Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesionsTRIAL REGISTRATION: Single-Center Prospective Observational Study with Consecutive Patients NCT2000141 at clinicaltrials.gov.
submitted 21. April 2017
accepted after revision 17. Juli 2017
11.Oktober 2017 (eFirst)
Background and aims Non-lifting large laterally spreading colorectal lesions (LSLs) are challenging to resect endoscopically and often necessitate surgery. A safe, simple technique to treat non-lifting LSLs endoscopically with robust long-term outcomes has not been described.
Methods In this single-center prospective observational study of consecutive patients referred for endoscopic mucosal resection (EMR) of LSLs ≥ 20 mm, LSLs not completely resectable by snare because of non-lifting underwent standardized completion of resection with cold-forceps avulsion and adjuvant snare-tip soft coagulation (CAST). Scheduled surveillance colonoscopies were performed at 4 – 6 months (SC1) and 18 months (SC2). Primary outcomes were endoscopic evidence of adenoma clearance and avoidance of surgery. The secondary outcome was safety.
Results From January 2012 to October 2016, 540 lifting LSLs (82.2 %) underwent complete snare excision at EMR. CAST was required for complete removal in 101 non-lifting LSLs (17.8 %): 63 naïve non-lifting lesions (NNLs; 62.7 %) and 38 previously attempted non-lifting lesions (PANLs; 37.3 %). PANLs were smaller (P < 0.001) and more likely to be non-granular (P = 0.001) than the lifting LSLs. NNLs were of similar size (P = 0.77) and morphology (P = 0.10) to the lifting LSLs. CAST was successful in all cases and adverse events were comparable to lifting LSLs resected by complete snare excision. Recurrence at SC1 was comparable for PANLs (15.2 %) and lifting LSLs (15.3 %; P = 0.99), whereas NNLs recurred more frequently (27.5 %; P = 0.049); however, surgery was no more common for either type of non-lifting LSL than for lifting LSLs.
Conclusion CAST is a safe, effective, and surgery-sparing therapy for the majority of non-lifting LSLs. It is easy to use, inexpensive, and does not require additional equipment.
- 1 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 2014; 64: 57-65
- 2 Keswani RN, Law R, Ciolino JD. et al. Adverse events after surgery for nonmalignant colon polyps are common and associated with increased length of stay and costs. Gastrointest Endosc 2016; 84: 296-303.e1
- 3 Ahlenstiel G, Hourigan LF, Brown G. et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80: 668-676
- 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: 271-272
- 5 Kim HG, Thosani N, Banerjee S. et al. Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions. Gastrointest Endosc 2015; 81: 204-213
- 6 Chedgy F, Bhattacharyya R, Kandiah K. et al. Knife-assisted snare resection: a novel technique for resection of scarred polyps in the colon. Endoscopy 2016; 48: 277-280
- 7 Tsiamoulos ZP, Bourikas LA, Saunders BP. Endoscopic mucosal ablation: a new argon plasma coagulation/injection technique to assist complete resection of recurrent, fibrotic colon polyps (with video). Gastrointest Endosc 2012; 75: 400-404
- 8 Andrawes S, Haber G. Avulsion: a novel technique to achieve complete resection of difficult colon polyps. Gastrointest Endosc 2014; 80: 167-168
- 9 Veerappan SG, Ormonde D, Yusoff IF. et al. Hot avulsion: a modification of an existing technique for management of nonlifting areas of a polyp (with video). Gastrointest Endosc 2014; 80: 884-848
- 10 Anderson MA, Ben-Menachem T, Gan SI. et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
- 11 Bourke M. Endoscopic mucosal resection in the colon: A practical guide. Tech Gastrointest Endosc 2011; 13: 35-49
- 12 Burgess NG, Bassan MS, McLeod D. et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut DOI: 10.1136/gutjnl-2015-309848.
- 13 Swan MP, Bourke MJ, Moss A. et al. The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection. Gastrointest Endosc 2011; 73: 79-85
- 14 Holmes I, Kim HG, Yang D-H. et al. Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos). Gastrointestinal endoscopy 2016; 84: 822-829
- 15 Metz AJ, Moss A, McLeod D. et al. A blinded comparison of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy in a porcine model. Gastrointest Endosc 2013; 77: 484-490
- 16 Kudo K, Tamegai Y, Koike T. Indication of endoscopic submucosal dissection (ESD) for large colorectal tumors accompanied with fibrosis in submucosal layer. Gastrointest Endosc 2009; 69: AB285
- 17 Azzolini F, Camellini L, Sassatelli R. et al. Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (ESD in scar-embedded rectal polyps). Clin Res Hepatol Gastroenterol 2011; 35: 572-579
- 18 Kuroki Y, Hoteya S, Mitani T. et al. Endoscopic submucosal dissection for residual/locally recurrent lesions after endoscopic therapy for colorectal tumors. J Gastroenterol Hepatol 2010; 25: 1747-1753
- 19 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
- 20 Lee SP, Kim JH, Sung I-K. et al. Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: pathologic review of 173 cases. J Gastroenterol Hepatol 2015; 30: 872-878
- 21 Tate DJ, Desomer L, Singh R. et al. Two-stage endoscopic mucosal resection is a safe and effective salvage therapy after a failed single-session approach. Endoscopy DOI: 10.1055/s0043-110671.
- 22 Schmidt A, Bauerfeind P, Gubler C. et al. Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience. Endoscopy 2015; 47: 719-725
- 23 Fahrtash-Bahin F, Holt BA, Jayasekeran V. et al. Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos). Gastrointest Endosc 2013; 78: 158-163.e1
- 24 Gupta S, Miskovic D, Bhandari P. et al. A novel method for determining the difficulty of colonoscopic polypectomy. Frontline Gastroenterol 2013; 4: 244-248
- 25 Desomer L, Tutticci N, Tate DJ. et al. A standardized imaging protocol is accurate in detecting recurrence after EMR. Gastrointest Endosc 2017; 85: 518-526