34 - Distal Cap-Assisted Endoscopic Mucosal Resection Is a Safe and Effective Technique for Resection of Non-Lifting or Adherent Colorectal Polyps: An International, Multicenter, Retrospective Study

Tuesday, October 25, 2022

9:30 AM – 9:40 AM ET

Location: Hall C1

Presenting Author(s)

Scott R. Douglas, MD

Penn State Health Milton S. Hershey Medical Center
Hershey, PA

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Award: Outstanding Research Award in the Colon Category (Trainee)

Scott R. Douglas, MD¹, Douglas K. Rex, MD, MACG², Alessandro Repici, MD³, Melissa Kelly, BSN, RN, CGRN⁴, Wes Heinle, MPH⁵, Matthew T. Moyer, MD, MS⁶
¹Penn State Health Milton S. Hershey Medical Center, Hershey, PA; ²Indiana University School of Medicine, Indianapolis, IN; ³Humanitas Clinical & Research Center, Rozzano, Molise, Italy; ⁴Penn State Health, Hershey, PA; ⁵Penn State College of Medicine, Hershey, PA; ⁶Penn State Hershey Medical Center, Hershey, PA

Introduction: Distal Cap-Assisted Endoscopic Mucosal Resection (EMR-DC) is a developing technique for management of non-lifting or fibrotic polyps, a commonly encountered problem amongst endoscopists at referral centers. Biopsy sampling, submucosal tattoo, and prior unsuccessful attempts at polyp resection have all been shown to induce submucosal fibrosis, making subsequent complete endoscopic mucosal resection more difficult and increases the risk of recurrence. Multiple interventions have been proposed for management of these polyps, however each have limitations.

EMR-DC is performed utilizing a clear distal attachment cap fitted 3-4mm from the tip of the colonoscope. Following submucosal injection, adherent areas are approximated into the open snare. Tissue is suctioned through the snare into the cap and the snare is closed on the adherent lesion. Tissue transection is accomplished with electrocautery and the process is repeated in a piecemeal fashion until resection is complete (Figure 1). Here we demonstrate EMR-DC as a safe, effective, and efficient means of managing noncancerous colon lesions with submucosal fibrosis.

Methods: We conducted a multicenter, international, retrospective study of 61 EMR-DC cases done for the indication of a non-lifting lesion occurring after previous biopsy, tattoo, or attempted resection. Procedures were performed by three expert endoscopists.

Results: EMR-DC was preceded by attempted polypectomy or EMR in 88.5%, submucosal tattoo injection in 1.6%, prior biopsy in 4.9% and both biopsy and tattoo in 4.9% of cases (Table 1). Complete macroscopic resection was achieved in 100% of EMR-DC. Lesion size ranged from 15mm to 95mm (average: 49mm). Procedure time averaged 49.5 minutes. The adenoma recurrence rate for these complex and adherent lesions at six month surveillance was only 9.8%. Two serious post-procedural adverse events occurred (3.3%). These included one instance of post-procedural bleeding requiring repeat colonoscopy, and one episode of post-polypectomy syndrome requiring hospitalization.

Discussion: This large, multicenter series demonstrates EMR-DC to be a safe and efficacious approach to a difficult and common clinical problem; adherent and non-lifting polyps. EMR-DC may offer several advantages over more expensive or invasive endoscopic techniques used for this indication.

Figure: Distal Cap-Assisted EMR Technique:
A) Lesion assessment using white light and snare to assess size of lesion. Submucosal injection is performed with commercially available lifting agent (not pictured). B) The snare is positioned to capture non-lifting tissue. Mucosa is suctioned through the snare and into the distal attachment cap. This will cause an endoscopic “blue out”. The snare is then blindly closed. C) Suction is released for assessment of captured tissue, prior to application of electrocautery for tissue transection. D) Completed EMR-DC resection base, with application of prophylactic snare tip soft coagulation.

