Endoscopy 2017; 49(09): 888-898
DOI: 10.1055/s-0043-110671
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Two-stage endoscopic mucosal resection is a safe and effective salvage therapy after a failed single-session approach

David J. Tate
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
2   Westmead Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
,
Lobke Desomer
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
,
Luke F. Hourigan
3   Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
4   Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
,
Alan Moss
5   Department of Gastroenterology and Hepatology, The Western Hospital, Melbourne, Victoria, Australia
6   Department of Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
,
Rajvinder Singh
7   Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, South Australia, Australia
,
Michael J. Bourke
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
2   Westmead Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
› Author Affiliations
Further Information

Publication History

submitted 07 November 2016

accepted after revision 03 April 2017

Publication Date:
31 May 2017 (online)

Abstract

Background and study aims Endoscopic mucosal resection (EMR) of laterally spreading colonic lesions ≥ 20 mm (LSLs) is ideally performed in a single session (ssEMR) and avoids surgery in > 90 % of patients. We investigated whether a second attempt is safe or useful when ssEMR fails at a tertiary center.

Patients and methods In a multicenter prospective observational study of patients with LSL treated by EMR at four tertiary centers over 8 years, incompletely resected LSLs were referred for surgery or underwent two-stage EMR (tsEMR). At tsEMR, the scar was located and all visible residual tissue removed by snare, with thermal treatment permitted thereafter. Scheduled surveillance was performed at 5 months (SC1) and 18 months (SC2). The primary outcome was avoidance of surgery.

Results A total of 1944 LSLs (median size 35 mm) underwent EMR. ssEMR was unsuccessful in 127 lesions, 43 of which underwent tsEMR, with success in 36 (83.7 %). Compared with ssEMR, tsEMR lesions were larger (median size 50 mm vs. 30 mm; P < 0.001), exhibited more submucosal fibrosis (P < 0.001), and histology was more often tubular adenoma and less often serrated (P = 0.005). Lesions mainly required tsEMR for nonlifting (41.9 %) or poor endoscopic access (37.2 %). Failure of tsEMR was predicted by larger LSL (P = 0.03). Safety was comparable to ssEMR. Of the 33 LSLs that underwent tsEMR for benign disease and completed first surveillance, 27 (81.8 %) avoided surgery to long term follow-up.

Conclusions tsEMR shows promise as a salvage therapy for LSLs that cannot be resected in a single session for patients in whom other options such as surgery are not preferred or not possible.

Trial registered at ClinicalTrials.gov (NCT01368289).

Fig. e5, Table e4, Table e5

 
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