Underwater Endoscopic Mucosal Resection in Non-pedunculated Colorectal Lesions: A Prospective Series in a Tertiary Center in Peru
DOI:
https://doi.org/10.52787/agl.v55i3.530Keywords:
Underwater endoscopic mucosal resection, colorectal neoplasms, colorectal polyps, colonoscopyAbstract
Introduction. Underwater endoscopic mucosal resection is an alternative technique to conventional endoscopic mucosal resection, with potential advantages in efficacy and safety. In Latin America, there are few reports on its application.
Objective. To evaluate the effectiveness, feasibility, and safety of underwater endoscopic mucosal resection for non-pedunculated colorectal lesions in a Latin American series.
Materials and Methods. A prospective, observational study conducted between December 2023 and December 2024. Consecutive patients with non-pedunculated colorectal lesions ≥ 10 mm without endoscopic signs of deep submucosal invasion were included. Demographic data, lesion characteristics, technical success, resection type, histological findings, complications, and six-month recurrence were recorded.
Results. Sixty patients with 67 lesions were included. The mean lesion size was 16.7 mm. The most common location was the right colon (56.7%), and the predominant morphology was granular LST (59.7%). Technical success was 100%, and en bloc resection was achieved in 91% of cases (96.5% for lesions ≤ 20 mm). Histology showed: tubular adenomas (47.7%), tubular adenomas with high-grade dysplasia (16.4%), serrated adenomas without dysplasia (4.4%), serrated adenomas with low-grade dysplasia (16.4%), and intramucosal adenocarcinomas (5.9%). Intraprocedural bleeding occurred in 11.9% and delayed bleeding in 2.9%, with no perforations. A significant association was found between lesion size and resection type (p < 0.001). Piecemeal resection was more frequent in lesions > 20 mm (RR 12.88; 95% CI: 2.75 - 60.43). At six months, control colonoscopy was performed in 85.1% of cases, with no evidence of recurrence.
Conclusions. Underwater endoscopic mucosal resection proved to be effective, safe, and feasible, with high en bloc resection rates, low complication rates, and absence of short-term recurrence.
References
-1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209-49. https://doi.org/10.3322/CAAC.21660
-2. Arnold M, Abnet CC, Neale RE, Vignat J, Giovannucci EL, McGlynn KA, et al. Global burden of 5 major types of gastrointestinal cancer. Gastroenterology. 2020;159(2):335-349.e15. https://doi.org/10.1053/j.gastro.2020.02.068
-3. Zauber AG, Winawer SJ, O’Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Hankey BF, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366(8):687-96. https://doi.org/10.1056/NEJMOA1100370
-4. Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau JM, Paspatis G, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017;49(3):270-97. https://doi.org/10.1055/s-0043-102569
-5. Karstensen JG, Ebigbo A, Desalegn H, Afihene M, Anigbo G, Antonelli G, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy Cascade Guideline. Endosc Int Open. 2022;10(7):E1427-E1439. https://doi.org/10.1055/a-1964-7965
-6. Facciorusso A, Antonino M, Di Maso M, Muscatiello N. Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: a meta-analysis. World J Gastrointest Endosc. 2014;6(11):555-63. https://doi.org/10.4253/wjge.v6.i11.555
-7. Binmoeller KF, Weilert F, Shah J, Bhat Y, Kane S. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc. 2012;75(6):1086-91. https://doi.org/10.1016/j.gie.2011.12.022
-8. Spadaccini M, Fuccio L, Lamonaca L, Frazzoni L, Maselli R, Di Leo M, et al. Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video). Gastrointest Endosc. 2019;89(6):1109-1116.e4. https://doi.org/10.1016/j.gie.2018.10.023
-9. Zhang Z, Xia Y, Cui H, Yuan X, Wang C, Xie J, et al. Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial. BMC Gastroenterol. 2020;20:257. https://doi.org/10.1186/s12876-020-01457-y
-10. Curcio G, Granata A, Ligresti D, Tarantino I, Barresi L, Liotta R, et al. Underwater colorectal EMR: remodeling endoscopic mucosal resection. Gastrointest Endosc. 2015;81(6):1238-42. https://doi.org/10.1016/j.gie.2014.12.055
-11. Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy. 2024. https://doi.org/10.1055/a-2304-3219
-12. Nogueira PB, Albuquerque W, Nascimento RC, Marianelli BS, Campos FF, Carreiro RA, et al. Underwater endoscopic mucosal resection of adenomas and colorectal serrated lesions: a prospective clinical study. Ann Gastroenterol. 2021;34(5):552-7. https://doi.org/10.20524/aog.2021.0625
