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Underwater endoscopic mucosal resection for colorectal lesions: a meta-analysis

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Abstract

Background

Underwater endoscopic mucosal resection (UEMR) of colorectal lesions is emerging as an alternative method to conventional endoscopic mucosal resection (CEMR). This study aimed to evaluate the feasibility and safety of UEMR for colorectal lesions.

Methods

The PubMed, Embase, Cochrane and Web of Science databases were searched before May 10, 2020. The primary outcomes were en bloc resection rate (feasibility) and adverse event rate (safety). The secondary outcome was recurrence and residual adenoma rate. If there was a comparison between UEMR and CEMR, data about en bloc resection, delayed bleeding, and recurrence and residual adenoma were extracted and compared. The pooling of the effect size was conducted using random-effects models, and the Q-statistic, τ2, and I2 were used to evaluate heterogeneity.

Results

Seventeen studies (759 patients, 893 lesions) were included. The pooled estimate for the en bloc resection rate was 59% (95% CI 43–75%) with significant heterogeneity (I2 = 97%). Due to the heterogeneity, it is not suitable to conduct pooled estimates analysis, so the en bloc resection rate was from 10 to 89%. The pooled estimate for delayed bleeding was 2% (95% CI, 1%-3%) and only two cases had perforation. The pooled rate of recurrence and residual adenoma was 5% (95% CI 2%-8%). Compared with CEMR, UEMR could achieve a higher en bloc resection rate (OR 1.61; 95% CI 1.02–2.53; p = 0.04) with a lower rate of recurrence and residual adenoma (OR 0.18; 95% CI 0.07–0.46; p < 0.01).

Conclusions

UEMR for colorectal lesions was capable of a high en bloc resection rate, low adverse event rate and low recurrence. UEMR may be considered an effective and safe alternative for treating colorectal lesions.

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References

  1. Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK (2016) Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer. Gastroenterology 150:758–768.e711

    Article  Google Scholar 

  2. Zauber AG, Winawer SJ, O'Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Hankey BF, Shi W, Bond JH, Schapiro M, Panish JF, Stewart ET, Waye JD (2012) Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. New Engl J Med 366:687–696

    Article  CAS  Google Scholar 

  3. Burgess NG, Bahin FF, Bourke MJ (2015) Colonic polypectomy (with videos). Gastrointest Endosc 81:813–835

    Article  Google Scholar 

  4. Binmoeller KF, Weilert F, Shah J, Bhat Y, Kane S (2012) "Underwater" EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 75:1086–1091

    Article  Google Scholar 

  5. Wang AY, Flynn MM, Patrie JT, Cox DG, Bleibel W, Mann JA, Sauer BG, Shami VM (2014) Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc 28:1348–1354

    Article  Google Scholar 

  6. Kim HG, Thosani N, Banerjee S, Chen A, Friedland S (2014) Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 80:1094–1102

    Article  Google Scholar 

  7. Curcio G, Granata A, Ligresti D, Tarantino I, Barresi L, Liotta R, Traina M (2015) Underwater colorectal EMR: remodeling endoscopic mucosal resection. Gastrointest Endosc 81:1238–1242

    Article  Google Scholar 

  8. Uedo N, Nemeth A, Johansson GW, Toth E, Thorlacius H (2015) Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy 47:172–174

    Article  Google Scholar 

  9. Binmoeller KF, Hamerski CM, Shah JN, Bhat YM, Kane SD, Garcia-Kennedy R (2015) Attempted underwater en bloc resection for large (2–4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc 81:713–718

    Article  Google Scholar 

  10. Amato A, Radaelli F, Spinzi G (2016) Underwater endoscopic mucosal resection: the third way for en bloc resection of colonic lesions? United Eur Gastroenterol J 4:595–598

    Article  Google Scholar 

  11. Siau K, Ishaq S, Cadoni S, Kuwai T, Yusuf A, Suzuki N (2018) Feasibility and outcomes of underwater endoscopic mucosal resection for >/= 10 mm colorectal polyps. Surg Endosc 32:2656–2663

    Article  Google Scholar 

  12. Schenck RJ, Jahann DA, Patrie JT, Stelow EB, Cox DG, Uppal DS, Sauer BG, Shami VM, Strand DS, Wang AY (2017) Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 31:4174–4183

    Article  Google Scholar 

  13. Kawamura T, Sakai H, Ogawa T, Sakiyama N, Ueda Y, Shirakawa A, Okada Y, Sanada K, Nakase K, Mandai K, Suzuki A, Morita A, Tanaka K, Uno K, Yasuda K (2018) Feasibility of underwater endoscopic mucosal resection for colorectal lesions: a Single Center Study in Japan. Gastroenterol Res 11:274–279

