John M. Levenick, MD1, Carl Manzo, MD2, Jennifer Maranki, MD2
1Penn State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA; 2Penn State University Milton S. Hershey Medical Center, Hershey, PA
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Introduction: The importance of colonoscopy in the prevention of the development of colon cancer is readily recognized. Although there has been a decline in rates of colon cancer, 5% of people continue to develop colon cancer and 2.5% will die from it. Roughly 5% of polyps removed are laterally-spreading lesions (LSL) that are greater than 10mm in size. Most large LSLs are now removed endoscopically which allows for removal on an outpatient basis with an improved safety profile. However, one drawback is the rate of recurrence, quoted at 10-30%. A key aspect to EMR is adequately lifting the lesion using an inert dye such as methylene blue infused solution into the submucosal space with special attention to avoiding extramural injection. It was originally felt that APC fulguration could be used to treat remaining tissue post-EMR. However, recurrence rates using this technique remained high. Resection of 3-5mm of normal tissue around the site also did not reduce recurrence though simple snare-tip soft coagulation of the edges improved recurrence rates. We hypothesize that high recurrence rates post-EMR polypectomy occur due to microscopic residual disease in the base and edges of the lesion and that using APC to treat the post-EMR site will decrease recurrence rates to less than 5%.
Case Description/Methods: Once the LSL is detected and assessed, the patient is grounded and the ERBE Vio300D system is assembled. A solution of saline and methylene blue is made. Using the needleless waterjet of the Hybrid APC system, the lesion is lifted with an effect of 30-50, helping to prevent extramural injection and allowing for optimal lift. EMR is then performed in typical fashion. We often prefer to use the Endo Cut setting with an effect of 2, cut duration of 1, and cut interval of 4. After the neoplasia has been completely removed, the base and borders are relifted with the needleless waterjet . This additional lift helps to avoid deep mucosal injury. APC is then performed using a flow of 0.8 L/min and 30 watts. The entire base of the site and the circumferential borders of the lesions undergo APC in their entirety. Endoclips can be used to close the post-polypectomy site.
Discussion: Thus far at our institution, we have used hybrid APC assisted EMR in roughly 50 cases. All of these procedures were tolerated well, and only two of them were complicated by delayed post-polypectomy bleeding. We are hopeful that this method will reduce rates of recurrence and eventually possibly become standard of care for these lesions.
Citation: John M. Levenick, MD; Carl Manzo, MD; Jennifer Maranki, MD. P0251 - HYBRID APC-ASSISTED EMR: A NEW TECHNIQUE TO PREVENT POLYP RECURRENCE. Program No. P0251. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.