Endoscopic mucosal resection-precutting vs conventional endoscopic mucosal resection for sessile colorectal polyps sized 10-20 mm

BACKGROUND The optimal method to remove sessile colorectal lesions sized 10-20 mm remains uncertain.Piecemeal and incomplete resection are major limitations in current practice,such as endoscopic mucosal resection(EMR)and cold or hot snare polypectomy.Recently,EMR with circumferential precutting(EMR-P)has emerged as an effective technique,but the quality of current evidence in comparative studies of conventional EMR(CEMR)and EMR-P is limited.AIM To investigate whether EMR-P is superior to CEMR in removing sessile colorectal polyps.METHODS This multicenter randomized controlled trial involved seven medical institutions in China.Patients with colorectal polyps sized 10-20 mm were enrolled and randomly assigned to undergo EMR-P or CEMR.EMR-P was performed following submucosal injection,and a circumferential mucosa incision(precutting)was conducted using a snare tip.Primary outcomes included a comparison of the rates of en bloc and R0 resection,defined as one-piece resection and one-piece resection with histologically assessed clear margins,respectively.RESULTS A total of 110 patients in the EMR-P group and 110 patients in the CEMR group were finally evaluated.In the per-protocol analysis,the proportion of en bloc resections was 94.3%[95%confidence interval(CI):88.2%-97.4%]in the EMR-P group and 86%(95%CI:78.2%-91.3%)in the CEMR group(P=0.041),while subgroup analysis showed that for lesions>15 mm,EMR-P also resulted in a higher en bloc resection rate(92.0%vs 58.8%P=0.029).The proportion of R0 resections was 81.1%(95%CI:72.6%-87.4%)in the EMR-P group and 76.6%(95%CI:68.8%-84.4%)in the CEMR group(P=0.521).The EMR-P group showed a longer median procedure time(6.4 vs 3.0 min;P<0.001).No significant difference was found in the proportion of patients with adverse events(EMR-P:9.1%;CEMR:6.4%;P=0.449).CONCLUSION In this study,EMR-P served as an alternative to CEMR for removing nonpedunculated colorectal polyps sized 10-20 mm,particularly polyps>15 mm in diameter,with higher R0 and en bloc resection rates and without increasing adverse events.However,EMR-P required a relatively longer procedure time than CEMR.Considering its potential benefits for en bloc and R0 resection,EMR-P may be a promising technique in colorectal polyp resection.

环周黏膜预切开内镜黏膜切除术与内镜黏膜下剥离术治疗直肠神经内分泌肿瘤疗效的Meta分析

目的系统评价环周黏膜预切开内镜黏膜切除术(EMR-CI)与内镜黏膜下剥离术(ESD)治疗直肠神经内分泌肿瘤(RNEN)的安全性和有效性。方法计算机检索PubMed、the Cochrane Library、EMBASE、Web of Science、SinoMed、中国知网(CNKI)、万方数据和维普数据库等多个中英文数据库,检索时限为从建库至2022年11月22日。收集关于EMR-CI和ESD治疗RNEN疗效的中英文文献。按照纳入和排除标准,对文献进行筛选和数据提取,并对纳入文献采用纽卡斯尔-渥太华量表(NOS),进行方法学质量评价,使用Rev Man 5.3软件进行Meta分析。结果最终纳入7篇临床对照研究。EMR-CI组199例,ESD组443例。有效性结局指标Meta分析结果显示,EMR-CI组组织学完全切除率与ESD组比较,差异无统计学意义(OR=0.56,95%CI:0.30~1.02,P=0.060);EMR-CI组内镜下完整切除率与ESD组比较,差异无统计学意义(OR=0.33,95%CI:0.09~1.17,P=0.090);EMR-CI组病变直径较ESD组小,差异有统计学意义(WMD=-0.86,95%CI:-1.33~-0.40,P=0.000);EMR-CI组手术时间明显短于ESD组,差异有统计学意义(WMD=-12.48,95%CI:-16.42~-8.54,P=0.000);EMR-CI组水平切缘阳性率与ESD组比较,差异无统计学意义(OR=1.74,95%CI:0.64~4.75,P=0.280);EMR-CI组垂直切缘阳性率高于ESD组,差异有统计学意义(OR=2.41,95%CI:1.09~5.32,P=0.030)。因局部复发率和远处转移率发生率极低,无法进行Meta分析。安全性结局指标Meta分析结果显示,并发症总发生率、出血发生率和穿孔发生率比较,差异均无统计学意义(P>0.05)。结论EMR-CI治疗RNEN,可以在明显节约手术时间和不增加手术并发症的前提下,达到与ESD相似的内镜下完整切除率、组织学完全切除率和水平切缘阳性率,但需注意该术式与ESD在垂直切缘阳性率方面的差异。

结直肠侧向发育型肿瘤内镜治疗效果及术后迟发性出血的危险因素

目的评价结直肠侧向发育型肿瘤(LST)内镜治疗的效果,分析术后迟发性出血(DPPB)的危险因素。方法收集浙江大学医学院附属第二医院消化内科2015年1月至2020年12月因结直肠LST行内镜黏膜下剥离术(ESD)(ESD组)、预切开内镜下黏膜切除术(杂交ESD)(杂交ESD组)治疗的患者临床资料,比较ESD与杂交ESD的穿孔发生率、出血率、完整切除率、手术操作时间、病灶粘连情况;根据DPPB发生与否,将患者分为出血组与未出血组,通过多因素logistic回归模型分析DPPB可能的危险因素。结果共纳入665例结直肠LST患者,男376例,女289例,年龄(57.4±0.4)岁;行ESD 471例,杂交ESD 194例。两组患者性别、年龄、吸烟饮酒情况、高血压患病率差异均无统计学意义(均P>0.05);ESD组与杂交ESD组病灶粘连发生率(4.2%比7.7%,P=0.067)、病灶完整切除率(96.8%比93.8%,P=0.418)、穿孔率(0.6%比1.0%,P=0.594)、迟发性出血率(2.8%比2.1%,P=0.605)差异均无统计学意义。17例(2.6%)患者内镜治疗术后出现DPPB,多因素logistic回归分析结果显示,病灶部位在直肠(OR=3.594,95%CI:1.237~10.443,P=0.019)、病灶直径>2 cm(OR=3.776,95%CI:1.411~10.106,P=0.008)为DPPB的危险因素。结论ESD和杂交ESD术是结直肠LST治疗的有效手段。结直肠LST的病灶部位在直肠、病灶直径>2 cm是DPPB的危险因素。