Skip to main content
SpringerLink
Log in

Cap-assisted endoscopic mucosal resection as a salvage technique for challenging colorectal laterally spreading tumors

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Cap-assisted endoscopic mucosal resection (EMR-c) has emerged as a potential alternative to standard piecemeal wide-field EMR (WF-EMR) for the resection of laterally spreading tumors (LSTs). However, clear indications for this technique are still lacking. Our objective was to investigate the performance of salvage EMR-c after WF-EMR failure in the resection of large colorectal LSTs.

Methods

The data of consecutive patients undergoing WF-EMR for large colorectal LSTs (2015–2021) were analyzed in this single-center, retrospective, observational study. In the event of a WF-EMR failure, the procedure was switched to EMR-c in the same session. The efficacy of the two techniques was evaluated in terms of complete endoscopic resection, R0 resection, and recurrence rate. Safety was also assessed.

Results

Overall, the data from 81 WF-EMRs were collected. Eighteen cases of WF-EMR failure were switched to EMR-c in the same session and complete endoscopic resection was achieved in 17/18 patients (94.4%). No statistically significant difference was observed between WF-EMR and salvage EMR-c in terms of macroscopic radicality (P = 0.40) and R0 resection (P = 0.12). However, recurrence was more common with EMR-c (44.4% vs. 23.5%; P = 0.05), as were adverse events, particularly intraprocedural bleeding (27.8% vs. 7.9%; P = 0.04).

Conclusion

EMR-c is an effective salvage technique for challenging colorectal LSTs following WF-EMR failure. Due to the elevated risk of adverse events associated with this procedure, careful patient selection, endoscopic expertise, and close follow-up are strongly recommended.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Moss A, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R, Zanati S, Burgess NG, Sonson R, Byth K, Bourke MJ (2015) 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 64:57–65

    Article  PubMed  Google Scholar 

  2. Buchner AM, Guarner-Argente C, Ginsberg GG (2012) Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center. Gastrointest Endosc 76:255–263

    Article  PubMed  Google Scholar 

  3. Castillo-Regalado E, Uchima H (2022) Endoscopic management of difficult laterally spreading tumors in colorectum. World J Gastrointest Endosc 14:113–128

    Article  PubMed  PubMed Central  Google Scholar 

  4. Inoue H, Endo M, Takeshita K, Yoshino K, Muraoka Y, Yoneshima H (1992) A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC). Surg Endosc 6:264–265

    Article  CAS  PubMed  Google Scholar 

  5. Tada M, Inoue H, Yabata E, Okabe S, Endo M (1996) Colonic mucosal resection using a transparent cap-fitted endoscope. Gastrointest Endosc 44:63–65

    Article  CAS  PubMed  Google Scholar 

  6. Conio M, Blanchi S, Repici A, Ruggeri C, Fisher DA, Filiberti R (2010) Cap-assisted endoscopic mucosal resection for colorectal polyps. Dis Colon Rectum 53:919–927

    Article  PubMed  Google Scholar 

  7. Kashani A, Lo SK, Jamil LH (2016) Cap-assisted endoscopic mucosal resection is highly effective for nonpedunculated colorectal lesions. J Clin Gastroenterol 50:163–168

    Article  PubMed  Google Scholar 

  8. Conio M, Manta R, Filiberti RA, Baron TH, Pasquale L, Marini M, De Ceglie A (2022) Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos). Gastrointest Endosc 96:829–839 e821

    Article  PubMed  Google Scholar 

  9. Michielan A, Merola E, Vieceli F, Rogger TM, Crispino F, Sartori C, Decarli NL, de Pretis G, de Pretis N (2023) Recurrence rates after piecemeal endoscopic mucosal resection of large colorectal laterally spreading tumors. Ann Gastroenterol 36:195–202

    PubMed  PubMed Central  Google Scholar 

  10. Quirke P, Risio M, Lambert R, von Karsa L, Vieth M (2011) Quality assurance in pathology in colorectal cancer screening and diagnosis—European recommendations. Virchows Arch 458:1–19

    Article  PubMed  Google Scholar 

  11. Burgess NG, Bassan MS, McLeod D, Williams SJ, Byth K, Bourke MJ (2017) Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 66:1779–1789

    Article  PubMed  Google Scholar 

  12. Yang DH, Park Y, Park SH, Kim KJ, Ye BD, Byeon JS, Myung SJ, Yang SK (2016) Cap-assisted EMR for rectal neuroendocrine tumors: comparisons with conventional EMR and endoscopic submucosal dissection (with videos). Gastrointest Endosc 83:1015–1022 (quiz 1023–e1016)

    Article  PubMed  Google Scholar 

  13. Zimmer V (2020) Cap-assisted detection and characterization of a spurting deep duodenal vascular lesion. Clin Res Hepatol Gastroenterol 44:387–388

    Article  PubMed  Google Scholar 

  14. Moreels TG (2013) The endoscopic cap and upper GI bleeding. Gastrointest Endosc 77:155

    Article  PubMed  Google Scholar 

  15. Belderbos TD, Leenders M, Moons LM, Siersema PD (2014) Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 46:388–402

    Article  PubMed  Google Scholar 

  16. Raju GS, Lum P, Abu-Sbeih H, Ross WA, Thirumurthi S, Miller E, Lynch P, Lee J, Bhutani MS, Shafi M, Weston B, Rashid A, Wang Y, Chang GJ, Carlson R 3rd, Hagan K, Davila M, Stroehlein J (2020) Cap-fitted endoscopic mucosal resection of ≥ 20 mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate. Endosc Int Open 8:E115–E121

