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• W2910117095 abstract "See “Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection,” by Klein A, Tate DJ, Jayasekeran V, et al, on page 604. See “Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection,” by Klein A, Tate DJ, Jayasekeran V, et al, on page 604. Endoscopic mucosal resection (EMR) has become the primary approach to remove large, nonpedunculated colorectal polyps. However, a high risk of recurrence, ranging from 10% to 30%, has remained a major challenge.1Bahin F.F. Pellise M. Williams S.J. et al.Extended endoscopic mucosal resection does not reduce recurrence compared with standard endoscopic mucosal resection of large laterally spreading colorectal lesions.Gastrointest Endosc. 2016; 84: 997-1006 e1Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 2Belderbos T.D. Leenders M. Moons L.M. et al.Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis.Endoscopy. 2014; 46: 388-402Crossref PubMed Scopus (210) Google Scholar, 3Buchner A.M. Guarner-Argente C. Ginsberg G.G. Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center.Gastrointest Endosc. 2012; 76: 255-263Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar, 4Klein A. Tate D.J. Jayasekeran V. et al.Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection.Gastroenterology. 2019; 156: 604-613Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 5Knabe M. Pohl J. Gerges C. et al.Standardized long-term follow-up after endoscopic resection of large, nonpedunculated colorectal lesions: a prospective two-center study.Am J Gastroenterol. 2014; 109: 183-189Crossref PubMed Scopus (105) Google Scholar, 6Moss A. Williams S.J. Hourigan L.F. et al.Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study.Gut. 2015; 64: 57-65Crossref PubMed Scopus (324) Google Scholar, 7Pellise M. Burgess N.G. Tutticci N. et al.Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions.Gut. 2017; 66: 644-653Crossref PubMed Scopus (81) Google Scholar The main risk factors for recurrence include piecemeal resection, larger size, and intraprocedural bleeding.8Tate D.J. Desomer L. Klein A. et al.Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool.Gastrointest Endosc. 2017; 85: 647-656 e6Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar So far, systematic attempts to reduce recurrence and assure complete resection, for instance by extending the resection margin, have not been successful.1Bahin F.F. Pellise M. Williams S.J. et al.Extended endoscopic mucosal resection does not reduce recurrence compared with standard endoscopic mucosal resection of large laterally spreading colorectal lesions.Gastrointest Endosc. 2016; 84: 997-1006 e1Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The search for a method to reduce recurrence after EMR and improve its efficacy was therefore ongoing. Perhaps no longer. In the current issue of Gastroenterology, Klein et al4Klein A. Tate D.J. Jayasekeran V. et al.Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection.Gastroenterology. 2019; 156: 604-613Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar from the Australian Colonic Endoscopic resection study group report the results of a randomized trial that included 390 patients with 416 large (≥20 mm) nonpedunculated colorectal polyps. After visibly complete polyp removal by EMR, polyps were randomized to ablation or no ablation of the resection margin. In the ablation group, the entire resection margin was ablated with soft coagulation using the tip of the resection snare (snare tip soft coagulation [STSC]). Recurrence was observed far less frequently in the ablation group (5%) than in the control group (21%). Ablation was most beneficial for polyps that were ≥40 mm (36% vs 3% recurrence), and less so for polyps that were <40 mm (12 vs 6%; P = .1). Importantly, a reduction in risk was only seen for polyps that were removed with piecemeal and not with en bloc resection. The findings corroborate a small prior randomized, controlled trial, in which margin ablation with argon plasma coagulation decreased adenoma recurrence.9Brooker J.C. Saunders B.P. Shah S.G. et al.Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.Gastrointest Endosc. 2002; 55: 371-375Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar However, the small sample size (n = 22) and the use of older generation endoscopes without high-definition white light to properly visualize the margins question the generalizability of the findings. An unusually high recurrence rate of 64% in the control group further raises questions about the quality of the resection technique used in the study. The results of the study by Klein et al4Klein A. Tate D.J. Jayasekeran V. et al.Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection.Gastroenterology. 2019; 156: 604-613Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar are potentially practice changing because of the magnitude of the observed effect and the quality of the underlying trial methodology. The randomized design, a large sample size, adequate power, and participation of multiple endoscopists at several centers are factors that strengthen the validity and generalizability of the findings. The main limitations include that endoscopists could not be blinded to the intervention (which is in the nature of such studies) and the definition of recurrence. Recurrence was based on visible assessment of the resection site at follow-up, not on histology, because biopsies were missing for 24% of cases. However, in additional analysis, the authors also show that visible assessment of recurrence achieved a negative predictive value of 99%, ensuring the reader that the obtained results are valid. Are there any concerns that might give us pause in adopting margin ablation as a new standard? Three considerations come to mind. First, the results are in contrast with a prior study by the same group, in which extending the resection to include a 5-mm healthy tissue margin had no effect on recurrence.1Bahin F.F. Pellise M. Williams S.J. et al.Extended endoscopic mucosal resection does not reduce recurrence compared with standard endoscopic mucosal resection of large laterally spreading colorectal lesions.Gastrointest Endosc. 