Post written by Dennis Yang, MD, from the Center of Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.
Traditionally, during endoscopic submucosal dissection, lesion margins are meticulously examined and defined by placing coagulation marks lateral to the borders of the target lesion. The intended purpose of this step is to avoid inadvertent incomplete resection at the outer margins. Margin marking prior to resection may represent a simple method to achieve a healthy resection margin during EMR (EMR-MM).
Recurrence is a major problem because it invariably increases the risk of progression to cancer if left untreated and thereby demands short interval surveillance with repeated interventions. The ability to identify strategies to safely optimize EMR techniques to provide definitive resection and minimize the risk of recurrence ensures high-quality patient care and potentially curtails unnecessary surgery.
In this single-center study of 210 patients (74 EMR-MM vs 136 conventional EMR), EMR-MM was associated with a significantly lower rate of recurrence than conventional EMR (8% vs 29%; P < .001). EMR-MM was not associated with a higher risk for adverse events. On multivariable analysis, EMR-MM remained the strongest predictor of recurrence (odds ratio [OR], .20; 95% confidence interval [CI], .13-.64; P = .003) aside from polyp size (OR, 2.81; 95% CI, 1.35-6.01; P = .008).
In this single-center historical control study, EMR-MM of large nonpedunculated colorectal polyps reduced the recurrence risk by 80% when compared with conventional EMR. This simple technique may provide an alternative to margin ablation. Future larger studies are needed to corroborate these preliminary findings and to confirm performance with other strategies aimed at mitigating recurrence.
Margin marking before EMR. A, Under digital chromoendoscopy to visualize the lesion, cautery marks using snare-tip soft coagulation mode are placed along the lateral margin (highlighted by the red line) of the polyp. B, Successive cautery marks approximately 3 mm apart are placed along the entire margin of the polyp before EMR. C, The cautery marks serve as visual cues to help direct snare placement during EMR. D, Piecemeal EMR is performed to include all healthy lateral margins including the cautery marks. E, Complete resection including a healthy margin is confirmed by nonvisualization of any cautery marks after EMR.
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