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ishigaki T, Kudo SE, Miyachi H, Hayashi T, Minegishi Y, Toyoshima N, Misawa M, Mori Y, Kudo T, Wakamura K, Baba T, Sawada N, Ishida F, Hamatani S (2020) Treatment policy for colonic laterally spreading tumors based on each clinicopathologic feature of 4 subtypes: actual status of pseudo-depressed type. Gastrointest Endosc 92:1083–1094 e1086

    Article  PubMed  Google Scholar 

  18. Shaukat A, Kaltenbach T, Dominitz JA, Robertson DJ, Anderson JC, Cruise M, Burke CA, Gupta S, Lieberman D, Syngal S, Rex DK (2020) Endoscopic recognition and management strategies for malignant colorectal polyps: recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 159:1916–1934 e1912

    Article  PubMed  Google Scholar 

  19. Bahin FF, Heitman SJ, Bourke MJ (2019) Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 68:1130

    Article  PubMed  Google Scholar 

  20. Bahin FF, Heitman SJ, Rasouli KN, Mahajan H, McLeod D, Lee EYT, Williams SJ, Bourke MJ (2018) Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 67:1965–1973

    Article  PubMed  Google Scholar 

  21. Takeuchi Y, Shichijo S, Uedo N, Ishihara R (2022) Underwater endoscopic mucosal resection for colorectal lesions: can it be an “Underwater” revolution? DEN Open 2:e84

    Article  PubMed  PubMed Central  Google Scholar 

  22. Tziatzios G, Gkolfakis P, Triantafyllou K, Fuccio L, Facciorusso A, Papanikolaou IS, Antonelli G, Nagl S, Ebigbo A, Probst A, Hassan C, Messmann H (2021) Higher rate of en bloc resection with underwater than conventional endoscopic mucosal resection: a meta-analysis. Dig Liver Dis 53:958–964

    Article  PubMed  Google Scholar 

  23. Nagl S, Ebigbo A, Goelder SK, Roemmele C, Neuhaus L, Weber T, Braun G, Probst A, Schnoy E, Kafel AJ, Muzalyova A, Messmann H (2021) Underwater vs conventional endoscopic mucosal resection of large sessile or flat colorectal polyps: a prospective randomized controlled trial. Gastroenterology 161:1460–1474 e1461

    Article  CAS  PubMed  Google Scholar 

  24. Binmoeller KF, Hamerski CM, Shah JN, Bhat YM, Kane SD (2016) Underwater EMR of adenomas of the appendiceal orifice (with video). Gastrointest Endosc 83:638–642

    Article  PubMed  Google Scholar 

  25. Kim HG, Thosani N, Banerjee S, Chen A, Friedland S (2014) Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 80:1094–1102

    Article  PubMed  Google Scholar 

  26. Matsueda K, Takeuchi Y, Ishihara R (2021) Underwater endoscopic mucosal resection for a laterally spreading tumor involving the ileocecal valve and terminal ileum. Dig Endosc 33:206

    Article  PubMed  Google Scholar 

  27. Conio M, Blanchi S, Filiberti R, Ruggeri C, Fisher DA (2010) Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve. Endoscopy 42:677–680

    Article  CAS  PubMed  Google Scholar 

  28. Lew D, Kashani A, Lo SK, Jamil LH (2020) Efficacy and safety of cap-assisted endoscopic mucosal resection of ileocecal valve polyps. Endosc Int Open 8:E241–E246

    Article  PubMed  PubMed Central  Google Scholar 

  29. Matsueda K, Takeuchi Y, Kitamura M, Yamashina T, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, Kawamura T, Fujii S, Kusaka T, Shimokawa T, Uedo N (2022) Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: post-hoc analysis of a randomized study. J Gastroenterol Hepatol 37:741–748

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Largo Medaglie D’Oro 9, 38122, Trento, Italy

    Andrea Michielan, Federica Crispino, Nicolò de Pretis, Giovanni de Pretis & Elettra Merola

  2. Gastroenterology and Hepatology Section, PROMISE, University of Palermo, Palermo, Italy

    Federica Crispino

  3. Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy

    Nicolò de Pretis

  4. Surgical Pathology Unit, Department of Laboratory Medicine, Santa Chiara Hospital, Largo Medaglie D’Oro 9, 38122, Trento, Italy

    Chiara Sartori & Nicola Libertà Decarli

  5. Pathology Unit, San Giovanni di Dio Hospital, Via Torregalli, 3, 50143, Florence, Italy

    Nicola Libertà Decarli

  6. Gastroenterology Unit, G.B. Grassi Hospital (ASL Roma 3), Rome, Italy

    Elettra Merola

Authors
  1. Andrea Michielan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Federica Crispino
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nicolò de Pretis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chiara Sartori
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nicola Libertà Decarli
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Giovanni de Pretis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Elettra Merola
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Elettra Merola.

Ethics declarations

Disclosures

Andrea Michielan, Federica Crispino, Nicolò de Pretis, Chiara Sartori, Nicola Libertà Decarli, Giovanni de Pretis, and Elettra Merola have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Michielan, A., Crispino, F., de Pretis, N. et al. Cap-assisted endoscopic mucosal resection as a salvage technique for challenging colorectal laterally spreading tumors. Surg Endosc 37, 7859–7866 (2023). https://doi.org/10.1007/s00464-023-10347-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-023-10347-9

Keywords

Search

Navigation