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CC BY-NC-ND 4.0 · Endosc Int Open 2022; 10(01): E154-E162
DOI: 10.1055/a-1633-3230
Original article

Is underwater endoscopic mucosal resection of colon polyps superior to conventional techniques? A network analysis of endoscopic mucosal resection and submucosal dissection

Darren Jun Hao Tan
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Cheng Han Ng
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Xiong Chang Lim
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Wen Hui Lim
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Linus Zhen Han Yuen
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Jin Hean Koh
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Kameswara Rishi Yeshayahu Nistala
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
,
Khek-Yu Ho
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
2   Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
,
Choon Seng Chong‡
3   Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
,
Mark D. Muthiah‡
1   Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
2   Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
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Abstract

Background and study aims Evidence from recent trials comparing conventional endoscopic mucosal resection (EMR) to underwater EMR (UEMR) have matured. However, studies comparing UEMR to endoscopic submucosal dissection (ESD) are lacking. Hence, we sought to conduct a comprehensive network meta-analysis to compare the efficacy of UEMR, ESD, and EMR.

Methods Embase and Medline databases were searched from inception to December 2020 for articles comparing UEMR with EMR and ESD. Outcomes of interest included rates of en bloc and complete polyp resection, risk of perforation and bleeding, and local recurrence. A network meta-analysis comparing all three approaches was conducted. In addition, a conventional comparative meta-analysis comparing UEMR to EMR was performed. Analysis was stratified according to polyp sizes (< 10 mm, ≥ 10 mm, and ≥ 20 mm).

Results Twenty-two articles were included in this study. For polyps ≥ 10 mm, UEMR was inferior to ESD in achieving en bloc resection (P = 0.02). However, UEMR had shorter operating time for polyps ≥ 10 mm (P < 0.001), and ≥20 mm (P = 0.019) with reduced perforation risk for polyps ≥ 10 mm (P = 0.05) compared to ESD. In addition, en bloc resection rates were similar between UEMR and EMR, although UEMR had reduced recurrence for polyps ≥ 10 mm (P = 0.013) and ≥ 20 mm (P = 0.014). UEMR also had shorter mean operating than EMR for polyps ≥ 10 mm (P < 0.001) and ≥ 20 mm (P < 0.001). Risk of bleeding and perforation with UEMR and EMR were similar for polyp of all sizes.

Conclusions UEMR has demonstrated technical and oncological outcomes comparable to ESD and EMR, along with a desirable safety profile. UEMR appears to be a safe and effective alternative to conventional methods for resection of polyps ≥ 10 mm.

