Endoscopic mucosal resection for challenging colonic mucosal lesions

We read the article by Uchima et al. that retrospectively analyzed a register of consecutive cap suction underwater endoscopic mucosal resection (UEMR) procedures, which facilitated the resection of flat lesions or those at the appendiceal orifice or ileocecal valve [11]. During UEMR, the mucosa and submucosa “float” away from the deeper muscularis layer, eliminating the need for submucosal injection [22]. In this article, the author employed cap suction to induce pseudopolyps from flat colon lesions. Similarly to band ligation EMR, the formation of a pseudopolyp following cap suction enables the direct excision of the lesion [33]. However, the process of prefilling the colonic lumen with water appears to be a laborious and time-consuming procedure.

Given the failure of snares to capture flat lesions, we suggest employing a hybrid EMR procedure that incorporates endoscopic submucosal dissection (ESD) techniques for dissection of the circumferential mucosa of the lesion, followed by snare resection [44]. The hybrid EMR procedure not only facilitates effective lesion capture by anchoring the snare beneath the dissected mucosa, but also provides clear visualization of the lesion extent. The main advantage of UEMR is its technical ease; however, the en bloc resection rate and recurrence rate of UEMR for larger mucosal lesions are still not ideal compared with ESD [55]. We aspire to further exploration to promote the development of EMR.

Publication History

Article published online:
29 May 2024

• References

• 1 Uchima H, Calm A, Muñoz-González R. et al. Underwater cap-suction pseudopolyp formation for endoscopic mucosal resection: a simple technique for treating flat, appendiceal orifice or ileocecal valve colorectal lesions. Endoscopy 2023; 55: 1045-1050 DOI: 10.1055/a-2115-7797. (PMID: 37348544)
• 2 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
• 3 Soehendra N, Seewald S, Growth S. et al. Use of modified multiband ligator facilitates circumferential EMR in Barrett’s esophagus (with video). Gastrointest Endosc 2006; 63: 847-852
• 4 Esaki M, Ihara E, Sumida Y. et al. Hybrid and conventional endoscopic submucosal dissection for early gastric neoplasms: a multi-center randomized controlled trial. Clin Gastroenterol Hepatol 2023; 21: 1810-1818.e8
• 5 Saito Y, Ono A. Underwater endoscopic mucosal resection for colorectal lesions: a bridge between conventional endoscopic mucosal resection and endoscopic submucosal dissection. Gastroenterology 2021; 161: 1369-1371 DOI: 10.1053/j.gastro.2021.08.039. (PMID: 34454918)