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Tip-in EMR as an alternative to endoscopic submucosal dissection for 20- to 30-mm nonpedunculated colorectal neoplasms

      Background and Aims

      Tip-in EMR, which includes anchoring the snare tip, has recently shown a favorable en-bloc and R0 resection rate for colorectal neoplasms. Thus, Tip-in EMR may be an alternative to endoscopic submucosal dissection (ESD). We aimed to compare clinical outcomes between Tip-in EMR and ESD for large colorectal neoplasms.

      Methods

      This retrospective study evaluated consecutive patients who underwent Tip-in EMR or ESD for 20- to 30-mm nonpedunculated colorectal neoplasms at a Japanese tertiary cancer center between January 2014 and December 2019. Baseline characteristics, treatment results, and long-term outcomes were analyzed using 1:1 propensity score matching.

      Results

      Seven hundred nine lesions were evaluated. The Tip-in EMR group included 1 lesion with a nonlifting sign but no lesions with fold convergence. After propensity score matching, each group included 140 lesions. The ESD group showed significantly higher en-bloc resection rates (99.3% vs 85.0%) and R0 resection rates (90.7% vs 62.9%). Procedure time was significantly shorter in the Tip-in EMR group (8 minutes vs 60 minutes). The Tip-in EMR and ESD groups did not differ significantly with respect to local recurrence rate (2.1% vs 0%).

      Conclusions

      Tip-in EMR is comparable with ESD with respect to the local recurrence rate but has a shorter procedure time, despite the lower en-bloc and R0 resection rates for 20- to 30-mm nonpedunculated colorectal neoplasms without fold convergence or nonlifting sign. Thus, Tip-in EMR could be a feasible alternative to ESD in these lesions.

      Abbreviations:

      C-EMR (conventional EMR), ESD (endoscopic submucosal dissection), NBI-ME (narrow-band imaging with magnifying endoscopy), PSM (propensity score matching)
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      References

