Skip to main content
SpringerLink
Log in

Outcomes for Underwater Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection of 21–30-mm Colorectal Polyps: A Feasible Study

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background and Aims

This randomized controlled trial (RCT) was designed to evaluate the short-term outcomes of underwater endoscopic mucosal resection (UEMR) and endoscopic submucosal dissection (ESD) of 21–30 mm colonic polyps.

Method

We conducted a single-center RCT. Patients diagnosed with suspected colorectal intramucosal carcinoma (21–30 mm and adaptable for both UEMR and ESD) were randomly assigned to the UEMR and ESD groups at a 1:1 ratio. The primary endpoint was the R0 resection rate. We independently performed one-sample tests against the set threshold for each treatment. The significance level was set at p = 0.224.

Result

Eleven polyps each in the UEMR and ESD groups, respectively, were analyzed. The R0 resection rate (%) was 36 (95% confidence interval 11–69) and 100 (72–100) for UEMR and ESD, respectively, with a significant difference between the two groups (p = 0.002). The p-value against the set threshold for UEMR was 0.743, whereas that for ESD was < 0.001 (one-sample binomial test). The en bloc resection rates (%) were 82 (48–97) and 100 (72–100) for UEMR and ESD, respectively; however, no significant difference was observed (p = 0.167). The mean treatment time (min) was significantly shorter in the UEMR group (8 ± 6) than in the ESD group (48 ± 29) (p = 0.001).

Conclusion

ESD could achieve a high R0 resection rate, while the en bloc resection rate was comparable between the two treatment techniques with less burden on patients undergoing UEMR for 21–30-mm colorectal polyps.

Clinical Trial Registration

The study was registered at the Japan Registry of Clinical Trial as jRCT1030210015 and jRCT1030210177.

Graphical Abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Fitzmaurice C, Allen C, Barber RM et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol 2017;3:524–548.

    Article  PubMed  Google Scholar 

  2. Zauber AG, Winawer SJ, O’Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012;366:687–696.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993;329:1977–1981.

    Article  CAS  PubMed  Google Scholar 

  4. Tanaka S, Kashida H, Saito Y et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015;27:417–434.

    Article  PubMed  Google Scholar 

  5. Tajika M, Niwa Y, Bhatia V et al. Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors. Eur J Gastroenterol Hepatol 2011;23:1042–1049.

    Article  PubMed  Google Scholar 

  6. Yahagi N, Fujishiro M, Imagawa A et al. Endoscopic submucosal dissection for the reliable en bloc resection of colorectal mucosal tumors. Dig Endosc 2004;16:S89–S92.

    Article  Google Scholar 

  7. De Ceglie A, Hassan C, Mangiavillano B et al. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: a systematic review. Crit Rev Oncol Hematol 2016;104:138–155.

    Article  PubMed  Google Scholar 

  8. Fujishiro M, Yahagi N, Kakushima N et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol 2007;5:678–683.

    Article  PubMed  Google Scholar 

  9. Puli SR, Kakugawa Y, Saito Y et al. Successful complete cure en-bloc resection of large nonpedunculated colonic polyps by endoscopic submucosal dissection: a meta-analysis and systematic review. Ann Surg Oncol 2009;16:2147–2151.

    Article  PubMed  Google Scholar 

  10. 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;75:1086–1091.

    Article  PubMed  Google Scholar 

  11. Spadaccini M, Fuccio L, Lamonaca L et al. Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video). Gastrointest Endosc 2019;89:1109-1116.e4.

    Article  PubMed  Google Scholar 

  12. Siau K, Ishaq S, Cadoni S et al. Feasibility and outcomes of underwater endoscopic mucosal resection for ≥ 10 mm colorectal polyps. Surg Endosc 2018;32:2656–2663.

    Article  PubMed  Google Scholar 

  13. Wang AY, Flynn MM, Patrie JT et al. Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc 2014;28:1348–1354.

    Article  PubMed  Google Scholar 

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

    PubMed  Google Scholar 

  15. Kawamura T, Sakai H, Ogawa T et al. Feasibility of underwater endoscopic mucosal resection for colorectal lesions: a single center study in Japan. Gastroenterol Res 2018;11:274–279.

    Article  Google Scholar 

  16. Yamashina T, Uedo N, Akasaka T et al. Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology 2019;157:451–461.

    Article  PubMed  Google Scholar 

  17. Fujimoto K, Fujishiro M, Kato M et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc 2014;26:1–14.

    Article  PubMed  Google Scholar 

  18. Kato M, Uedo N, Hokimoto S et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants. Dig Endosc 2018;30:433–440.

    Article  PubMed  Google Scholar 

  19. Sano Y, Tanaka S, Kudo SE et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016;28:526–533.

    Article  PubMed  Google Scholar 

  20. Wada Y, Kashida H, Kudo SE et al. Diagnostic accuracy of pit pattern and vascular pattern analyses in colorectal lesions. Dig Endosc 2010;22:192–199.

    Article  PubMed  Google Scholar 

  21. Participants in the Paris workshop. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach. Gastrointest Endosc 2003;58:S3–S43.

    Article  Google Scholar 

  22. Binmoeller KF. Underwater EMR without submucosal injection: is less more? Gastrointest Endosc 2019;89:1117–1119.

    Article  PubMed  Google Scholar 

  23. Nagl S, Ebigbo A, Goelder SK et al. Underwater vs conventional endoscopic mucosal resection of large sessile or flat colorectal polyps: a prospective randomized controlled trial. Gastroenterology 2021;161:1460-1474.e1.