    Article  Google Scholar 

  14. Cadoni S, Liggi M, Gallittu P, Mura D, Fuccio L, Koo M, Ishaq S (2018) Underwater endoscopic colorectal polyp resection: Feasibility in everyday clinical practice. United Eur Gastroenterol J 6:454–462

    Article  Google Scholar 

  15. Chaves DM, Brito HP, Chaves LT, Rodrigues RA, Sugai BM (2018) Underwater endoscopic mucosal resection of serrated adenomas. Clinics 73:e339

    Article  Google Scholar 

  16. Yamashina T, Uedo N, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, Kawamura T, Takeuchi Y, Fujii S, Kusaka T, Shimokawa T (2019) Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology 157(451–461):e452

    Google Scholar 

  17. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med 151:W65–94

    Article  Google Scholar 

  18. Stang A (2010) Critical evaluation of the Newcastle–Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605

    Article  Google Scholar 

  19. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses BMJ (Clinical research ed) 327:557–560

    Google Scholar 

  20. Viechtbauer W (2010) Conducting meta-analyses in R with the metafor Package. J Stat Softw 36:48

    Article  Google Scholar 

  21. Schwarzer G (2007) meta: An R package for meta-analysis. R News 7:40

    Google Scholar 

  22. Yen AW, Amato A, Cadoni S, Friedland S, Hsieh YH, Leung JW, Liggi M, Sul J, Leung FW (2019) Underwater polypectomy without submucosal injection for colorectal lesions ≤ 20 mm in size-a multicenter retrospective observational study. Surg Endosc 33:2267–2273

    Article  CAS  Google Scholar 

  23. Park SS, Han KS, Kim B, Chang Kim B, Hong CW, Sohn DK, Chang HJ (2020) Comparison of underwater endoscopic mucosal resection and endoscopic submucosal dissection of rectal neuroendocrine tumors (with videos). Gastrointest Endosc 91(1164–1171):e1162

    Google Scholar 

  24. Sandhu DS, Lee YJ, Gerke H (2018) Underwater endoscopic mucosal resection: an alternative treatment for large colorectal polyp removal. Minerva Gastroenterol Dietol 64:106–110

    PubMed  Google Scholar 

  25. Chien HC, Uedo N, Hsieh PH (2019) Comparison of underwater and conventional endoscopic mucosal resection for removing sessile colorectal polyps: a propensity-score matched cohort study. Endosc Int Open 7:E1528–E1536

    Article  Google Scholar 

  26. Barclay RL, Percy DB (2020) Underwater endoscopic mucosal resection without submucosal injection (UEMR) for large colorectal polyps: a community-based series. Am J Surg. https://doi.org/10.1016/j.amjsurg.2020.01.023

    Article  PubMed  Google Scholar 

  27. Yen AW, Leung JW, Wilson MD, Leung FW (2020) Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video). Gastrointest Endosc 91(643–654):e642

    Google Scholar 

  28. Heldwein W, Dollhopf M, Rosch T, Meining A, Schmidtsdorff G, Hasford J, Hermanek P, Burlefinger R, Birkner B, Schmitt W (2005) The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 37:1116–1122

    Article  CAS  Google Scholar 

  29. Hassan C, Repici A, Sharma P, Correale L, Zullo A, Bretthauer M, Senore C, Spada C, Bellisario C, Bhandari P, Rex DK (2016) Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 65:806–820

    Article  CAS  Google Scholar 

  30. Kantsevoy SV, Adler DG, Conway JD, Diehl DL, Farraye FA, Kwon R, Mamula P, Rodriguez S, Shah RJ, Wong Kee Song LM, Tierney WM (2008) Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 68:11–18

    Article  Google Scholar 

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Acknowledgements

Special thanks to Dr. Bin Ma for his selfless teaching and help for Dr. Peiwen Li to conduct this study.

Funding

This study was supported by the Natural Science Foundation of Liaoning Province (Grant No. 2015020561), the Fund for Scientific Research of The First Hospital of China Medical University (Grant No. fsfh1514) and Wu Jieping Medical Foundation (Grant No. 320.6750.18293).

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Authors and Affiliations

  1. Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People’s Republic of China

    Peiwen Li, Shulei Gong, Xinyu Zhang & Wenya Li

  2. Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People’s Republic of China

    Bin Ma

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  1. Peiwen Li
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Correspondence to Wenya Li.

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Peiwen Li, Bin Ma, Shulei Gong, Xinyu Zhang, and Wenya Li have no conflicts of interest or financial ties to disclose.

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Supplementary Figure 1 Forest plots of the included studies evaluating en bloc resection.

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Li, P., Ma, B., Gong, S. et al. Underwater endoscopic mucosal resection for colorectal lesions: a meta-analysis. Surg Endosc 35, 3003–3013 (2021). https://doi.org/10.1007/s00464-020-07745-8

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