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Margin marking earlier than endoscopic mucosal resection (EMR) of huge colorectal polyps reduce the chance of recurrence by 80% in comparison with conventional EMR, new knowledge counsel.
A workforce of researchers, led by Dennis Yang, MD, with the Heart for Interventional Endoscopy at AdventHealth in Orlando, Florida, in contrast polyp recurrence after sufferers obtained EMR with margin marking vs recurrence after typical EMR in a historic management group. They conclude the easy margin-marking technique might provide an alternative choice to margin ablation.
Dr Dennis Yang
The findings of the research have been revealed on-line November 29 in Gastrointestinal Endoscopy.
A Single-Heart, Historic Management Research
A complete of 210 sufferers (common age, 66 years; 56.2% ladies) with 210 polyps (common dimension, 30 mm; interquartile vary: 25-40 mm) had both EMR with margin marking (EMR-MM; n=74) or typical EMR (n=136). The teams had comparable affected person and lesion traits.
For EMR-MM, cautery marks have been drawn alongside the lateral margins of the polyp with the snare tip. EMR adopted with resection of the wholesome mucosa with the marks.
Physicians can affirm full resection, together with a wholesome margin, when no cautery marks are seen after EMR, the authors write.
A follow-up colonoscopy was carried out 3 to six months later, the outcomes of which have been in contrast towards historic controls.
After 6 months, EMR-MM led to a decrease recurrence fee in contrast with the historic management group with conventional EMR (8% vs 29%, respectively; P <.001>
“This technique allowed a extra dependable wide-field EMR, which can account for why our preliminary outcomes demonstrated an 80% discount within the chance of recurrence even after controlling for different components, together with polyp dimension and histopathology,” the authors write.
Recurrence danger has been one of many principal limitations of EMR in contrast with surgical procedure, with charges from 10%-35%, the authors notice, although it has fewer adversarial reactions and provides higher high quality of life than surgical procedure.
Yang instructed Medscape Medical Information that a number of research have checked out attainable components for recurrence, which is assumed to primarily happen on the lateral resection margins of the polyp.
“That’s based mostly on current knowledge that has proven that burning the resection margins after you really take the lesion out reduces recurrence,” he mentioned. “What that not directly implies is that at any time when we resect one thing, we might imagine we’ve acquired your complete lesion on the lateral margins, however we don’t.”
As Yang described, it was this implication that led to the premise of the research.
“If we have been to by some means put seen marks exterior the margins of the lesion, the marks would function seen cues to inform us how far more tissue we wanted to resect, and thereby assist us get a extra dependable means of making certain clear resection margins.”
Yang and colleagues additionally discovered that EMR-MM was not linked with a rise in adversarial occasions. On multivariable evaluation, EMR-MM was the principle predictor of recurrence (odds ratio [OR], 0.20; 95% CI, 0.13-0.64; P =.003) other than polyp dimension (OR, 2.81; 95% CI, 1.35-6.01; P =.008).
Professional: Normal of Care Seemingly Nonetheless Higher
Gastroenterologist Douglas Rex, MD, Distinguished Professor Emeritus of Drugs at Indiana College Faculty of Drugs in Indianapolis, who was not concerned within the research, instructed Medscape Medical Information that he’s not satisfied that it’s mandatory or clever to make use of the margin-marking method described within the paper over the present customary of care.
Dr Douglas Rex
Rex defined that presently physicians inject massive lesions submucosally with fluid coloured for distinction to delineate the margin of the polyp. This raises the query, if you happen to can see the lesion effectively with that technique, do you want to place the marks earlier than you begin across the border on the conventional mucosa, as they did for the margin-marking group on this research?
Rex additionally famous that the researchers’ 29% management group recurrence fee is comparatively excessive.
“Many of the proof — if you happen to have a look at the massive meta-analyses — means that the recurrence fee with conventional strategies is round 15%,” he mentioned.
He added that even the recurrence fee within the present research’s energetic remedy arm is way larger than the two%-5% fee seen in current thermal ablation trials by Klein and colleagues and Sidhu and colleagues, each revealed in Gastroenterology.
“The strategies described in these two papers must be thought of the present customary of care,” Rex mentioned. “Neither a type of entails this [margin-marking] technique.”
Yang agrees that the Klein and Sidhu trials signify the usual of care, however he says it’s necessary to notice that the two% recurrence might not signify the precise follow of endoscopists of all talent ranges.
“These are extremely managed research coming from very skilled endoscopists,” he mentioned.
“Our knowledge aren’t making an attempt to supplant what the high-quality research on thermal ablation have proven. The purpose is to point out that it is a idea that would probably assist,” he mentioned.
“What I’m proposing is a possible different that might be higher than that. Clearly, we gained’t know till a comparative kind of trial is carried out.”
On that time, Yang and Rex agree.
Rex mentioned a randomized management trial would make clear some factors and be helpful to check margin marking instantly with the present customary of care, “which is to take away the entire thing after which deplete the margin.”
“Based mostly on what we’ve seen to date, I’d predict the present customary of care would have an excellent likelihood of profitable when it comes to efficacy, as a result of it’s exhausting to get decrease than 2% [recurrence],” he mentioned. “And it would effectively win with regard to security, as a result of burning the margin is not less than theoretically safer than what they’re doing right here.”
Rex mentioned margin marking could also be useful with the type of EMR that doesn’t contain submucosal injection: underwater EMR. In underwater EMR, there’s no submucosal injection, and a few folks will mark the margin in these cases, he mentioned.
“I do assume it’s affordable to do margin marking for underwater EMR,” Rex mentioned.
Yang is a advisor for Boston Scientific, Olympus, Lumendi, and Steris. A coauthor is a advisor for Olympus, Boston Scientific, Cook dinner Medical, Benefit, Microtech, Steris, Lumendi, and Fujifilm. One other coauthor receives analysis grants from Steris and Cosmo/Aries Prescribed drugs. Rex disclosed no related monetary relationships.
Gastrointestinal Endoscopy. Revealed on-line November 29, 2021. https://www.giejournal.org/article/S0016-5107(21)01842-3/pdf
Marcia Frellick is a contract journalist based mostly in Chicago. She has beforehand written for the Chicago Tribune, Science Information, and Nurse.com, and was an editor on the Chicago Solar-Instances, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Instances. Comply with her on Twitter at @mfrellick .
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