Thomas Rösch plaudert mit Ingo Steinbrück
Kaltschlingenresektion für große Colonpolypen – Neuigkeiten von der UEGW
Abstracts der beiden präsentierten Studien
LB06 COLD VS. HOT SNARE RESECTION OF NON-PEDUNCULATED POLYPS ≥2CM IN THE COLORECTUM – FIRST RESULTS FROM THE PROSPECTIVE, RANDOMIZED, CONTROLLED, MULTICENTRIC CHRONICLE-TRIAL
I. Steinbrück1, A. Ebigbo2, A. Küllmer3, K. Kouladouros4, A. Meining5, T. Koenen6, V. Rempel7, A. Wannhoff8, S. Faiss9, O. Pech10, O. Möschler11, F.L. Dumoulin12, M.M. Kirstein13, T. von Hahn14, H.-D. Allescher15, S. Gölder16, M. Götz17, S. Hollerbach18, B. Lewerenz19, A. Schmidt20, S. Nagl2, S. Belle4, M. Brand5, J. Tischendorf6, K. Caca8, M. Mende9, L. Pfeifer10, V. Weigart15, F. Wiedbrauck18, H. Messmann2, H.-P. Allgaier1
1Evangelisches Diakoniekrankenhaus Freiburg, Department of Medicine and Gastroenterology, Freiburg, Germany, 2Universitätsklinikum Augsburg, Department of Gastroenterology, Augsburg, Germany, 3University of Freiburg, Faculty of medicine, Department of Medicine II, Medical Center, Freiburg, Germany, 4Universitätsmedizin Mannheim, Zentrale Interdisziplinäre Endoskopie, Mannheim, Germany, 5University of Würzburg, Gastroenterology, Würzburg, Germany, 6Rhein-Maas Klinikum Würselen, Department of Internal Medicine and Gastroenterology, Würselen, Germany, 7St. Anna Hospital, Klinik für Gastroenterologie, Herne, Germany, 8RKH Klinikum Ludwigsburg, Department of Gastroenterology, Ludwigsburg, Germany, 9Sana Klinikum Lichtenberg, Department of Gastroenterology, Berlin, Germany, 10Krankenhaus Barmherzige Brüder Regensburg,, Department of Gastroenterology and Endoscopy, Regensburg, Germany, 11Marienhospital Osnabrück, Department of Endoscopy and Ultrasound, Osnabrück, Germany, 12Gemeinschaftskrankenhaus Bonn, Department of Medicine and Gastroenterology, Bonn, Germany, 13University Hospital Lübeck, Department of Medicine I, Lübeck, Germany, 14Asklepios Klinik Barmbek, Department of Gastroenterology, Hepatology and Endoscopy, Hamburg, Germany, 15Klinikum Garmisch-Partenkirchen, Department of Gastroenterology, Garmisch-Partenkirchen, Germany, 16Ostalb-Klinikum Aalen, Department of Internal Medicine I, Aalen, Germany, 17Klinikum Sindelfingen-Böblingen, Department of Gastroenterology/Oncology, Böblingen, Germany, 18AKH Celle, Gastroenterology, Celle, Germany, 19Klinikum Traunstein, Department of Gastroenterology and Hepatology, Traunstein, Germany, 20Robert-Bosch-Krankenhaus, Department of Gastroenterology, Hepatology and Endocrinology, Stuttgart, Germany
Introduction: For the removal of diminutive colorectal polyps <10mm cold snare (CS) resection is standard of care. For polyps ≥20mm endoscopic mucosal resection (EMR) with a hot snare (HS) is recommended, which is usually accomplished in piece meal technique1. Recently, a retrospective trial showed a favorable safety profile and a comparable recurrence rate for CS-EMR in comparison to HS-EMR for sessile serrated adenomas (SSA) ≥20mm2. We investigated if CS-EMR is superior to HS-EMR for the removal of larger, non-pedunculated, colorectal polyps.
Aims & Methods: In this prospective, randomized, controlled trial non-pedunculated colorectal polyps ≥20mm were randomly assigned to CS-EMR or HS-EMR. Primary endpoint was major complication (=perforation or clinically significant post-endoscopic bleeding (CSPEB)), secondary endpoints were intraprocedural bleeding (IPB), postpolypectomy syndrome (PPS), technical success, resection speed and recurrence rate after 4 months.
Results: 394 polyps were finally enrolled for intention-to-treat analysis. Rates of major complication were significantly lower in the CS-EMR group with 1.0% vs. 8.0% (p=0.001) including rates of perforation of 0% vs. 4.0% (p=0.007) and rates of CSPEB of 1.0% vs. 4.5% (p=0.038). Independent predictor for major complication in uni-/multivariable regression analysis was polyp size (OR 1.10).
Rates of IPB were 14.0% for CS-EMR and 22.9% for HS-EMR (p=0.023), rates of PPS 3.1% and 4.5% (p=0.478). Rates of technical success were 92.2% in CS-EMR group and 97.5% in HS-EMR group (p=0.017), resection speed was 22.61 (±16.62) cm2/h and 21.71 (±19.27) cm2/h (p=0.248) and recurrence rates 24.8% for CS-EMR and 15.0% for HS-EMR (p=0.037). In subgroup analysis a significant difference was observed for the recurrence rate of Laterally spreading tumors (LST) nodular-mixed type (43.8% vs. 16.7%, p=0.014) but not for suspected SSA (5.9% vs. 5.3%, p=1), LST non-granular type (11.5% vs. 11.1%, p=1) and LST granular-type homogenous (33.3% vs. 23.9%, p=0.320).
