Post written by Dhruvil Radadiya, MD, from the University of Kansas Medical Center, Kansas City, Kansas, USA.

The focus of our study was to compare EMR with snare tip soft coagulation (STSC), EMR with argon plasma coagulation (APC), and underwater EMR (U-EMR) techniques routinely used for resection of large nonpedunculated polyps indirectly with each other with a network meta-analysis approach and identify the preferred intervention to reduce post-polypectomy recurrence rates.

EMR is a preferred method for resecting large nonpedunculated lesions >1.5 cm. However, post-polypecotmy recurrence rates remain around 15% after resection of such large lesions. Over the years, research has looked at different variations of EMR such as application of thermal cautery to normal margins or performing U-EMR to reduce recurrence.

Yet, there was paucity of direct comparison among these modalities in literature in the form of large randomized trials. Therefore, use of such techniques remains at the discretion of the endoscopist. Our study was conducted to provide guidance on what would be a preferred intervention to prevent post-polypectomy recurrence. We also identified areas of future improvement in research methodology to produce high-quality clinical trials.

In our analysis, we included 9 studies, of which 5 were randomized trials. On direct comparisons, EMR + STSC had 82% reduced odds, whereas U-EMR alone had 77% reduced odds of polyp recurrence compared with EMR alone.

On indirect comparison, all interventions had significantly lower odds of polyp recurrence compared with EMR alone. The p-score ranking showed that EMR + STSC seems a potential first method in reducing the odds of polyp recurrence, followed by U-EMR, EMR + APC, and EMR alone. We had similar results after exclusion of prospective and retrospective cohort studies from the analysis.

We also found the need for better comparative study for EMR + STSC and EMR + APC, as the studies for this comparison were small in sample size. In addition, we identified the need for a consensus method to define polyp recurrence and time to first colonoscopy after resection of large nonpedunculated polyps to be incorporated in future trials.

Direct meta-analysis EMR + argon plasma coagulation versus EMR alone. OR, Odds ratio; CI, confidence interval.

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