        • Siegel R.L.
        • Miller K.D.
        • Fuchs H.E.
        • et al.
        Cancer statistics, 2021.
        CA Cancer J Clin. 2021; 71: 7-33
        • Sung H.
        • Ferlay J.
        • Siegel R.L.
        • et al.
        Global cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J Clin. 2021; 71: 209-249
        • Winawer S.J.
        • Zauber A.G.
        • Ho M.N.
        • et al.
        Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
        N Engl J Med. 1993; 329: 1977-1981
        • Zauber A.G.
        • Winawer S.J.
        • O’Brien M.J.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • Moss A.
        • Williams S.J.
        • Hourigan L.F.
        • 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. 2015; 64: 57-65
        • Fujiya M.
        • Tanaka K.
        • Dokoshi T.
        • et al.
        Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.
        Gastrointest Endosc. 2015; 81: 583-595
        • De Ceglie A.
        • Hassan C.
        • Mangiavillano B.
        • et al.
        Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: a systematic review.
        Crit Rev Oncol Hematol. 2016; 104: 138-155
        • Oka S.
        • Tanaka S.
        • Saito Y.
        • et al.
        Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan.
        Am J Gastroenterol. 2015; 110: 697-707
        • Belderbos T.D.
        • Leenders M.
        • Moons L.M.
        • et al.
        Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis.
        Endoscopy. 2014; 46: 388-402
        • Hotta K.
        • Fujii T.
        • Saito Y.
        • et al.
        Local recurrence after endoscopic resection of colorectal tumors.
        Int J Colorectal Dis. 2009; 24: 225-230
        • Imai K.
        • Hotta K.
        • Yamaguchi Y.
        • et al.
        Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training.
        Gastrointest Endosc. 2016; 83: 954-962
        • Imai K.
        • Hotta K.
        • Ito S.
        • et al.
        A risk-prediction model for en bloc resection failure or perforation during endoscopic submucosal dissection of colorectal neoplasms.
        Dig Endosc. 2020; 32: 932-939
        • Chien H.
        • Imai K.
        • Hotta K.
        • et al.
        Tip-in EMR for R0 resection for a large flat colonic tumor.
        Gastrointest Endosc. 2016; 84: 743
        • Imai K.
        • Hotta K.
        • Ono H.
        Tip-in endoscopic mucosal resection: simple, efficacious trick for endoscopic mucosal resections of large colorectal polyps.
        Dig Endosc. 2021; 33: 203
        • Shumeiko O.
        • Imai K.
        • Hotta K.
        Tip-in endoscopic mucosal resection for R0 resection of a poorly lifted colonic laterally spreading tumor with possible submucosal invasion.
        Dig Endosc. 2020; 32: e15-e16
        • Sato Y.
        • Ozawa S.I.
        • Yasuda H.
        • et al.
        Tip-in endoscopic mucosal resection for large colorectal sessile polyps.
        Surg Endosc. 2021; 35: 1820-1826
        • Noh S.M.
        • Kim J.Y.
        • Park J.C.
        • et al.
        Tip-in versus conventional endoscopic mucosal resection for flat colorectal neoplasia 10 mm or larger in size.
        Int J Colorectal Dis. 2020; 35: 1283-1290
        • Imai K.
        • Hotta K.
        • Ito S.
        • et al.
        Tip-in endoscopic mucosal resection for 15- to 25-mm colorectal adenomas: a single-center, randomized controlled trial (STAR Trial).
        Am J Gastroenterol. 2021; 116: 1398-1405
        • Vandenbroucke J.P.
        • von Elm E.
        • Altman D.G.
        • et al.
        Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.
        Epidemiology. 2007; 18: 805-835
        • 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
        • 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
        • Yamashina T.
        • Takeuchi Y.
        • Uedo N.
        • et al.
        Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm.
        J Gastroenterol Hepatol. 2016; 31: 615-620
        • Ito S.
        • Hotta K.
        • Imai K.
        • et al.
        Risk factors of post-endoscopic submucosal dissection electrocoagulation syndrome for colorectal neoplasm.
        J Gastroenterol Hepatol. 2018; 33: 2001-2006
        • Endoscopic Classification Review Group
        Update on the Paris classification of superficial neoplastic lesions in the digestive tract.
        Endoscopy. 2005; 37: 570-578
        • Hashiguchi Y.
        • Muro K.
        • Saito Y.
        • et al.
        Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer.
        Int J Clin Oncol. 2020; 25: 1-42
        • Rosenbaum P.R.
        • Rubin D.B.
        The central role of the propensity score in observational studies for causal effects.
        Biometrika. 1983; 70: 41-55
        • Kanda Y.
        Investigation of the freely available easy-to-use software “EZR” for medical statistics.
        Bone Marrow Transplant. 2013; 48: 452-458
        • Pioche M.
        • Wallenhorst T.
        • Lepetit H.
        • et al.
        Endoscopic mucosal resection with anchoring of the snare tip: multicenter retrospective evaluation of effectiveness and safety.
        Endosc Int Open. 2019; 7: E1496-E1502
        • Lee C.Y.
        • Chen M.Y.
        • Lin H.J.
        • et al.
        Safety and efficacy of tip-in endoscopic mucosal resection for large sessile colorectal polyps: a single-center experience in Taiwan.
        Adv Dig Med. 2019; 7: 58-62
        • Yoshida N.
        • Inoue K.
        • Dohi O.
        • et al.
        Efficacy of precutting endoscopic mucosal resection with full or partial circumferential incision using a snare tip for difficult colorectal lesions.
        Endoscopy. 2019; 51: 871-876
        • McCarty T.R.
        • Bazarbashi A.N.
        • Thompson C.C.
        • et al.
        Hybrid endoscopic submucosal dissection (ESD) compared with conventional ESD for colorectal lesions: a systematic review and meta-analysis.
        Endoscopy. 2021; 53: 1048-1058
        • Binmoeller K.F.
        • Hamerski C.M.
        • Shah J.N.
        • et al.
        Attempted underwater en bloc resection for large (2-4 cm) colorectal laterally spreading tumors (with video).
        Gastrointest Endosc. 2015; 81: 713-718
        • Inoue T.
        • Nakagawa K.
        • Yamasaki Y.
        • et al.
        Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20-30 mm colorectal polyps.
        J Gastroenterol Hepatol. 2021; 36: 2549-2557
        • Gaglia A.
        • Sarkar S.
        Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection.
        Ann Gastroenterol. 2017; 30: 145-151
        • Kandel P.
        • Brand E.C.
        • Pelt J.
        • et al.
        Endoscopic scar assessment after colorectal endoscopic mucosal resection scars: when is biopsy necessary (EMR Scar Assessment Project for Endoscope (ESCAPE) trial).
        Gut. 2019; 68: 1633-1641