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

Post written by Kazunori Takada, MD, and Kinichi Hotta, MD, from the Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.


Compared with conventional EMR, endoscopic submucosal dissection (ESD) provides a higher en-bloc resection rate and a lower local recurrence rate for large lesions. However, ESD is technically demanding and associated with a higher risk of adverse events, making it less popular.

Recently, Tip-in EMR, which includes a simple technique of anchoring the snare tip within the submucosal layer proximal to the lesion, has shown a favorable en-bloc resection rate for large flat lesions. Tip-in EMR might be an alternative to ESD for colorectal neoplasms, but no study has directly compared these 2 modalities.

Thus, this study aimed to compare clinical outcomes between Tip-in EMR and ESD for large colorectal neoplasms. The study found that Tip-in EMR is comparable with ESD with respect to local recurrence rate, but it has a shorter procedure time, despite lower en-bloc and R0 resection rates for 20- to 30-mm nonpedunculated colorectal neoplasms without fold convergence or a nonlifting sign.


We believe that our study makes a significant contribution to the literature because it shows instrumental evidence that Tip-in EMR is a feasible alternative to ESD for 20- to 30-mm nonpedunculated colorectal neoplasms.

In contrast to conventional EMR, Tip-in EMR requires only a mucosal incision with a snare tip. The technical simplicity of Tip-in EMR increases the probability of its widespread application in clinical practice.

This was a single-center study, and only experienced endoscopists performed the procedures. Therefore, the generalizability of the study outcomes may be limited. Future multicenter prospective research, including nonexpert endoscopists, is warranted to confirm our results.

Takada_Hotta_figureCase of local recurrence after Tip-in EMR. A, A 22-mm protruded lesion in the cecum. B, Opening the snare after insulating the snare tip on the oral side of the lesion. C, After the first snaring. Recurrence at the oral side of the lesion. A snare tip–insulated scar (white arrow) is observed at the oral side of the lesion, suggesting the snare tip slipped away from the incision point. D, Mucosal defect after piecemeal resection (white arrow). The lesion is resected with >4 pieces. E, Surveillance colonoscopy 6 months after piecemeal resection. An adenomatous lesion is observed on the scar using narrow-band imaging and diagnosed as local recurrence. F, Recurrent lesion is resected using conventional EMR.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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