17 (S0138). - Soft Coagulation of the Resection Margin for the Prevention of Residual or Recurrent Adenoma After Endoscopic Mucosal Resection of Large Sessile Colonic Polyps: A Multi-Center, Randomized Controlled Trial
Peter A. Senada, MD1, Pujan Kandel, MD1, Michael Bourke, MBBS2, Colleen Ball, MS1, Julia Crook, PhD1, Massimo Raimondo, MD1, Louis Wong Kee Song, MD3, Norio Fukami, MD4, Rahul Pannala, MD4, Suryakanth Gurudu, MD4, Timothy Woodward, MD1, Victoria Gomez, MD1, Bhaumik Brahmbhatt, MBBS1, Ernest P. Bouras, MD1, Francisco C. Ramirez, MD4, Michael Wallace, MD, MPH1; 1Mayo Clinic, Jacksonville, FL; 2University of Sydney, Westmead, New South Wales, Australia; 3Mayo Clinic, Rochester, MN; 4Mayo Clinic, Scottsdale, AZ
Introduction: Endoscopic mucosal resection (EMR) of large (≥20 mm) lateral spreading lesions (LSLs) of the colon is effective in decreasing the incidence of colorectal malignancy and avoiding surgery. A drawback of colonic EMR is the adenoma residual/recurrence rate (15-30%) on first surveillance colonoscopy. A single randomized controlled trial (RCT) from Australia showed that prophylactic coagulation of the EMR margin with the tip of a snare (snare tip soft coagulation - STSC) reduced adenoma recurrence. Definitive evidence usually requires at least two RCTs that corroborate the findings. The aim of our study was to confirm the efficacy of STSC to reduce the rate of residual/recurrent adenoma following EMR. Methods: An RCT comparing standard EMR (control arm) to EMR+STSC (active arm) for the resection of large LSLs at three tertiary referral centers (Mayo Clinic campuses in Jacksonville, FL; Scottsdale, AZ; and Rochester, MN) was performed. Surveillance colonoscopies with photo documentation using standardized near-focus NBI and biopsies were performed at 6 months post resection. The primary endpoint was the presence of residual/recurrent adenoma at the prior EMR site. The protocol was approved by the Institutional Review Board of Mayo Clinic and registered (NCT01789749). Results: A total of 148 patients from the 3 sites (117, FL; 17, AZ; and 14, MN) were randomized: 75 in the control arm and 73 in the active arm. The primary outcome, histologically confirmed residual/recurrence at first follow-up, was available for 114 patients. Median duration to first follow-up was 6.7 months [IQR 6, 8.7]. Except for the variables of prior biopsy and adenoma recurrence, there were no differences between the two groups with regard to other variables, including patient demographics, size and location of lesions, polyp histology, and use of clips (Table 1). Among the 114 patients who had their first follow-up, 27 patients had histologically confirmed residual/recurrence: 20/58 (34%) in the control arm versus 7/56 (12%) in the active arm, unadjusted RR = 0.36 (95% CI 0.17-0.79, P = 0.011) (table 2). When adjusting for previous biopsy, the use of STSC was associated with a lower rate of residual/recurrent adenoma with adjusted RR= 0.37 (95% CI 0.17 - 0.83; P=0.015). Discussion: The use of snare tip soft coagulation as adjuvant treatment to EMR of large lateral spreading lesions significantly reduces the risk of residual or recurrent adenoma at follow-up.
Table 1: EMR versus EMR+STSC for Large Lateral Spreading Lesions
Table 2: Adenoma residual/recurrence among patients who had a first follow-up colonoscopy
Disclosures: Peter Senada indicated no relevant financial relationships. Pujan Kandel indicated no relevant financial relationships. Michael Bourke indicated no relevant financial relationships. Colleen Ball indicated no relevant financial relationships. Julia Crook indicated no relevant financial relationships. Massimo Raimondo indicated no relevant financial relationships. Louis Wong Kee Song indicated no relevant financial relationships. Norio Fukami indicated no relevant financial relationships. Rahul Pannala indicated no relevant financial relationships. Suryakanth Gurudu indicated no relevant financial relationships. Timothy Woodward indicated no relevant financial relationships. Victoria Gomez indicated no relevant financial relationships. Bhaumik Brahmbhatt: COOK medical – Other Financial or Material Support, General payments/travel lodging/minor Food and Beverage. Ernest Bouras indicated no relevant financial relationships. Francisco Ramirez indicated no relevant financial relationships. Michael Wallace: Fujifilm, Boston Scientific, Olympus, Medtronic, Ninepoint Medical, Cosmo /Aries Pharmaceuticals. – Grant/Research Support. Synergy Pharmaceuticals, Boston Scientific, Cook Medical. – Other Financial or Material Support, General payments/Minor Food and Beverage. Virgo Inc – Other Financial or Material Support, Stock/Stock Options. Virgo Inc, Cosmo/Aries Pharmaceuticals, Anx Robotica – Consultant.