    Article  CAS  PubMed  Google Scholar 

  24. Chandan S, Khan SR, Kumar A et al. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021;94:471-482.e9.

    Article  PubMed  Google Scholar 

  25. Choi AY, Moosvi ZM, Shah S et al. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc 2021;93:378–389.

    Article  PubMed  Google Scholar 

  26. Garg R, Singh A, Mohan BP et al. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis. Endosc Int Open 2020;8:E1884–E1894.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kamal F, Khan MA, Lee-Smith W et al. Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2020;8:E1264–E1272.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ni DQ, Lu YP, Liu XQ, Gao LY, Huang X. Underwater vs conventional endoscopic mucosal resection in treatment of colorectal polyps: a meta-analysis. World J Clin Cases 2020;8:4826–4837.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Inoue T, Nakagawa K, Yamasaki Y et al. Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20–30 mm colorectal polyps. J Gastroenterol Hepatol 2021;36:2549–2557.

    Article  PubMed  Google Scholar 

  30. Albéniz E, Álvarez MA, Espinós JC et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 2019;157:1213–1221.

    Article  PubMed  Google Scholar 

  31. Gupta S, Sidhu M, Shahidi N et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2022;7:152–160.

    Article  PubMed  Google Scholar 

  32. Fuccio L, Hassan C, Ponchon T et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 2017;86:74–86.

    Article  PubMed  Google Scholar 

  33. Nakajima T, Saito Y, Tanaka S et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013;27:3262–3270.

    Article  PubMed  Google Scholar 

  34. Akintoye E, Kumar N, Aihara H, Nas H, Thompson CC. Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis. Endosc Int Open 2016;4:E1030–E1044.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Taku K, Sano Y, Fu KI et al. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol 2007;22:1409–1414.

    Article  PubMed  Google Scholar 

  36. Tamegai Y, Saito Y, Masaki N et al. Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 2007;39:418–422.

    Article  CAS  PubMed  Google Scholar 

  37. Hassan C, Repici A, Sharma P et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016;65:806–820.

    Article  CAS  PubMed  Google Scholar 

  38. Sakamoto T, Matsuda T, Otake Y, Nakajima T, Saito Y. Predictive factors of local recurrence after endoscopic piecemeal mucosal resection. J Gastroenterol 2012;47:635–640.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank the staff of the Endoscopy Center of Chiba University Hospital for providing technical assistance and for helping in the documentation and Hideki Hanaoka, Yoko Hattori, and Park Inkyung at the Clinical Research Data Center of Chiba University Hospital for their data administration. The authors also thank Enago (https://www.enago.jp/) for English language editing.

Funding

The author received the Japanese Foundation for Research and Promotion of Endoscopy Grant (No 1008).

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan

    Kenichiro Okimoto, Tomoaki Matsumura, Tsubasa Ishikawa, Naoki Akizue, Tatsuya Kaneko, Yuki Ohta, Takashi Taida, Keiko Saito, Sadahisa Ogasawara, Daisuke Maruoka, Jun Kato & Naoya Kato

  2. Department of Pathology, Chiba University Hospital, Chiba, Japan

    Keisuke Matsusaka & Jun-ichiro Ikeda

  3. Biostatistics Section, Chiba University Hospital Clinical Research Center, Chiba, Japan

    Yosuke Inaba

  4. Department of Diagnostic Pathology, Graduate School of Medicine, Chiba University, Chiba, Japan

    Masayuki Ota & Jun-ichiro Ikeda

  5. Kameido Endoscopy and Gastroenterology Clinic, Tokyo, Japan

    Daisuke Maruoka

Authors
  1. Kenichiro Okimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tomoaki Matsumura
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Keisuke Matsusaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yosuke Inaba
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tsubasa Ishikawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Naoki Akizue
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Tatsuya Kaneko
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Masayuki Ota
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Yuki Ohta
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Takashi Taida
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Keiko Saito
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Sadahisa Ogasawara
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Daisuke Maruoka
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Jun Kato
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Jun-ichiro Ikeda
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Naoya Kato
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Wrote manuscript: K.O., K.M, and Y.I. Performed endoscopic procedure. K.O., T.M., T.I., and N.A. Interpretation of the data: K.O., T.M., T.I., N.A., T.K., Y.O., T.T., K.S., S.O., and D.M. Statistical analysis: Y.I. Pathological diagnosis: K.M. Supervised manuscript: M.O., J.K., JI.I., and N.K. Generated the random allocation sequence: Y.I. Enrolled participants and who assigned participants to interventions: K.O., T.M., T.I., and N.A.

Corresponding author

Correspondence to Kenichiro Okimoto.

Ethics declarations

Conflict of interest

All authors were involved in the final approval of the version of the manuscript submitted and have agreed to be accountable for all aspects of the work. There is no relevant conflict of interest or disclosures, including financial and material support for the research and work in this manuscript.

Ethical approval

This study was conducted in accordance with the Helsinki Declaration. Patients’ data were coded, and the anonymity of patients was guaranteed. The study protocol was reviewed and approved by the Ethics Review Committee of Chiba University Graduate School of Medicine (registration no. G2020032 on January 21, 2021 and 4211 on June 17 (in relation to recurrence evaluation)). The study protocol was unchanged after the initiation of this trial.

Informed consent

All patients provided written informed consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (TIF 7431 kb)

Supplementary file2 (DOCX 22 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Okimoto, K., Matsumura, T., Matsusaka, K. et al. Outcomes for Underwater Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection of 21–30-mm Colorectal Polyps: A Feasible Study. Dig Dis Sci 68, 3963–3973 (2023). https://doi.org/10.1007/s10620-023-08093-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-023-08093-y

Keywords

Search

Navigation