2016; 84: 997-1006 e1Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar If residual tissue is the nidus for regrowth, an extended margin must lower recurrence, unless (a) the recurrence originates from islands at the resection base—but this should have been an issue in both studies, or (b) an intended 5-mm margin was not truly achieved in that study. The latter seems a more plausible explanation, because one might easily lose sight of the extent of the lesion when removing it piece by piece and when cautery artifacts may further obscure visibility. The discordant results also caution us to change practice based on a single study, no matter what quality. Second, the recurrence rate of 21% in the control group was greater than reported in a systematic review (15%)10Hassan C. Repici A. Sharma P. et al.Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis.Gut. 2016; 65: 806-820Crossref PubMed Scopus (212) Google Scholar and in previous reports by the same group (16%).6Moss A. Williams S.J. Hourigan L.F. et al.Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study.Gut. 2015; 64: 57-65Crossref PubMed Scopus (324) Google Scholar Such recurrence was observed despite the exclusion of more difficult lesions that failed previous resection attempts into the study. Furthermore, there was a broad variation of recurrence rates among individual endoscopists, ranging from 0% to 42% in the control arm and 0% to 21% in the treatment arm. These observations raise the question of endoscopist bias. However, even when excluding the endoscopists with high recurrence rates in the control group, the benefit of ablation remained apparent. Potentially, some endoscopists obtain a wider margin and additional ablation may be less useful. It seems, therefore, important to better understand what specific technical details make ablation more or less effective. Third, complete ablation of the margin with STSC may seem easy in expert hands. In this study, the primary investigator trained all participating endoscopists. It is unclear if this technique will be as effective in the broader community of endoscopists. It is important to note that a visibly clean resection base is required to minimize recurrence. Although polyps with previous incomplete resection were excluded from the study, one can imply that margin treatment may lower recurrence in these lesions too; however, ensuring a clean base is particularly important for these lesions with a higher risk of submucosal fibrosis. So, how should we approach our next large polyp? Perhaps the most important take home message is: It is all about the margin! The study is convincing that the margin harbors the seed for neoplastic regrowth and bears extra attention. Ablating the resection margin with STSC after piecemeal resection should be strongly considered. Other techniques might work too and should be investigated. For instance, extending the resection to reliably obtain a healthy margin—that is, after marking the extent of the lesion as done with ESD—should yield a similar decrease in recurrence. Argon plasma coagulation may also be effective; however, whether it has the same ablation effect on tissue as STSC is unclear. Directed marginal ablation will likely become the new addition to the armamentarium of EMR skills, which already includes recognizing pit patterns and morphology, applying the right electrocautery setting, controlling of bleeding, treating perforation, and mastering clipping.11Ferlitsch M. Moss A. Hassan C. et al.Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.Endoscopy. 2017; 49: 270-297Crossref PubMed Scopus (530) Google Scholar, 12Hwang J.H. Konda V. Abu Dayyeh B.K. et al.ASGE Technology Committee: endoscopic mucosal resection.Gastrointest Endosc. 2015; 82: 215-226Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 13Pohl H. Grimm I.S. Moyer M.T. et al.886 - Clip closure after endoscopic resection of large intestinal polyps: a randomized trial (Clip Trial).Gastroenterology. 2018; 154: S1362-S1363Abstract Full Text PDF Google Scholar Such skills will ensure that EMR of large colorectal polyps will be as effective and safe as possible, emphasizing the need for complex polyp resections to be done by adequately trained endoscopists. Future studies should be encouraged that examine how STSC performs in general practice and how STSC compares to other margin treatments. Furthermore, long-term data on delayed recurrence and need for surgery would be helpful to understand the cost effectiveness of STSC. Overall, the presented study solidifies EMR as the primary choice for removal of large colorectal nonpedunculated polyps. With the right technique almost all polyps can be removed safely and completely. Thermal Ablation of Mucosal Defect Margins Reduces Adenoma Recurrence After Colonic Endoscopic Mucosal ResectionGastroenterologyVol. 156Issue 3PreviewColorectal cancer (CRC) can be prevented by colonoscopy and polypectomy. Endoscopic mucosal resection (EMR) is performed to remove large laterally spreading colonic lesions that have a high risk of progression to CRC. Endoscopically invisible micro-adenomas at the margins of the EMR site might contribute to adenoma recurrence, which occurs in 15% to 30% of patients who undergo surveillance. We aimed to determine the efficacy of adjuvant thermal ablation of the EMR mucosal defect margin in reducing polyp recurrence. Full-Text PDF Covering the CoverGastroenterologyVol. 156Issue 3PreviewImmune reactivity against synthesized neoepitopes can be used to diagnosis and monitor disease status in patients with celiac disease. Full-Text PDF" @default.
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• W2910117095 title "Is Ablation of the Endoscopic Mucosal Resection Margin the New Standard for Colorectal Polyps?" @default.
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