Conclusion: Safety of CS-EMR is superior to HS-EMR for the removal of large, non-pedunculated colorectal polyps with an almost complete elimination of major complications. As general recurrence rate is higher after CS-EMR careful selection of the target lesion should be made. CS-EMR should be considered as new standard of care for suspected SSA, LST non-granular type with no macroscopic signs of malignancy and selected LST granular-type homogenous ≥20mm.
**References: **
1 Ferlitsch 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(03): 270-97.
2 Hattem A, Shahidi N, Vosko S et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70(9): 1691-97.
LB07 RECURRENCE IN LARGE NON-PEDUNCULATED COLONIC LESIONS IS SIGNIFICANTLY HIGHER AFTER COLD SNARE ENDOSCOPIC MUCOSAL RESECTION THAN AFTER THE STANDARD TECHNIQUE. RESULTS OF A RANDOMIZED CONTROLLED TRIAL
Ó. Nogales1, C. Carbonell Blanco2, M. Pellisé3, J.F. Martínez Sempere4, F. Riu Pons5, C. Mangas-Sanjuan4, M. Daca Alvarez6, H. Uchima7, J. Aranda Hernández2, A. Alvarez Delgado8, E. Albéniz-Arbizu9, GSEED de resección endoscópica (RMEFRÍA.2019 group) 1Hospital General Universitario Gregorio Marañón, Gastroenterology and Hepatology, Madrid, Spain, 2Hospital General Universitario Gregorio Marañon, Gastroenterology and Hepatology, Madrid, Spain, 3Hospital Clinic de Barcelona. Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Gastroenterology, Barcelona, Spain, 4Hospital Universitario de Alicante Dr. Balmis, Gastroenterology, Alicante, Spain, 5Hospital del Mar, Gastroenterology Department, Barcelona, Spain, 6Hospital Clinic, Gastroenterology, Barcelona, Spain, 7Hospital Germans Trias i Pujol, Gastroenterology (GI Endoscopy Unit), Barcelona, Spain, 8Hospital Universitario de Salamanca, Gastroenterology, Salamanca, Spain, 9Hospital Universitario de Navarra, Servicio Aparato Digestivo, Pamplona, Spain
Introduction: Cold snare EMR (CS-SEMR) in large non-pedunculated colonic lesions is an alternative to the standard procedure (C-EMR), with a better theoretical safety profile. Robust scientific evidence on its efficacy is not available.
Aims & Methods: Objectives: Primary: to compare the efficacy between the 2 techniques, measured as the absence of recurrence at 6 months. Secondary: to compare safety profile and technical aspects.
This is a randomized controlled trial (1:1), multicenter, non-blinded, of consecutive non-pedunculated lesions with adenoma or serrated histology, homogeneous type, with size > 20mm.
Results: 229 patients, mean age 68 years, male 56.7% (N=130), were randomized to CS-EMR (N=115) or C-EMR (N=114). Overall, 49% were homogeneous granular LST lesions, predominantly adenomas (74.2%); median size 25mm. No differences between groups in baseline or lesion characteristics were found. The recurrence rate at first surveillance colonoscopy (N=215) was significantly higher in the CS-EMR group vs. C-EMR group: 33.6 vs. 16.7% (p=0.007), and 35.1 vs 15.2% (p=0.002) in ITT and PP analysis, respectively. En bloc and R0 resection rates were higher in C-EMR vs. CS-EMR: 23.7% vs. 1.7% p=0.001, and 21.1% vs. 1.7% p=0.001, respectively. There was no difference in the rate of complications: delayed bleeding (CS-EMR 2.6% vs C-EMR 3.5% p=0.722), perforation (0% in both groups) and post-polypectomy syndrome (CS-EMR 0.9% vs C-EMR 1.8% p=0.622). No differences were found in resection time either: CS-EMR 28.23 min vs C-EMR 22.30 min, p=0.297. The median number of fragments was higher in CS-EMR (6) vs. C-EMR (3) p=0.001, while the use of clips was higher in C-EMR (2.21) vs. CS-EMR (1.30) p=0.001.
**Conclusion: **The recurrence rate is significantly higher after CS-EMR compared to the standard technique. There is a trend towards fewer adverse effects in CS-EMR, without statistical significance in our study.
Andere zitierte Studien über Übersichten zur Kaltschlingenresektion
van Hattem WA, et al.
Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods.
Gut. 2021 Sep;70(9):1691-1697. doi: 10.1136/gutjnl-2020-321753. Epub 2020 Nov
Abuelazm M, et al. Cold polypectomy techniques for small and diminutive colorectal polyps: a systematic review and network meta-analysis of randomized controlled trials. Curr Med Res Opin. 2023 Oct;39(10):1329-1339. doi: 10.1080/03007995.2023.2262374. Epub 2023 Oct 1
Ramprasad Jegadeesan et al. Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies. Endosc Int Open. 2019 May;7(5):E708-E716. doi: 10.1055/a-0808-3680. Epub 2019 May 8.
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Endoskopie, Polypen, Resektion
