laterally spreading tumors involving the ileocecal valve. Gastrointestinal Endoscopy 2017; 85: AB366
27. Watabe H, Yamaji Y, Okamoto M, et al. Risk assessment for delayed hemorrhagic complications of colonic polypectomy polyp-related factors and patient-related factors. Gastrointest Endosc 2006; 64:73-78.
28. Buchner AM, Guarner-Argente C, Ginsberg GG. Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center. Gastrointest Endosc 2012; 76:255-263.
29. Nakajima T, Saito Y, Tanaka S, et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013; 27: 3262–3270.
30. Belderbos TD, Leenders M, Moons LM, et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy. 2014;46(5):388-402.
31. Briedigkeit A, Sultanie O, Sido B, et al. Endoscopic mucosal resection of colorectal adenomas > 20 mm: Risk factors for recurrence. World J Gastrointest Endosc. 2016;8(5):276-281. doi:10.4253/wjge.v8.i5.276
32. Yandrapu H, Desai M, Siddique S, et al. Normal saline solution versus other viscous solutions for submucosal injection during endoscopic mucosal resection: a systematic review and meta-analysis. Gastrointest Endosc. 2017;85(4):693-699.
33. 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(3):604-613.e3.
34. Dhillon AS, Ravindran S, Thomas-Gibson S. Recurrence after endoscopic mucosal resection: there's more to it than meets the eye. Gastrointest Endosc. 2021;94(2):376-378.
35. Tanaka S, Kashida H, Saito Y, et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417–434
36. Gaglia A, Sarkar S. Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection. Ann Gastroenterol 2017; 30: 145–151.
37. Saito Y, Uraoka T, Yamaguchi Y, et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217–1225
38. Uraoka T, Parra-Blanco A, Yahagi N. Colorectal endoscopic submucosal dissection: is it suitable in western countries? J Gastroenterol Hepatol 2013; 28: 406–414.
Related articles

Letter

Colonic adenocarcinoma arising from traditional serrated adenoma

DOI: 10.17235/reed.2020.6818/2019

Letter

Endoscopic mucosal resection for cap poliposis treatment

DOI: 10.17235/reed.2020.6537/2019

Letter to the Editor

Acute appendicitis after a colonic endoscopic submucosal resection

DOI: 10.17235/reed.2018.5307/2017

Review

Serrated lesions and serrated polyposis syndrome

DOI: 10.17235/reed.2017.4065/2015

Citation tools
Sundaram S, Seth V, Jearth V, Giri S. Underwater versus conventional endoscopic mucosal resection for sessile colorectal polyps: an updated systematic review and meta-analysis. 8956/2022


Download to a citation manager

Download the citation for this article by clicking on one of the following citation managers:

Metrics
This article has received 2349 visits.
This article has been downloaded 232 times.

Statistics from Dimensions


Statistics from Plum Analytics

Publication history

Received: 24/05/2022

Accepted: 06/09/2022

Online First: 23/09/2022

Published: 05/05/2023

Article revision time: 98 days

Article Online First time: 122 days

Article editing time: 346 days


Share
This article hasn't been rated yet.
Reader rating:
Valora este artículo:




Asociación Española de Ecografía Digestiva Sociedad Española de Endoscopia Digestiva Sociedad Española de Patología Digestiva
The Spanish Journal of Gastroenterology is the official organ of the Sociedad Española de Patología Digestiva, the Sociedad Española de Endoscopia Digestiva and the Asociación Española de Ecografía Digestiva
Cookie policy Privacy Policy Legal Notice © Copyright 2023 y Creative Commons. The Spanish Journal of Gastroenterology