Don’t Refer Large Nonpedunculated Colorectal Lesions to Surgeons After Failed EMR Attempts
Douglas K. Rex, MD, MASGE, reviewing Shahidi N, et al. Am J Gastroenterol 2021 Feb 9.
In clinical practice, colonoscopists sometimes think that patients with large nonpedunculated colorectal lesions should be referred to surgery after one or two attempts at resection and polyps persist.
In a study from an Australian consortium, 12% of 1292 large (≥20 mm) nonpedunculated colon polyps underwent a prior attempt at resection (PAs). In the PA lesions, technical success of resection was 93%, which increased to 95.6% if the procedure was performed in two stages.
For all lesions, nonfibrotic portions were removed by conventional EMR, followed by the CAST technique (cold forceps avulsion with adjuvant snare-tip soft coagulation [STSC] in the avulsed region). The total time to remove PA lesions was longer (35 vs 25 minutes), and the CAST technique was used more often (46.2% vs 7.6%). Among 127 PA lesions undergoing follow-up, overall recurrence was 7.8%, and no patients were referred for surgery at first follow-up. Of 65 lesions in which the margin was treated by STSC, there was no recurrence versus an 18% recurrence rate at first follow-up if STSC had not been used. Clip closure was used routinely in areas of CAST treatment to prevent delayed perforation, and no delayed perforations occurred.
COMMENTWe use a similar approach to previously attempted lesions at our center, with similar success rates, though we use hot avulsion followed by clip closure rather than the CAST technique. EMR with adjuvant therapy should be the first-line treatment when one or more previous attempts at EMR have failed, as surgery has higher morbidity, mortality, and cost than additional EMR. In my opinion, community colonoscopists who attempt EMR and abort it before completing the procedure should refer the patient to a regional center for colonoscopic resection of the lesion rather than making additional attempts.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
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 Feb 9. (Epub ahead of print) (https://doi.org/10.14309/ajg.0000000000001096)