Supplementary material



Publication History

Received: 21 March 2021

Accepted: 11 August 2021

Article published online:
14 January 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Bray F, Ferlay J, Soerjomataram I. et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68: 394-424
    CrossrefPubMedGoogle Scholar
  • 2 Shaukat A, Kaltenbach T, Dominitz JA. et al. Endoscopic recognition and management strategies for malignant colorectal polyps: recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 159: 1916-1934.e1912
    CrossrefPubMedGoogle Scholar
  • 3 Choi AY, Moosvi ZM, Shah S. et al. Underwater versus conventional endoscopic mucosal resection for colorectal polyps: a systematic review and meta-analysis. Gastrointest Endosc 2020; DOI: 10.1016/j.gie.2020.10.009.
    CrossrefPubMedGoogle Scholar
  • 4 Binmoeller KF, Weilert F, Shah J. et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012; 75: 1086-1091
    CrossrefPubMedGoogle Scholar
  • 5 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Sagawa T, Kakizaki S, Iizuka H. et al. Analysis of colonoscopic perforations at a local clinic and a tertiary hospital. World J Gastroenterol 2012; 18: 4898-4904
    CrossrefPubMedGoogle Scholar
  • 7 Yamashina T, Uedo N, Akasaka T. et al. Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology 157: 451-461.e452
    CrossrefPubMedGoogle Scholar
  • 8 Yen AW, Leung JW, Wilson MD. et al. Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video). Gastrointest Endosc 2020; 91: 643-654.e642
    CrossrefPubMedGoogle Scholar
  • 9 Tufanaru C, Munn Z, Stephenson M. et al. Fixed or random effects meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evid Based Healthc 2015; 13: 196-207
    CrossrefPubMedGoogle Scholar
  • 10 Lim XC, Nistala KRY, Ng CH. et al. Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal polyps: A meta-analysis and meta-regression with single arm analysis. World J Gastroenterol 2021; 27: 3925-3939
    CrossrefPubMedGoogle Scholar
  • 11 Arezzo A, Passera R, Marchese N. et al. Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United European Gastroenterol J 2016; 4: 18-29
    CrossrefPubMedGoogle Scholar
  • 12 De Ceglie A, Hassan C, Mangiavillano B. et al. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review. Crit Rev Oncol Hematol 2016; 104: 138-155
    CrossrefPubMedGoogle Scholar
  • 13 Garg R, Singh A, Mohan BP. et al. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: A systematic review and meta-analysis. Endosc Int Open 2020; 8: E1884-E1894
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Li P, Ma B, Gong S. et al. Underwater endoscopic mucosal resection for colorectal lesions: a meta-analysis. Surgical Endoscopy 2020; DOI: 10.1007/s00464-020-07745-8.
    CrossrefPubMedGoogle Scholar
  • 15 Li DF, Lai MG, Yang MF. et al. The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: Systematic review and meta-analysis. Endoscopy 2020; DOI: 10.1055/a-1234-8918.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Liu Y, Shi M, Ren J. et al. Effectiveness of underwater endoscopic mucosal resection versus conventional endoscopic mucosal resection for 10 to 20 mm colorectal polyps: A protocol of systematic review and meta-analysis. Medicine 2020; 99: e23041
    CrossrefPubMedGoogle Scholar
  • 17 Wan X, Wang W, Liu J. et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014; 14: 135
    CrossrefPubMedGoogle Scholar
  • 18 Riley RD, Higgins JPT, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342: d549
    CrossrefPubMedGoogle Scholar
  • 19 White IR. Network Meta-analysis. Stata J 2015; 15: 951-985
    CrossrefPubMedGoogle Scholar
  • 20 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
    Google Scholar
  • 21 Wells G, Shea B, OConnell DL. et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Ottawa Health Research Institute Web site. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (25.12.2020)
    PubMedGoogle Scholar
  • 22 Rodríguez-Sánchez J, Uchima-Koecklin H, González-López L. et al. Short and long-term outcomes of underwater EMR compared to the traditional procedure in the real clinical practice. Revista Espanola de Enfermedades Digestivas 2019; 111: 543-549
    PubMedGoogle Scholar
  • 23 Mouchli M, Walsh C, Reddy S. et al. Outcomes of GI polyps resected using underwater endoscopic mucosal resection (UEMR) compared to conventional EMR (CEMR). Gastroenterology 2019; 156: S379-S380
    CrossrefPubMedGoogle Scholar
  • 24 Hamerski C, Samarasena J, Lee DP. et al. Underwater versus conventional endoscopic mucosal resection for the treatment of colorectal laterally spreading tumors: Results from an International, Multicenter, randomized controlled trial. Am J Gastroenterol 2019; 114: S75
