Combining endoscopic mucosal resection with hybrid argon plasma coagulation to reduce local colorectal lesion recurrence: a video tutorial

Endoscopic mucosal resection (EMR) is a safe, effective, and surgery-sparing technique for removing large colorectal lesions [1]. Although piecemeal EMR is recommended for polyps > 20 mm in size, it remains a suboptimal technique for complete lesion resection, with high rates of residual polyp and recurrence rates reaching 15 % [2]. Hybrid argon plasma coagulation (hAPC) is a novel approach allowing ablation of resection margins and surface after EMR. hAPC combines waterjet injection and argon plasma coagulation (APC) in a single device. On-demand, repeatable saline cushioning without instrument exchange reduces thermal ablative insult to deep tissue structures, allowing for effective destruction of micro-remnants with reduced risk of perforation. High technical success and low recurrence rates (0 %) were shown in a pilot study using EMR in combination with hAPC [3]. A prospective international multicenter study showed that the local recurrence rate was only 2.2 % when using hAPC after EMR [4]. One recent meta-analysis found the local recurrence rate to be 3.3 % after hot EMR and margin ablation at 12-month follow-up [5].

We present a step-by-step video tutorial demonstrating how hAPC-assisted EMR is performed while providing technical tips to achieve optimal ablation results ([Video 1]).

Video 1 Video tutorial demonstrating how to perform hybrid argon plasma coagulation-assisted endoscopic mucosal resection in different clinical examples.

hAPC-assisted EMR is done after standard initial assessment of polyp morphology and submucosal invasion. The polyp is removed in piecemeal fashion using a combination of an electrosurgical snare, cold snare, and forceps avulsion techniques ([Fig. 1]). Following complete resection of the entire visible polyp, the base and margins of the submucosal defect are then lifted using the waterjet function of the hAPC probe and thermal ablation is performed. EMR margin ablation is performed with combinations alternating between 25–40 W pulsed-APC and precise-APC Effect 8–10 (11–21 W), with both modes using a flow of 0.8 L/min. Vessels can be prophylactically ablated; however, the clinical benefit of this is unclear at present.

Fig. 1 The hybrid argon plasma coagulation (hAPC)-assisted endoscopic mucosal resection (EMR) technique for removal of colon polyps. a EMR is performed. b The resection area post-EMR. c Needless waterjet injection for margin and base lifting prior to hAPC. d Thermal ablation using hAPC.

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Citation Format

Endoscopy 2023; 54 (S01); E229–E230, DOI: 10.1055/a-1966-0441.

Competing interests

D. von Renteln has received research funding and speaker honoraria from Erbe.

• References

• 1 Kaltenbach T, Anderson J, Singh R. et al. Endoscopic removal of colorectal lesions: recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115: 435-464
• 2 Belderbos TD, Leenders M, Moons LM. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-402
• 3 Motz VL, Lester C, Moyer MT. et al. Hybrid argon plasma coagulation-assisted endoscopic mucosal resection for large sessile colon polyps to reduce local recurrence: a prospective pilot study. Endoscopy 2022; 54: 580-584
• 4 Motchum L, Levenick JM, Djinbachian R. et al. EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos). Gastrointest Endosc 2022; DOI: 10.1016/j.gie.2022.06.018.
• 5 Rotermund C, Djinbachian R, Taghiakbari M. et al. Recurrence rates after endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. World J Gastroenterol 2022; 28: 4007-4018

Publication History

Article published online:
29 March 2023