Masterclass Colonoscopy: Trends and Recommendations Forward (On-demand)

Managing Recurrences

Pdf Summary

Recurrence of adenoma after endoscopic mucosal resection (EMR) occurs in 10% to 30% of cases, with late recurrence occurring in 4% of cases. Risk factors for recurrence include larger size, unfavorable or difficult-to-access locations, depressed morphology, non-lifting areas, intra-procedural bleeding, advanced histology, and previous use of argon plasma coagulation (APC). The Sydney EMR Recurrence Tool (SERT) can help predict recurrence based on size, bleeding, and high-grade dysplasia. Incomplete resection rates are higher for non-pedunculated polyps and sessile serrated adenomas/polyps (SSA/P) compared to adenomas.<br /><br />Several methods can help reduce the risk of recurrence. Thermal ablation of the mucosal defect margins after EMR can significantly decrease recurrence rates. Complete thermal ablation of the post-EMR margins is successful in over 95% of cases. Cap-fitted EMR with margin treatment using APC or snare tip soft coagulation (STSC) also reduces recurrence rates. Extended EMR, which involves excising a 5mm margin of normal mucosa around the lesion, is another option. Double ablation of the base and margins using hybrid APC has shown promising results.<br /><br />Training and experience of the endoscopist play a crucial role in reducing recurrence rates. Margin marking, scar assessment with high-definition white light and narrow-band imaging, and recognizing residual/recurrent adenoma are important for effective management. Various techniques can be used to remove residual/recurrent adenoma, including submucosal lift and snare, cap suction/assisted techniques, underwater EMR, full-thickness resection devices, and the endorotor.<br /><br />It is important to follow up with patients for late recurrence and continuously monitor for residual/recurrent adenoma. The majority of recurrences can be successfully treated endoscopically, avoiding the need for surgery. In conclusion, with meticulous technique, proper training, and the use of appropriate methods, the risk of recurrence can be reduced, and effective management of residual/recurrent adenoma after EMR can be achieved.

Keywords

adenoma recurrence

endoscopic mucosal resection

risk factors

Sydney EMR Recurrence Tool

thermal ablation

cap-fitted EMR

extended EMR

hybrid APC

endoscopist training

residual adenoma management