    Google Scholar
  • 25 Schenck RJ, Jahann DA, Patrie JT. et al. Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 2017; 31: 4174-4183
    CrossrefPubMedGoogle Scholar
  • 26 Gohil V, Wu Y, Rashid S. et al. Underwater endoscopic mucosal resection (UEMR) vs. saline assisted endoscopic mucosal resection (EMR): Does one confer an advantage over the other? . Gastrointest Endosc 2015; 81: AB287-AB288
    CrossrefPubMedGoogle Scholar
  • 27 Zhang Z, Xia Y, Cui H. et al. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: A randomized controlled trial. BMC Gastroenterol 2020; 20: 311
    CrossrefPubMedGoogle Scholar
  • 28 Chien HC, Uedo N, Hsieh PH. Comparison of underwater and conventional endoscopic mucosal resection for removing sessile colorectal polyps: A propensity-score matched cohort study. Endosc Int Open 2019; 7: E1528-E1536
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Tamegai Y, Saito Y, Masaki N. et al. Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 2007; 39: 418-422
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Iizuka H, Okamura S, Onozato Y. et al. Endoscopic submucosal dissection for colorectal tumors. Gastroenterol Clin Biol 2009; 33: 1004-1011
    CrossrefPubMedGoogle Scholar
  • 31 Saito Y, Fukuzawa M, Matsuda T. et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24: 343-352
    CrossrefPubMedGoogle Scholar
  • 32 Tajika M, Niwa Y, Bhatia V. et al. Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors. Eur J Gastroenterol Hepatol 2011; 23: 1042-1049
    CrossrefPubMedGoogle Scholar
  • 33 Lee EJ, Lee JB, Lee SH. et al. Endoscopic treatment of large colorectal tumors: comparison of endoscopic mucosal resection, endoscopic mucosal resection-precutting, and endoscopic submucosal dissection. Surg Endosc 2012; 26: 2220-2230
    CrossrefPubMedGoogle Scholar
  • 34 Terasaki M, Tanaka S, Oka S. et al. Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm. J Gastroenterol Hepatol 2012; 27: 734-740
    CrossrefPubMedGoogle Scholar
  • 35 Kim YJ, Kim ES, Cho KB. et al. Comparison of clinical outcomes among different endoscopic resection methods for treating colorectal neoplasia. Dig Dis Sci 2013; 58: 1727-1736
    CrossrefPubMedGoogle Scholar
  • 36 Acquistapace F, Maternini F, Snider L. et al. Endoscopic treatment of superficial colorectal neoplasms. Retrospective analysis of a single center technique and results. G Chir 2015; 36: 247-250
    PubMedGoogle Scholar
  • 37 Sato T, Fukuzawa M, Gotoda T. et al. Comparison of clinical outcomes between colorectal EMR and ESD. J Tokyo Med University 2016; 74: 154-162
    PubMedGoogle Scholar
  • 38 Emmanuel A, Gulati S, Burt M. et al. Combining eastern and western practices for safe and effective endoscopic resection of large complex colorectal lesions. Europ J Gastroenterol Hepatol 2018; 30: 506-513
    CrossrefPubMedGoogle Scholar
  • 39 Soliman H, Brieau B, Guillaumot MA. et al. Invasive pit pattern, macronodule and depression are predictive factors of submucosal invasion in colorectal laterally spreading tumours from a Western population. United Europ Gastroenterol J 2018; 6: 1569-1577
    CrossrefPubMedGoogle Scholar
  • 40 Urban O, Falt P, Fojtik P. et al. Comparison of endoscopic mucosal resection and endoscopic submucosal dissection in the treatment of flat neoplastic lesions in the rectum. Gastroenterol Hepatol 2018; 72: 193-198
    CrossrefPubMedGoogle Scholar
  • 41 Jung JS, Hong JY, Oh HH. et al. Clinical outcomes of endoscopic resection for colorectal laterally spreading tumors with advanced histology. Surg Endosc 2019; 33: 2562-2571
    CrossrefPubMedGoogle Scholar
  • 42 Belderbos TD, Leenders M, Moons LM. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-402
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Leung FW, Leung JW, Siao-Salera RM. et al. The water method significantly enhances proximal diminutive adenoma detection rate in unsedated patients. J Interv Gastroenterol 2011; 1: 8-13
    CrossrefPubMedGoogle Scholar
  • 44 Hotta K, Fujii T, Saito Y. et al. Local recurrence after endoscopic resection of colorectal tumors. Int J Colorectal Dis 2009; 24: 225-230
    CrossrefPubMedGoogle Scholar
  • 45 Spadaccini M, Fuccio L, Lamonaca L. et al. Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video). Gastrointest Endosc 2019; 89: 1109-1116.e1104
    CrossrefPubMedGoogle Scholar
  • 46 Akintoye E, Kumar N, Aihara H. et al. Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis. Endosc Int Open 2016; 4: E1030-E1044
    Article in Thieme ConnectPubMedGoogle Scholar