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DOI: 10.1055/a-1287-9621
Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis
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Abstract
Background and study aims Underwater endoscopic mucosal resection (UEMR) for colorectal polyps has been reported to have good outcomes in recent studies. We conducted a systematic review and meta-analysis comparing the effectiveness and safety of UEMR to conventional EMR (CEMR).
Methods A comprehensive search of multiple databases (through May 2020) was performed to identify studies that reported outcome of UEMR and CEMR for colorectal lesions. Outcomes assessed included incomplete resection, rate of recurrence, en bloc resection, adverse events (AEs) for UEMR and CEMR.
Results A total of 1,651 patients with 1,704 polyps were included from nine studies. There was a significantly lower rate of incomplete resection (odds ratio [OR]: 0.19 (95 % confidence interval (CI), 0.05–0.78, P = 0.02) and polyp recurrence (OR: 0.41, 95 % CI, 0.24–0.72, P = 0.002) after UEMR. Compared to CEMR, rates overall complications (relative risk [RR]: 0.66 (95 % CI, 0.48–0.90) (P = 0.008), and intra-procedural bleeding (RR: 0.59, 95 % CI, 0.41–0.84, P = 0.004) were significantly lower with UEMR. The recurrence rate was also lower for large non-pedunculated polyps ≥ 10 mm (OR 0.24, 95 % CI, 0.10–0.57, P = 0.001) and ≥ 20 mm (OR 0.14, 95 % CI, 0.02–0.72, P = 0.01). The rates of en bloc resection, delayed bleeding, perforation and post-polypectomy syndrome were similar in both groups (P > 0.05).
Conclusions In this systematic review and meta-analysis, we found that UEMR is more effective and safer than CEMR with lower rates of recurrence and AEs. UEMR use should be encouraged over CEMR.
Publication History
Received: 24 June 2020
Accepted: 21 September 2020
Article published online:
27 November 2020
© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Georg Thieme Verlag KG
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References
- 1 Burgess NG, Bahin FF, Bourke MJ. Colonic polypectomy (with videos). Gastrointest Endosc 2015; 81: 813-835
- 2 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
- 3 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
- 4 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 e271–272
- 5 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
- 6 Fukami N, Lee JH. Endoscopic treatment of large sessile and flat colorectal lesions. Curr Opin Gastroenterol 2006; 22: 54-59
- 7 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
- 8 Binmoeller KF, Weilert F, Shah J. et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012; 75: 1086-1091
- 9 Nett A, Binmoeller K. Underwater endoscopic mucosal resection. Gastrointest Endosc Clin N Am 2019; 29: 659-673
- 10 Binmoeller KF. Underwater EMR without submucosal injection: Is less more?. Gastrointest Endosc 2019; 89: 1117-1119
- 11 Binmoeller KF, Hamerski CM, Shah JN. et al. Underwater EMR of adenomas of the appendiceal orifice (with video). Gastrointest Endosc 2016; 83: 638-642
- 12 Binmoeller KF, Hamerski CM, Shah JN. et al. Attempted underwater en bloc resection for large (2-4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc 2015; 81: 713-718
- 13 Chien H-C, Uedo N, Hsieh P-H. Comparison of underwater and conventional endoscopic mucosal resection for removing sessile colorectal polyps: a propensity-score matched cohort study. Endosc Int Open 2019; 07: E1528-E1536
- 14 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: The prisma statement. Ann Int Med 2009; 151: 264-269
- 15 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA 2000; 283: 2008-2012
- 16 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Europ J Epidemiol 2010; 25: 603-605
- 17 DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled Clinical Trials 1986; 7: 177-188
- 18 Higgins J, Thompson SG, Spiegelhalter DJ. A re‐evaluation of random‐effects meta‐analysis. J Royal Stati Society 2009; 172: 137-159
- 19 Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. Br Med J 2011; 342: d549
- 20 Mohan BP, Adler DG. Heterogeneity in systematic review and meta-analysis: how to read between the numbers. Gastrointest Endosc 2019; 89: 902-903
- 21 Kanwal F, White D. Systematic reviews and meta-analyses. Clin Gastroenterol Hepatol 2012; 10: 1184-1186
- 22 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. Br Med J 2003; 327: 557
- 23 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines: 7 Rating the quality of evidence and inconsistency. . J Clin Epidemiol 2011; 64: 1294-1302
- 24 The Nordic Cochrane Centre TCC. Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen; 2014
- 25 Cadoni S, Liggi M, Gallittu P. et al. Underwater endoscopic colorectal polyp resection: Feasibility in everyday clinical practice. United European Gastroenterol J 2018; 6: 454-462
- 26 Hamerski CM, Wang AY, Amato A. et al. 121 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-AB56
- 27 Liverant ML, Yip B, Kwak N. et al. Su1690 Underwater Endoscopic mucosal resection (EMR) shows a higher single session curative resection rate than conventional EMR technique: a single center experience. Gastrointest Endosc 2016; 83: AB397
- 28 Rodriguez Sanchez J, Uchima Koecklin H, Gonzalez Lopez L. et al. Short and long-term outcomes of underwater EMR compared to the traditional procedure in the real clinical practice. Rev Esp Enferm Dig 2019; 111: 543-549
- 29 Schenck RJ, Jahann DA, Patrie JT. et al. Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 2017; 31: 4174-4183
- 30 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 e452
- 31 Mouchli M, Walsh C, Reddy S. et al. Sa1727 – Outcomes of gi polyps resected using underwater endoscopic mucosal resection (UEMR) Compared to conventional EMR (CEMR). Gastroenterology 2019; 156: S379-S380
- 32 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 e642
- 33 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: 697-707
- 34 Silva MA, Hegab B, Hyde C. et al. Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis. Gut 2008; 57: 1592-1596
- 35 Yokoyama K, Ushio J, Numao N. et al. Esophageal seeding after endoscopic ultrasound-guided fine-needle aspiration of a mediastinal tumor. Endosc Int Open 2017; 5: E913-E917
- 36 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
- 37 Ponugoti PL, Rex DK. Perforation during underwater EMR. Gastrointest Endosc 2016; 84: 543-544
- 38 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
- 39 Kim HG, Thosani N, Banerjee S. et al. Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 2014; 80: 1094-1102
- 40 Sakamoto T, Matsuda T, Otake Y. et al. Predictive factors of local recurrence after endoscopic piecemeal mucosal resection. J Gastroenterol 2012; 47: 635-640
- 41 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434
- 42 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
- 43 Uraoka T, Parra-Blanco A, Yahagi N. Colorectal endoscopic submucosal dissection: is it suitable in western countries?. J Gastroenterol Hepatol 2013; 28: 406-414
- 44 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: 1109-1116 e1104