Procedural outcomes of a novel underwater injection endoscopic mucosal resection technique for colorectal polyps ≥10 mm

Abstract

Background

It is uncertain whether underwater endoscopic mucosal resection (UEMR) enables resection of the submucosal tissue with sufficient margins for T1 colorectal cancer (CRC) because UEMR forgoes submucosal injection. Therefore, we developed a novel “underwater injection EMR” (UIEMR) method that combines submucosal injection with UEMR to obtain an adequate vertical margin.

Methods

We retrospectively analyzed procedure-related outcomes of 135 consecutive lesions from patients who underwent UIEMR for ≥10-mm nonpedunculated colorectal polyps (median size 15 mm). The outcomes included the en bloc, R0, RX, and R1 resection rates, and adverse events. Additionally, the vertical margin distance of seven T1 CRCs was evaluated.

Results

En bloc resection was achieved in 127 lesions (94.1%). R0 and RX resections were observed in 92 (68.1%) and 42 lesions (31.1%), respectively, while R1 resection was seen in only one lesion (0.7%). There were two cases with adverse events (1.5%), both delayed bleeding. In T1 CRCs, all seven cases had free vertical margins, and the median vertical margin distance was 1140 µm (range 731–1570 µm).

Conclusions

UIEMR safely demonstrated high success rates for en bloc resection, and potentially ensures a sufficient vertical margin. This technique might be an option, particularly for relatively small lesions concerning for T1 CRC, and deserves further study.

Publication History

Received: 22 March 2024

Accepted after revision: 20 November 2024

Accepted Manuscript online:
20 November 2024

Article published online:
28 January 2025

• 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
• 2 Tanaka S, Kashida H, Saito Y. et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2020; 32: 219-239
• 3 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
• 4 Chandan S, Bapaye J, Khan SR. et al. Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs. Endosc Int Open 2023; 11: E768-E777
• 5 Leung FW, Leung JW, Mann SK. et al. The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy. Endoscopy 2011; 43: 816-821
• 6 Fukuda H, Takeuchi Y, Shoji A. et al. Curative value of underwater endoscopic mucosal resection for submucosally invasive colorectal cancer. J Gastroenterol Hepatol 2021; 36: 2471-2478
• 7 Sano Y, Tanaka S, Kudo SE. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533
• 8 Kudo S, Tamura S, Nakajima T. et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14
• 9 Sakamoto T, Matsuda T, Nakajima T. et al. Clinicopathological features of colorectal polyps: evaluation of the 'predict, resect and discard' strategies. Colorectal Dis 2013; 15: e295-e300
• 10 Pimentel-Nunes P, Libânio D, Bastiaansen BAJ. et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54: 591-622
• 11 Hirata S, Toyoshima N, Takamaru H. et al. Underwater endoscopic mucosal resection with submucosal injection. Endoscopy 2023; 55: E70-E71
• 12 Saito Y, Kodashima S, Matsuda T. et al. Current status of diagnostic and therapeutic colonoscopy in Japan: The Japan Endoscopic Database Project. Dig Endosc 2022; 34: 144-152
• 13 Japanese Society for Cancer of the Colon and Rectum.. Japanese classification of colorectal, appendiceal, and anal carcinoma: the 3rd English Edition [Secondary Publication]. J Anus Rectum Colon 2019; 3: 175-195
• 14 Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut 2002; 51: 130-131
• 15 Makazu M, Sakamoto T, So E. et al. Relationship between indeterminate or positive lateral margin and local recurrence after endoscopic resection of colorectal polyps. Endosc Int Open 2015; 3: E252-E257
• 16 Matsueda K, Takeuchi Y, Kitamura M. et al. Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post-hoc analysis of a randomized study. J Gastroenterol Hepatol 2022; 37: 741-748
• 17 Nomura H, Tsuji S, Utsunomiya M. et al. Resection depth and layer of underwater versus conventional endoscopic mucosal resection of intermediate-sized colorectal polyps: A pilot study. Endosc Int Open 2022; 10: E1037-E1044
• 18 Nishimura T, Oka S, Kamigaichi Y. et al. Vertical tumor margin of endoscopic resection for T1 colorectal carcinoma affects the prognosis of patients undergoing additional surgery. Surg Endosc 2022; 36: 5970-5978
• 19 Takatori Y, Kato M, Masunaga T. et al. Efficacy of partial injection underwater endoscopic mucosal resection for superficial duodenal epithelial tumor: Propensity score-matched study (with video). Dig Endosc 2022; 34: 535-542
• 20 Hashiguchi K, Yamaguchi N, Shiota J. et al. 'Underwater endoscopic mucosal resection with submucosal injection and marking' for superficial non-ampullary duodenal epithelial tumors to achieve R0 resection: a single-center case series. Scand J Gastroenterol 2023; 58: 813-821