Reduction of recurrent rate after colonic EMR Endoscopic

Reduction of recurrent rate after colonic EMR 김 지원

Endoscopic treatment method for colon polyp • Conventional snare polypectomy • Endoscopic mucosal resection (EMR) • EMR with pre-cutting (EMR-P), EMR with a cap (EMR-C), EMR with ligation (EMR-L) • Piecemeal endoscopic mucosal resection (EPMR) • Endoscopic submucosal dissection (ESD)

Risk Factors for Incomplete Resection - CARE study • 418 polyps (5 -20 mm) resected by 11 endoscopists • Incomplete resectionrate: 10. 1% • Risk factors - Size - Morphology - Histology - Resection 10 – 14 mm 15 – 20 mm flat SSA piecemeal 13. 4% (RR 2. 3) 23. 3% (RR 4. 0 12. 4% (RR 1. 8) 31. 0% (RR 4. 3) 20. 4% (RR 2. 4)

en bloc resection : EPMR vs. ESD

en bloc resection : EPMR vs. ESD

Subtypes of LST lesions

Subtypes of LST lesions

Local Recurrence Rate Piemeal: 23. 5% En-bloc: 0. 7%

Risk factor of Local Recurrence Ø Piecemeal technique - lateral margin - vertical margin Ø Polyp size - large polyp size > 20 mm (>40 mm : 8 -fold increase) Ø Proximity of fold Ø Intra-procedure bleeding

Additional treatment of reduce local recurrence - Argon Plasma Coagulation -

Additional treatment of reduce local recurrence - Snare tip ablation -

Additional treatment of reduce local recurrence - Snare tip ablation -

Additional treatment of reduce local recurrence - Snare tip avulsion- Use endocut or soft coagulation current

Additional treatment of reduce local recurrence - Snare tip avulsion-

Underwater EMR • Luminal air is suctioned, and water is instilled to fill the GI lumen and immerse the target lesion. • It is postulated to “float” the mucosa and submucosa away from the deeper muscularis propria layer and allows EMR without requiring submucosal injection

Underwater EMR • Luminal air is suctioned, and water is instilled to fill the GI lumen and immerse the target lesion. • It is postulated to “float” the mucosa and submucosa away from the deeper muscularis propria layer and allows EMR without requiring submucosal injection

Underwater EMR • Theoretical advantage - Eliminating any risk of tracking neoplastic cells into deeper layer of the GI tract wall by the injection needle - Making capture of flat lesions easier • Effective in managing recurrences after previous EMR, as well as patients with previous partial resections and biopsies of lesions

Underwater EMR vs. Conventional EMR

Endoscopic treatment method for colon polyp • En-bloc resection is appropriate for lesions up to 20 mm • EPMR: LST-G, proximal colon, < 40 mm, low grade dysplasia • Additional treatment to reduce recurrenc : APC, Snare tip ablation, Avulsion • Make a plan and be prepared according to the situation !!!