Rectal EMR: Techniques and Tips

Transcription

1 Rectal EMR: Techniques and Tips Dr Paul Urquhart Epworth Eastern Eastern Health (Head of Endoscopy) The context of EMR Basic Technique Recurrence Perforation Bleeding Introduction 1

2 I don t treat rectal cancer Adenoma Carcinoma Sequence Prevention is better than cure 2

3 Polypectomy 3

4 Endoscopic Mucosal Resection Safe and Effective removal of medium to large colorectal polyps Largely supplanted colonic resection for benign lesions Polyp selection Polypectomy / EMR Other 4

5 Polyps assessment Is it intra mucosal? Morphology Paris classification Surface Pit Pattern Kudo Paris Classification 5

6 Paris Classification Tuttici Exp Rev Gastro Hep 2014 Kudo Pit Pattern Superficial SMI Deep SMI Tanaka Dig Endos

7 Basic technique En bloc if polyp <20mm Repeated Inject and resect Fluid composition Snare choice Electrocautery CO2 EMR technique 7

8 EMR technique Basic technique En bloc if polyp <20mm Repeated Inject and resect Fluid composition Snare choice Stiff wire Several sizes 20mm +/ braided +/ hinged Electrocautery CO2 Rectal EMR 8

9 But is it effective?? Australian Colonic EMR (ACE) study Multi centre prospective data from 7 centres around Australia 1000 patients Underwent EMR >20mm polyp Surveillance colonoscopies performed at: 4 months (SC1) 16 months (SC2) Moss GUT

10 ACE conclusion 98.1% of patients were adenoma free and had avoided surgery at 16months following EMR Moss GUT 2015 Reducing recurrence Meticulous resection of all visible adenoma Treatment of non lifting areas / non resectable islands CAST = Cold Avulsion and Snare Tip Cautery Empiric treatment of polypectomy margin STSC = snare tip soft coag 10

11 CAST rectal polyp SCAR study Treating Margin Multi centre RCT of thermal ablation of margin EMR of polyps >20mm Randomized 1:1 to STSC (soft tip snare coag) or nil Results 359 patients (267 completed F/U) STSC Nil p Recurrence at SC1 5.8% (8/138) 20.2% (26/129) p<0.001 RR=0.28 Perforation 0% (0/124) 0.7% (1/136) P=.341 Delayed bleeding 6.5% (8/124) 6.6% (9/136) P=.957 Klein DDW

12 Detecting and treating recurrence High index of suspicion Meticulous inspection (with NBI) Treatment with snare polypectomy (with cautery) or CAST Recurrence 12

13 Complications Perforation Target sign mucosa submucosa Muscularis propria mucosa submucosa Muscularis propria 13

14 911 lesions (EMR>20mm) Target sign in 3% Transverse colon location OR 3.55 En bloc resection OR 3.84 HGD or SMI OR 2.97 Frank perforation = 0.55% All patients successfully clipped No surgical intervention Burgess GUT 2017 Bleeding Same dataset as for ACE study (1172 pts) Burgess Clin Gastro Hep

15 Intraprocedural bleeding 11.3% Odd ratio P value Increasing lesion size 1.24/10mm <.001 Paris 2a + 1s Villous or TV histology Hospitals contributing <75 cases 3.78 <.001 All controlled endoscopically Prolonged procedure Increase risk of early recurrence RR 1.68 (p=.011) Burgess Clin Gastro Hep 2014 Bleeding STSC 15

16 Bleeding Coag graspers Post EMR bleeding 6.2% Relative Risk p Proximal colon 3.72 <.001 Electrocautery NOT controlled by a microprocessor Intra procedural bleeding Burgess Clin Gastro Hep

17 Are rectal polyps any different? Rectal specific factors Nervous supply Somatic sensation below dentate line Vascular supply Direct drainage into the systemic circulation Access / visualization 17

18 Rectal specific factors Nervous supply Somatic sensation below dentate line Long acting anaesthetic (bupivocaine / ropivocaine) 0.5% up to max 40mg Oral paracetamol Vascular supply Direct drainage into the systemic circulation Consider use of antibiotics for high risk lesions (large, within 2 3cm of dentate line, rich vascularity) Access / visualization Transparent cap and gastroscope EMR... Conclusion Evolving technique Demands a significant level of skill / expertise Safe and effective technique for removal of large colorectal polyps 18

19 Questions? What about in comparison to TEMS? TREND study Non inferiority study Patients with rectal adenomas (>3cm) Randomized to EMR or TEMS Recurrence at 3 months able to be treated Recurrence within 24 months Barendse GUT

20 204 patients treated at 18 University and community hospitals 27 (13%) excluded due to unexpected Cancer EMR TEM P value Overall Recurrence 15% 11% RR 1.33 Complications 18% 26% 0.23 Major complications 1% 8% Cost (Euro) Endoscopically visible recurrence n = 13 Histological recurrence n = 3 Snare alone 4 APC alone 1 Snare + APC 3 Cold bx + APC 5 20

21 Single center prospective observation study Year patients under EMR >20mm 101 required CAST for complete removal of non lifting polyps 63 naïve polyps 38 previously attempted Tate Endoscopy 2017 Complete resection rate 100% (101/101) 1 perforation (managed with clips) Naïve NL Previously attempted NL Lifting (no CAST) Recurrence at SC1 27.5% 15.2% 15.3% Recurrence at SC2 20.8% 6.3% 4.6% 3 pts to surgery (inability to resect) 1patient to surgery (Ca) 94/95 (98.9%) that underwent CAST had avoided surgery (at 16 months) Tate Endoscopy