Gastroenterology

Gastroenterology

Volume 140, Issue 7, June 2011, Pages 1909-1918
Gastroenterology

Clinical—Alimentary Tract
Endoscopic Mucosal Resection Outcomes and Prediction of Submucosal Cancer From Advanced Colonic Mucosal Neoplasia

https://doi.org/10.1053/j.gastro.2011.02.062Get rights and content

Background & Aims

Large sessile colonic polyps usually are managed surgically, with significant morbidity and potential mortality. There have been few prospective, intention-to-treat, multicenter studies of endoscopic mucosal resection (EMR). We investigated whether endoscopic criteria can predict invasive disease and direct the optimal treatment strategy.

Methods

The Australian Colonic Endoscopic (ACE) resection study group conducted a prospective, multicenter, observational study of all patients referred for EMR of sessile colorectal polyps that were 20 mm or greater in size (n = 479, mean age, 68.5 y; mean lesion size, 35.6 mm). We analyzed data on lesion characteristics and procedural, clinical, and histologic outcomes. Multiple logistic regression analysis identified independent predictors of EMR efficacy and recurrence of adenoma, based on findings from follow-up colonoscopy examinations.

Results

Risk factors for submucosal invasion were as follows: Paris classification 0–IIa+c morphology, nongranular surface, and Kudo pit pattern type V. The most commonly observed lesion (0–IIa granular) had a low rate of submucosal invasion (1.4%). EMR was effective at completely removing the polyp in a single session in 89.2% of patients; risk factors for lack of efficacy included a prior attempt at EMR (odds ratio [OR], 3.8; 95% confidence interval, 1.77–7.94; P = .001) and ileocecal valve involvement (OR, 3.4; 95% confidence interval, 1.20–9.52; P = .021). Independent predictors of recurrence after effective EMR were lesion size greater than 40 mm (OR, 4.37; 95% confidence interval, 2.43–7.88; P < .001) and use of argon plasma coagulation (OR, 3.51; 95% confidence interval, 1.69–7.27; P = .0017). There were no deaths from EMR; 83.7% of patients avoided surgery.

Conclusions

Large sessile colonic polyps can be managed safely and effectively by endoscopy. Endoscopic assessment identifies lesions at increased risk of containing submucosal cancer. The first EMR is an important determinant of patient outcome—a previous attempt is a significant risk factor for lack of efficacy.

Section snippets

Study Design, Setting, and Patients

A prospective observational study of all patients referred for EMR of sessile colorectal polyps sized 20 mm or larger was conducted at 7 Australian academic endoscopy units. Institutional review board approval was obtained at each center. Consecutive patients were enrolled from July 2008 to May 2010.

All lesions were identified at a previous colonoscopy by the referring nationally accredited consultant endoscopist. Referral to the tertiary center followed an established clinical pathway.11 On

Patient and Lesion Characteristics

Over a 23-month period, 479 patients (53% men; mean age, 68.5 y; range, 34–91 y) with 514 lesions were enrolled. A total of 453 patients had 1 lesion, 22 patients had 2 lesions, and 4 patients had up to 5 lesions. A total of 192 patients (40.1%) had an American Society of Anesthesiology score of 1; 229 patients (47.8%) had a score of 2; and 58 patients (12.1%) had a score of 3. The median number of patients treated at each center was 45 (interquartile range, 18–81). The mean lesion size was

Discussion

This multicenter study shows that EMR is a safe and effective therapy for large sessile polyps. It is an alternative to surgery, which is the traditional standard and remains commonplace.24 However, these lesions frequently are detected in older patients with comorbidities that increase surgical risk. Surgery is associated with up to a 5% mortality risk.8, 9, 10 In our cohort, the mean age was 68.5 years, and American Society of Anesthesiology scores of 2 and 3 were present in 47.8% and 12.1%,

Acknowledgments

Oral presentations were performed at Digestive Disease Week, New Orleans, LA, 2010; United European Gastroenterology Week and World Congress Gastroenterology, London, UK, 2009; Digestive Disease Week, Chicago, IL, 2009; and Australian Gastroenterology Week, Sydney, Australia, 2009.

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    This article has an accompanying continuing medical education activity on page e13. Learning Objective: Upon completion of these questions, successful learners will be able to: distinguish between the various types of large sessile colonic lesions and assess their respective risks for containing submucosal cancer; explain to patients the likely clinical outcomes for endoscopic management of advanced colonic mucosal neoplasia; identify risk factors for successful and unsuccessful Endoscopic Mucosal Resection (EMR); and identify risk factors for recurrence following EMR.

    Conflicts of interest The authors disclose no conflicts.

    Funding The Cancer Institute New South Wales provided funding for a research nurse and data manager to assist with the administration of the study. There was no influence from the Institution regarding study design or conduct, data collection, management, analysis or interpretation, or preparation, review, or approval of the manuscript.

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