Randomized Clinical Trial
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 7, 2022; 28(45): 6397-6409
Published online Dec 7, 2022. doi: 10.3748/wjg.v28.i45.6397
Endoscopic mucosal resection-precutting vs conventional endoscopic mucosal resection for sessile colorectal polyps sized 10-20 mm
Xue-Qun Zhang, Jian-Zhong Sang, Lei Xu, Xin-Li Mao, Bo Li, Wan-Lin Zhu, Xiao-Yun Yang, Chao-Hui Yu
Xue-Qun Zhang, Bo Li, Chao-Hui Yu, Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
Jian-Zhong Sang, Department of Gastroenterology, Renmin Hospital of Yuyao City, Yuyao 315499, Zhejiang Province, China
Lei Xu, Department of Gastroenterology, Ningbo First Hospital, Ningbo 315010, Zhejiang Province, China
Xin-Li Mao, Department of Gastroenterology, Taizhou Hospital, Taizhou 317099, Zhejiang Province, China
Wan-Lin Zhu, Department of Gastroenterology, The Central Hospital of Lishui City, Lishui 323020, Zhejiang Province, China
Xiao-Yun Yang, Department of Gastroenterology, Jinhua Municipal Central Hospital, Jinhua 321099, Zhejiang Province, China
Author contributions: Zhang XQ, Xu L, and Yu CH designed the research; Zhang XQ, Sang JZ, Xu L, Mao XL, Li B, Zhu WL, and Yang XY participated in the operation; Zhang XQ and Xu L analyzed the data; Zhang XQ wrote the paper.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of First Affiliated Hospital, School of Medicine, Zhejiang University (No. 20191477); Ningbo First Hospital, Zhejiang (No. 2020-R013) and other participating institutions.
Clinical trial registration statement: This study is registered at ClinicalTrials.gov. The registration identification number is NCT04191473.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors have no conflicts of interest to declare.
Data sharing statement: Technical appendix, statistical code, and dataset are available from the corresponding author at zhangxuequn@zju.edu.cn. Participants gave informed consent for data sharing.
CONSORT 2010 statement: The authors have read the CONSORT 2010 statement, and the manuscript was prepared and revised according to the CONSORT 2010 statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Chao-Hui Yu, MD, PhD, Chief Doctor, Professor, Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou 310003, Zhejiang Province, China. zyyyych@zju.edu.cn
Received: July 30, 2022
Peer-review started: July 30, 2022
First decision: September 2, 2022
Revised: September 14, 2022
Accepted: October 19, 2022
Article in press: October 19, 2022
Published online: December 7, 2022
Abstract
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.

Keywords: Colorectal polyps, Medium size, Polypectomy, Endoscopic mucosal resection with circumferential precutting, Conventional endoscopic mucosal resection

Core Tip: The optimal method for removal of sessile colorectal lesions sized 10-20 mm remains uncertain. Piecemeal and incomplete resection are major limitations of conventional endoscopic mucosal resection (CEMR) in removing sessile colorectal polyps. In this study, we found that endoscopic mucosal resection with circumferential precutting achieved better en bloc resection (94.3% vs 86.0%; P = 0.041) with no increase in adverse events, and can serve as an alternative technique to CEMR in the removal of sessile colorectal lesions sized 10-20 mm.