Impact of margin thermal treatment after endoscopic mucosal resection of giant (≥40 mm) colorectal lateral spreading lesions

Published:October 24, 2022DOI:

      Background and aims

      Increasing lesion size is a risk factor for recurrence after piecemeal EMR (pEMR). Snare-tip soft coagulation (STSC) treatment of the normal-appearing margin after pEMR of lesions ≥ 20 mm has been shown to reduce recurrence rates by 75% to 80%. We sought to evaluate the impact of STSC on giant (≥ 40 mm) lateral spreading lesions treated by pEMR. We describe the relative risk and absolute risks of recurrence with and without STSC margin treatment after EMR of ≥ 40-mm lesions.


      We performed a retrospective evaluation of a prospectively collected database on large lesions describing lesion size, location, and methods of resection. We excluded lesions < 40 mm in maximum dimension, those that did not undergo follow-up care at our center, and those in which argon plasma coagulation was used for either ablative treatment of residual polyp or margin treatment. Propensity score analysis was used to account for potential differences between patients treated with and without STSC.


      There were 68 lesions ≥ 40 mm removed by pEMR without STSC treatment and 133 removed and treated with STSC. There were no differences between groups in demographics, polyp size, location, histologic features, and mean follow-up time. The recurrence rate in the no-treatment group was 35% versus 9% with STSC (P < .00001 by direct comparison and P = .008 by using the propensity score analysis).


      STSC treatment after pEMR of large lateral spreading lesions in the colorectum reduced recurrences by 75%. However, the absolute recurrence rate of 9% remained clinically significant in the STSC-treated group. Short-term follow-up care after STSC of lesions ≥ 40 mm is still warranted, and additional study of technical factors that eliminate recurrence after pEMR of giant lateral spreading lesions is warranted.


      APC (argon plasma coagulation), ESD (endoscopic submucosal dissection), pEMR (piecemeal endoscopic mucosal resection), STSC (snare-tip soft coagulation)
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        • Klein A.
        • Tate D.J.
        • Jayasekeran V.
        • et al.
        Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection.
        Gastroenterology. 2019; 156: 604-613.e3
        • Sidhu M.
        • Shahidi N.
        • Gupta S.
        • et al.
        Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps.
        Gastroenterology. 2021; 161: 163-170.e3
        • Meulen L.W.
        • Bogie R.
        • Winkens B.
        • et al.
        Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis.
        Endosc Int Open. 2022; 10: E1127-E1135
        • El Rahyel A.
        • Abdullah N.
        • Love E.
        • et al.
        Recurrence after endoscopic mucosal resection: early and late incidence, treatment outcomes, and outcomes in non-overt (histologic-only) recurrence.
        Gastroenterology. 2021; 160: 949-951.e2
        • 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
        • Andrawes S.
        • Haber G.
        Avulsion: a novel technique to achieve complete resection of difficult colon polyps.
        Gastrointest Endosc. 2014; 80: 167-168
        • Kumar V.
        • Broadley H.
        • Rex D.K.
        Safety and efficacy of hot avulsion as an adjunct to EMR (with videos).
        Gastrointest Endosc. 2019; 89: 999-1004
        • Brooker J.C.
        • Saunders B.P.
        • Shah S.G.
        • et al.
        Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.
        Gastrointest Endosc. 2002; 55: 371-375
        • Kandel P.
        • Werlang M.E.
        • Ahn I.R.
        • et al.
        Prophylactic snare tip soft coagulation and its impact on adenoma recurrence after colonic endoscopic mucosal resection.
        Dig Dis Sci. 2019; 64: 3300-3306
        • Albuquerque W.
        • Arantes V.N.
        • Coelho L.G.
        • et al.
        Complementation by argon plasma coagulation after endoscopic piecemeal resection of large colorectal adenomas.
        Rev Col Bras Cir. 2013; 40: 404-408
        • Katsinelos P.
        • Lazaraki G.
        • Chatzimavroudis G.
        • et al.
        A retrospective comparative study of argon plasma versus polypectome snare tip coagulation: effect on recurrence rate after resection of large laterally spreading type lesions.
        Ann Gastroenterol. 2019; 32: 178-184
        • Raju G.S.
        • Lum P.
        • Abu-Sbeih H.
        • et al.
        Cap-fitted endoscopic mucosal resection of ≥20 mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate.
        Endosc Int Open. 2020; 8: E115-E121
        • Park E.Y.
        • Baek D.H.
        • Song G.A.
        • et al.
        Long-term outcomes of endoscopically resected laterally spreading tumors with a positive histological lateral margin.
        Surg Endosc. 2020; 34: 3999-4010
        • Shahidi N.
        • Sidhu M.
        • Vosko S.
        • et al.
        Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction.
        Gut. 2020; 69: 673-680
        • Shahidi N.
        • Vosko S.
        • Gupta S.
        • et al.
        Previously attempted large nonpedunculated colorectal polyps are effectively managed by endoscopic mucosal resection.
        Am J Gastroenterol. 2021; 116: 958-966
        • Rex D.K.
        • Hassan C.
        • Dewitt J.M.
        Colorectal endoscopic submucosal dissection in the United States: why do we hear so much about it and do so little of it?.
        Gastrointest Endosc. 2017; 85: 554-558
        • Suresh S.
        • Zhang J.
        • Ahmed A.
        • et al.
        Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review.
        Endosc Int Open. 2021; 9: E867-E873
        • Motchum L.
        • Levenick J.M.
        • Djinbachian R.
        • et al.
        Endoscopic mucosal resection combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps.
        Gastrointest Endosc. 2022; 96: 840-848.e2
        • Holmes I.
        • Kim H.G.
        • 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).
        Gastrointest Endosc. 2016; 84: 822-829