-13. de Souza MHG, do Espirito Santo PA, Maluf-Filho F, Lenz L. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis of randomized clinical trials. Int J Colorectal Dis. 2023;38:1-11. https://doi.org/10.1007/S00384-023-04505-7
-14. Coutinho LMA, Lenz L, Kawaguti FS, Martins BC, Baba E, Gusmon C, et al. Underwater Endoscopic Mucosal Resection for Small Rectal Neuroendocrine Tumors. Arq Gastroenterol. 2021;58:210-3. https://doi.org/10.1590/S0004-2803.202100000-37
-15. Fujiyoshi MRA, Fujiyoshi Y, Gimpaya N, Bechara R, Jeyalingam T, Calo NC, et al. Unified Magnifying Endoscopic Classification (UMEC) of Gastrointestinal Lesions: A North American Validation Study. J Can Assoc Gastroenterol. 2024;7:246-54. https://doi.org/10.1093/JCAG/GWAD055
-16. Workshop P in the P. The Paris endoscopic classification of superficial neoplastic lesions: Esophagus, stomach, and colon - November 30 to December 1, 2002. Gastrointest Endosc. 2003;58:S3-43. https://doi.org/10.1016/S0016-5107(03)02159-X
-17. Siau K, Ishaq S, Cadoni S, Kuwai T, Yusuf A, Suzuki N. Feasibility and outcomes of underwater endoscopic mucosal resection for ≥ 10 mm colorectal polyps. Surg Endosc. 2018;32(7):2656-63. https://doi.org/10.1007/s00464-017-5960-8
-18. Wang AY, Flynn MM, Patrie JT, Cox DG, Bleibel W, Mann JA, et al. Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc. 2014;28(5):1348-54. https://doi.org/10.1007/s00464-013-3297-5
-19. Lenz L, Martins B, Andrade de Paulo G, Kawaguti FS, Baba ER, Uemura RS, et al. Underwater versus conventional EMR for nonpedunculated colorectal lesions: a randomized clinical trial. Gastrointest Endosc. 2023;97(3):549-58. https://doi.org/10.1016/j.gie.2022.10.033
-20. Yamashina T, Uedo N, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, et al. Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology. 2019;157(2):451-461.e2. https://doi.org/10.1053/j.gastro.2019.04.005
-21. Binmoeller KF, Hamerski CM, Shah JN, Bhat YM, Kane SD, Garcia-Kennedy R. Attempted underwater en bloc resection for large (2-4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc. 2015;81(3):713-8. https://doi.org/10.1016/j.gie.2014.10.044
-22. Tajika M, Niwa Y, Bhatia V, Kondo S, Tanaka T, Mizuno N, et al. Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors. Eur J Gastroenterol Hepatol. 2011;23(10):1042-9. https://doi.org/10.1097/MEG.0b013e32834aa47b
-23. Ponugoti PL, Rex DK. Perforation during underwater EMR. Gastrointest Endosc. 2016;84(3):543-4. https://doi.org/10.1016/j.gie.2016.01.021
-24. Paccos JL, De Oliveira DS, De Oliveira FJS, Pereira Junior EMA, Mota FL, Da Silva MMC, et al. Perforation and bleeding during an underwater endoscopic mucosal resection of a large colonic lesion. Endoscopy. 2021;53(12):E326-7. https://doi.org/10.1055/a-1275-9832
-25. Rodríguez Sánchez J, Alvarez-Gonzalez MA, Pellisé M, Coto-Ugarte D, Uchima H, Aranda-Hernández J, et al. Underwater versus conventional EMR of large nonpedunculated colorectal lesions: a multicenter randomized controlled trial. Gastrointest Endosc. 2023;97(5):941-951.e2. https://doi.org/10.1016/j.gie.2022.12.013
-26. Deng Q, Wu Z, Li J, Liang G, Yang C. Underwater endoscopic mucosal resection is superior to conventional endoscopic mucosal resection for medium-sized colorectal sessile polyps: a randomized controlled trial. Sci Rep. 2024;14(1):1-9. https://doi.org/10.1038/s41598-024-81817-w
-27. Yamashina T, Hanaoka N, Setoyama T, Watanabe J, Banno M, Marusawa H, et al. Efficacy of underwater endoscopic mucosal resection for nonpedunculated colorectal polyps: a systematic review and meta-analysis. Cureus. 2021;13(5):e17261. https://doi.org/10.7759/cureus.17261
-28. Choi AY, Moosvi Z, Shah S, Roccato MK, Wang AY, Hamerski CM, et al. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc. 2021;93(2):378-89. https://doi.org/10.1016/j.gie.2020.10.009
-29. Schenck RJ, Jahann DA, Patrie JT, Stelow EB, Cox DG, Uppal DS, et al. 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. 2017;31(11):4174-83. https://doi.org/10.1007/s00464-017-5474-4
-30. Takeuchi Y, Shichijo S, Uedo N, Ishihara R. Underwater endoscopic mucosal resection for colorectal lesions: Can it be an “Underwater” revolution? DEN Open. 2022;2(1):e84. https://doi.org/10.1002/deo2.84
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Copyright (c) 2025 Henry Tomas Vargas Marcacuzco, Sonia Irene Junes Pérez, Waldir Paucar Huamán, Edith Melissa Villafuerte Mendez, Jorge Luis Fernández Luque, Jessica Tatheana Matheus Sairitupac
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