Today, treatment of EMR recurrences on the ASGE SuTab tip of the week. I'm going to first review my own protocol for follow-up after EMR of non-pedunculate lesions greater than or equal to 20 millimeters in size. And I first want to say that I don't mean to imply that this is the standard of care. I think there are some variations around what different experts do. It may be broadly representative of the approach that is taken, but don't consider it to necessarily be the standard of care. I want to point out that for lesions under 20 millimeters in size, I usually follow them at three years, even if I have removed them piecemeal, I'm not one that believes that everything that's piecemealed has to be brought back in six months or a year. So these comments apply to lesions that are 20 millimeters or larger in size. So after the initial EMR, the traditional follow-up is in six months. At that time, I still biopsy the scar, even if it appears normal. And what you're looking for there is a so-called histologic-only recurrence. This is controversial. Many experts think that with modern colonoscopes, image-enhanced endoscopy, that the yield of this is very small, that it's not necessary. Looking across the literature, I'm not completely convinced, but occasionally you'll pick up some histologic-only recurrences, as I will show you. I do currently make exceptions because we are in the era, first of all, of snare-tip soft coag, and we are seeing recurrence rates drop. And recurrence rates are related to size. So now for some adenomas in the 20 to 30 millimeter size range, I will allow them to come back for their first follow-up at a year. And if the scar is normal, no recurrence will go directly to three years. So compared to the regular protocol we're describing, that skips a full colonoscopy. I often do that also with SSLs that are over 20 millimeters in size. SSLs on an individual basis are lower risk lesions than adenomas of similar size. For any given size, if you look at the prevalence of cancer in SSLs, it's about one-seventh that of conventional adenomas. But as I've mentioned, the explanation, the likely explanation for why they contribute disproportionately to interval cancers is that they are missed more often. But the individual SSL lesion that you have just removed is not an extremely high-risk lesion, and it grows slowly. So waiting a year gives it time to develop so that you can see a recurrence if it's going to be present. Now the second follow-up in the usual sort of traditional way of doing this is then done one year later or 18 months after the initial resection. I personally do not shorten it if there was either an overt or histologic-only recurrence. The rationale, again, is to give it time to grow into something that you can see where you can target therapy. The only exceptions to this are if the recurrence is quite large or there's high-grade dysplasia in the recurrence. I just want to point out that even when there's high-grade dysplasia in the initial EMR, it's quite uncommon for there to be high-grade dysplasia in the recurrence. But if there is, then I will bring the patient back for their second follow-up at six months rather than one year. If everything is clear at the 18-month follow-up, the next follow-up is in three years. Today we're discussing treatment of recurrences, which I distinguish from the treatment of partly resected polyps primarily because with a recurrence, it appeared to the first physician, the one who performed the EMR, that the lesion was completely removed. Whereas with a partly resected polyp, these, in my experience, are entirely referred lesions. The lesion was partly removed, and then for one technical challenge or another, the resection was stopped. So in the case of partly resected polyp, we still often will do an EMR on the area that was left in, and that portion of the lesion often lifts well, but we expect to get some fibrosis along the margin where the resection was performed previously. In the case of a recurrence, most of these, in my experience, are actually my own lesions. So occasionally, a referred lesion, the doctor will appear to have gotten the whole thing out, but because of some issues, may prefer that I do the follow-up on the lesion. That happens occasionally. But for the most part, they're lesions I've removed myself, and we expect it to become less of a problem because of the development of snare-tip soft COAG to the normal appearing margin, which, as we've discussed on a couple of occasions, drops the recurrence rate from the expected area or vicinity of 15%, 20%, even higher with very large lesions, down to just a few percent. So the characteristic features of recurrences are usually that they're very small, just a few millimeters in size. There's some variation about that, but most often, they are small. There is typically scar underneath the entire lesion, so lifting won't work, and the usual approach is, without lifting, to snare or avulse them, avulse them chosen if it's a very, very flat residual area, and then once we've actually resected it to burn up the margin of the defect that we've created, and traditionally, I used APC for this, but you could use snare-tip soft COAG. I don't know that one is better than the other, and then often, if there's any concern about deep thermal injury, we also will close the site, and I have noticed in looking at videos of people that tend to avulse cold, they take their residual tissue off cold and then use snare-tip soft COAG on the base of it, the so-called cast technique, but they also often clip close the site so there isn't any risk of delayed deep thermal injury. Here's one of the recurrences that we saw last week. This is a small adenoma in the center. The scar is down below it. This part is, this lesion is sticking up a little bit, so I'm going to try to remove it with a snare. I would rather use a snare than avulsion. I would rather get a rim of normal tissue all the way around and include it with the electrocautery. We're going to use forced coagulation current. We want to get a little bit of extra thermal injury, and you can see looking at this little defect, if there's any place you're concerned, there might have been any left. It's at the edge closest to us, and I was concerned about that, so I've decided to remove that by avulsion. So we have a high rate of success in treating recurrences if we are aggressive in eliminating all of the visible polyp tissue. So snaring, in this case, a combination of snaring and avulsion. Very flat lesions oftentimes will start off with avulsion, but I'd prefer to just start off with snaring. If we've got a good rim of tissue, then we, around after snaring, we don't need to use any avulsion. In this case, I felt that we did, so we used the hot forceps on the 141 setting, the endocut eye setting. So force coag with a snare and then endocut eye on the 141 setting to avulse, and now we're using STSC. We can use either STSC or APC. We don't have a randomized controlled trial showing that one is better than the other. Obviously, STSC is less expensive. Traditionally, I actually have used APC, again, in the spirit of being aggressive, and then finally we'll put a clip on this to close it. So treatment of a small recurrence. In the recurrence that we saw last week, this is about five or six millimeters, relatively small, this area right in the middle where there are nice two pits. We're using a 10 millimeter stiff snare, and we are trying to capture that thing as well as some of the surrounding normal mucosa that we're, again, using force coagulation current, so we're lifting up. We want to get a little bit of extra current in there to kill this tissue. So I always feel like the stakes are relatively high for trying to get the job done very completely, and we're using the snare tip soft coag, again, to burn up the margin, and this is just another safety measure, safety from the standpoint of reducing the possibility of further recurrence. Again, we're trying to be aggressive here with the management of this small lesion. Overall, the biology of this lesion is not good. It originally was about 40 millimeters in size, and now we're dealing with a relatively small recurrence, but we want to be relatively aggressive and get rid of it. We don't want to exhaust the patience of the patient for coming back for recurrences. We then finally, just because the layers are often fused together here by scarring, I do think there's a slightly increased risk of a deep thermal injury, so we're just being safe and closing this entirely, so a typical strategy for treatment of a recurrence. Next week, more on treatment of recurrences after EMR on the ASGE SuTab tip of the week.

EMR recurrences

follow-up protocol

histologic-only biopsy

treatment methods

visible polyp tissue