Endoscopic mucosal resection (EMR) is well established as the primary resection approach for large or complex colon polyps without signs of overt malignancy. With EMR, a submucosal injection is used to lift the mass lesion away from the muscularis propria, allowing it be effectively resected and protecting the muscularis from mechanical or thermal injury. However, submucosal fibrosis caused by previous attempts at removal, multiple previous biopsies, or tattoo can cause a “negative lift sign” and create difficulty for EMR. Several techniques have been described to solve this including full thickness resection (FTRD), endoscopic submucosal dissection (ESD), and cold forceps avulsion with adjuvant snare tip soft coagulation (CAST)^1. Recent multi-center studies have demonstrated the use of distal cap-assisted EMR (EMR-DC) in which a clear plastic distal attachment cap is used at the end of the scope to better visualize the polyp, suction the lesion through an open snare and into the cap, and then capturing the lesion in the snare for resection (Figure 1). Afterward, hot avulsion and thermal treatment of the resection margins are used to ensure that the polyp is completely removed. These recent studies have demonstrated EMR-DC to be a safe, effective, and inexpensive treatment option for adherent, fibrotic polyps without the need for surgery or significant adverse events. ^{2, 5, 7}

The SCENIC guidelines direct the management of dysplastic lesions in the setting of inflammatory bowel disease (IBD) which typically can be completely identified and characterized endoscopically, and if absent of signs of invasive malignancy, should be completely resected endoscopically.³ However, adherent dysplastic lesions due to submucosal fibrosis are very common in the IBD patient and can be technically challenging, requiring advanced techniques such as FTRD or ESD with higher rates of adverse events. ⁴ Here, we present the use of EMR-DC specifically for the use of fully resecting dysplastic colon lesions in the setting of inflammatory bowel disease patients where fibrotic lesions with the “negative lift sign” are common.16 EMR-DC IBD patients were retrospectively evaluated from two high volume centers to assess the performance and safety metrics of EMR-DC in IBD. The patient demographics included average age of 64, ASA score of II to III, with target lesions characterized by pathology, Paris and NICE classification. Results revealed that 75% of patients treated with EMR-DC achieved complete resection (no residual disease at 6-month surveillance colonoscopy), with 0% serious adverse events within 30 days of the procedure.⁶Overall, EMR-DC represents an attractive option for the resection of the adherent dysplastic lesion in the chronically inflamed colon which is effective, safe, efficient, and inexpensive in this retrospective study.

Allison Leisgang

Appearances