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Underwater vs. Conventional EMR of Large Nonpedunculated Colorectal Lesions: A Multicenter Randomized Controlled Trial

Published:December 23, 2022DOI:https://doi.org/10.1016/j.gie.2022.12.013
Underwater vs. Conventional EMR of Large Nonpedunculated Colorectal Lesions: A Multicenter Randomized Controlled Trial
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      Abstract

      Background & Aims

      Underwater endoscopic mucosal resection (UEMR) is an alternative procedure to conventional endoscopic mucosal resection (CEMR) to treat large nonpedunculated colorectal polyps (LNPCL). In this multicenter randomized clinical trial, we aimed to compare the efficacy and safety of UEMR versus CEMR on LNPCL.

      Methods

      We conducted a multicenter randomized controlled clinical trial from February 2018 to February 2020 in 11 hospitals in Spain. A total of 298 patients (311 lesions) were randomized to the UEMR (n=149) and CEMR (n=162) groups. The main outcome was the lesion recurrence rate in at least one follow-up colonoscopy. Secondary outcomes included technical aspects, en bloc resection rate, R0 and adverse events, among others.

      Results

      There were no differences in the overall recurrence rate [9.5% UEMR vs. 11.7% CEMR; absolute risk difference -2.2% (CI 95%: -9.4% to 4.9%)]. However, considering the polyp sizes between 20 and 30 mm, the recurrence rate was lower for UEMR [3.4% UEMR vs. 13.1% CEMR; absolute risk difference -9.7% (CI 95%: -19.4% to 0%)]. The R0 resection showed the same tendency, with significant differences favoring UEMR only for polyps between 20 and 30 mm. Overall, UEMR was faster and easier to perform than CEMR. Importantly, both techniques were equally safe.

      Conclusions

      UEMR is a valid alternative to CEMR of LNPCL and could be considered the first option of treatment for lesions between 20-30 mm due to its higher en bloc and R0 resection rates.

      Graphical abstract

      Figure thumbnail fx1
      Graphical Abstract

      Keywords

      Abbreviations:

      AEs (Adverse events), ASA (American Society of Anesthesiologists), ARD (Absolute risk difference), CEMR (Conventional mucosal endoscopic resection), CI (Confidence interval), EMR (Mucosal endoscopic resection), ESD (Endoscopic submucosal dissection), HGD (High-grade dysplasia), IQR (Interquartile range), ITT (Intention-to-treat), JNET (Japan NBI Expert Team), LGD (Low-grade dysplasia), LNPCL (Large nonpedunculated colonic lesions), LST (Laterally spreading tumors), NBI (Narrow band imaging), NICE (NBI international colorectal endoscopic), OR (Odds ratio), PP (per-protocol), PPS (Postpolypectomy syndrome), SD (Standard deviation), SEED (Spanish Society of Digestive Endoscopy), TC (Transverse colon), UEMR ("Underwater" mucosal endoscopic resection)
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      Article info

      Publication history

      Accepted: December 17, 2022
      Received in revised form: November 23, 2022
      Received: October 26, 2022

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      Author contributions:

      JRS and MAA: Conception and design of the study, performed the procedures, collected data and drafting of the article; EA: Designed the study, analysis and interpretation of the data and drafting of the article; ME and SM: analysis of the data and drafting of the article; AA, ERC, EVC, MRT and MSA: collected data and critical revision of the article for important intellectual content. The rest of the authors performed the procedures, collected data and critical revision of the article for important intellectual content.

      All authors had access to the study data and gave the final approval of the article.

      Grant support: The project obtained a grant from the Spanish Society of Digestive Endoscopy (SEED). Eduardo Albéniz has an Intensification Grant from the “La Caixa/Caja Navarra” Foundation (ID 100010434; Project PR15/11100006).

      Competing interests or Disclosures: Maria Pellisé is the board member of the SEED and chair of the Equity and Diversity working group of European Society of Endoscopy. She has been the editor of the Endoscopy journal (2015-2021). Maria declares the following conflicts of interest: Fujifilm Europe and Olympus Europe. Hugo Uchima declares a conflict of interest with Ambu, Lumendi and ERBE Spain. Luis Hernández is the Vicepresident of the Spanish Gastroenterology Association AEG (unpaid relationship starting in March 2022). Alberto Herreros de Tejada has been granted consulting fees and/or honoraria for lectures from Ambu Co., Olympus Co. and Creo Medical. Alberto Ávarez Delgado declares consulting fees from Olympus Iberia, S.A.U. and Norgine, and honoraria for lectures from SEED. Ramiro Carreño declares a conflict of interest with Viatris, Boston Scientific and Casen Recordati. The rest of the authors declare that there are no conflicts of interest regarding the publication of this article.

      WRITING ASSISTANCE

      English editing and manuscript formatting were performed by American Journal Experts, LLC (www.aje.com).

      ClinicalTrials.gov ID: NCT03567746; First Posted: June 26, 2018

      Identification

      DOI: https://doi.org/10.1016/j.gie.2022.12.013

      Copyright

      © 2022 by the American Society for Gastrointestinal Endoscopy

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