	N=61	(%)
Age (mean)	66.8
American Society of Anesthesiologists Classification
I	6	9.8
II	33	54.1
III	21	34.4
IV	1	1.6
Anticoagulation use
Aspirin	22	36.1
Antiplatelet	3	4.9
DOAC or warfarin	6	9.8
History of previous abdominal surgery	32	52.5
Previous manipulation
Biopsy	3	4.9
Tattoo	1	1.6
Biopsy and Tattoo	3	4.9
Attempted Polypectomy	54	88.5
Average number of attempted polypectomies	1.31
Pathology
Hyperplastic	1	1.6
Sessile Serrated Lesion	2	3.3
Sessile Serrated Lesion with high grade dysplasia	1	1.6
Tubular Adenoma	29	47.5
Tubular Adenoma with high grade dysplasia	5	8.2
Tubulovillous Adenoma	15	24.6
Tubulovillous Adenoma with high grade dysplasia	5	8.2
Villous adenoma with high grade dysplasia	1	1.6
Polyp Size (mm), [range], (SD)	49.5 [15-95] (8.4)
Location
Ileocecal valve	7	11.5
Cecum	6	9.8
Ascending colon	14	23.0
Hepatic flexure	4	6.6
Transverse colon	6	9.8
Splenic flexure	2	3.3
Descending colon	3	4.9
Sigmoid colon	8	13.1
Rectum	11	18.0
Paris Classification
Is	8	13.1
IIa	27	44.3
IIb	3	4.9
IIc	5	8.2
IIa+Is	10	16.4
IIb+Is	1	1.6
IIc+Is	3	4.9
IIa+IIc	3	4.9
IIa+IIb	1	1.6
Laterally Spreading Tumor specification
Granular	51	83.6
Non-granular	10	16.4
Performing Endoscopist
DKR	22	36.1
MTM	19	31.1
AR	20	32.8
Snare Type
Cold	12	19.7
Hot	42	68.9
Hot and Cold	7	11.5
Adjuvant Techniques
APC	21	34.4
Hot biopsy forceps/avulsion	17	27.9
Snare tip soft coagulation (includes prophylactic ablation to margins)	17	27.9
Cold forceps avulsion	6	9.8
Procedure time (minutes)
Mean	49.5
Median	48
Range	15-95
Complete Macroscopic Resection	61	100.0
Mean time to follow up colonoscopy (months)	6.6
Recurrence at follow up colonoscopy	6	9.8
Intra-procedural Adverse Events
Minor	2	3.3
Serious	0	0
Post-procedural Adverse Events
Minor	2	3.3
Serious	2	3.3

Table: Table 1. Patient Characteristics and Procedural Outcomes

Disclosures:

Scott Douglas indicated no relevant financial relationships.

Douglas Rex: Acacia Pharmaceuticals – Consultant. Aries Pharmaceutical – Consultant. Boston Scientific – Consultant. Braintree Laboratories – Consultant, Grant/Research Support. EndoAId – Grant/Research Support. Endokey – Consultant. Erbe USA – Grant/Research Support. GI Supply – Consultant. Lumendi, Ltd – Consultant. Medivators – Grant/Research Support. Medtronic – Consultant. Norgine – Consultant. Olympus Corporation – Consultant, Grant/Research Support. Satisfai Health – Stock Options.

Alessandro Repici: Boston Scientific – Consultant. FujiFilm – Grant/Research Support. Medtronic – Consultant.

Melissa Kelly indicated no relevant financial relationships.

Wes Heinle indicated no relevant financial relationships.

Matthew Moyer: Boston Scientific – Consultant, Speakers Bureau.

Scott R. Douglas, MD¹, Douglas K. Rex, MD, MACG², Alessandro Repici, MD³, Melissa Kelly, BSN, RN, CGRN⁴, Wes Heinle, MPH⁵, Matthew T. Moyer, MD, MS⁶, 34, Distal Cap-Assisted Endoscopic Mucosal Resection Is a Safe and Effective Technique for Resection of Non-Lifting or Adherent Colorectal Polyps: An International, Multicenter, Retrospective Study, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.