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Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video)

Published:October 25, 2018DOI:https://doi.org/10.1016/j.gie.2018.10.023

      Background and Aims

      Underwater EMR is an alternative way to have nonpedunculated colorectal lesions lifted before being resected. The endoscopist takes advantage of the behavior of mucosal lesions floating away from the muscular layer, once immersed in liquid. We performed a systematic review with meta-analysis to evaluate the efficacy and safety of this technique.

      Methods

      Electronic databases (Medline, Scopus, EMBASE) were searched up to May 2018. Full articles including patients with colorectal lesions resected by the underwater EMR technique were eligible. The complete resection (primary outcome), en bloc resection, recurrence, and adverse event rates were pooled by means of a random or fixed-effect model.

      Results

      Ten studies were eligible, providing data on 508 lesions removed from 433 patients (male/female = 239/194; mean age range 62.2-75.0 years). Six studies were performed in the United States and the other in Europe; 7 studies were prospective. The specific indications for performing underwater EMR varied widely across studies. The complete resection rate was 96.36% (95% confidence interval [CI], 91.77-98.44), with a rate of en bloc resection of 57.07% (95% CI, 43.20%-69.91%). The recurrence rate was 8.82% (95% CI, 5.78-13.25) in a mean endoscopy surveillance period of 7.7 months (range 4-15 months). The postprocedural bleeding rate was 2.85% (95% CI, 1.64-4.90). Bleeding during the procedure was always mild and was considered as part of the procedure in all series. The overall adverse event rate was 3.31% (95% CI, 1.97%-5.52%). No cases of perforation were reported.

      Conclusion

      According to the results of this systematic review, underwater EMR appears to be an effective and extremely safe technique for resecting nonpolypoid colorectal lesions.

      Graphical abstract

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      Linked Article

      • Underwater EMR for colorectal lesions
        Gastrointestinal EndoscopyVol. 90Issue 3
        • Preview
          We read with interest the article by Spadaccini et al1 evaluating underwater EMR (UEMR) for colorectal lesions. The authors found UEMR to be an effective and safe technique for resecting colorectal lesions. Because their findings are important to current practice, several questions deserve attention.
        • Full-Text
        • PDF
      • Underwater EMR without submucosal injection: Is less more?
        Gastrointestinal EndoscopyVol. 89Issue 6
        • Preview
          Conventional injection-assisted EMR is well established as the preferred method for the removal of sessile colonic polyps. Submucosal injection is based on the rationale that a fluid “cushion” separates the superficial mucosa-based lesion from the underlying muscular layer, thus protecting against perforation and transmural thermal injury when snare resection is performed. The 2015 ASGE Technology Status Evaluation Report on EMR states, “The cushion lifts the lesion, facilitating capture and removal by using a snare while minimizing mechanical or electrocautery damage to the deeper layers of the GI wall.”1 This practice has disseminated to become the standard of care despite an absence of studies proving its clinical benefit.
        • Full-Text
        • PDF