Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia.
Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia.
Gastroenterology. 2019 Feb;156(3):604-613.e3. doi: 10.1053/j.gastro.2018.10.003. Epub 2018 Oct 6.
BACKGROUND & AIMS: Colorectal cancer (CRC) can be prevented by colonoscopy and polypectomy. Endoscopic mucosal resection (EMR) is performed to remove large laterally spreading colonic lesions that have a high risk of progression to CRC. Endoscopically invisible micro-adenomas at the margins of the EMR site might contribute to adenoma recurrence, which occurs in 15% to 30% of patients who undergo surveillance. We aimed to determine the efficacy of adjuvant thermal ablation of the EMR mucosal defect margin in reducing polyp recurrence.
We performed a prospective study of 390 patients with large laterally spreading colonic lesions (≥ 20 mm, n = 416) referred for EMR at 4 tertiary centers in Australia. After complete lesion excision by EMR, lesions were randomly assigned to thermal ablation of the post-EMR mucosal defect margin (n = 210) or no additional treatment (controls, n = 206). We performed surveillance colonoscopies with standardized photo documentation and biopsies of the scar after 5 to 6 months. Patient, procedure, and lesion characteristics were similar between the groups. The primary endpoint was detection of lesion recurrence at first surveillance colonoscopy.
A significantly lower proportion of patients who received thermal ablation of the post-EMR mucosal defect margin had evidence of recurrence at first surveillance colonoscopy (10/192, 5.2%) than controls (37/176, 21.0%) (P < .001). The relative risk of recurrence in the thermal ablation group was 0.25 compared with the control group (95% confidence interval 0.13-0.48). Rates of adverse events were similar between the groups.
In a multicenter randomized trial, thermal ablation of the post-EMR mucosal defect margin significantly reduced polyp recurrence at first surveillance colonoscopy, compared with no additional treatment. Routine implementation of this simple and safe technique could increase the utility of EMR, decrease surveillance burdens, and reduce morbidity and mortality from CRC. ClinicalTrials.gov no: NCT01789749.
结直肠癌（CRC）可以通过结肠镜检查和息肉切除术进行预防。内镜黏膜切除术（EMR）用于切除具有高 CRC 进展风险的大型侧向扩展结肠病变。EMR 部位边缘的内镜下不可见微腺瘤可能导致腺瘤复发，接受监测的患者中有 15%至 30%发生腺瘤复发。我们旨在确定辅助性 EMR 黏膜缺损边缘热消融治疗在降低息肉复发率方面的疗效。
我们对澳大利亚 4 个三级中心的 390 名患有大型侧向扩展结肠病变（≥20mm，n=416）的患者进行了一项前瞻性研究。在 EMR 完全切除病变后，将病变随机分配至 EMR 后黏膜缺损边缘热消融（n=210）或不进行额外治疗（对照组，n=206）。我们在 5 至 6 个月后进行了具有标准化照片记录的监测结肠镜检查和瘢痕活检。两组患者、手术和病变特征相似。主要终点是首次监测结肠镜检查时发现病变复发。
接受 EMR 后黏膜缺损边缘热消融治疗的患者中，首次监测结肠镜检查时发现有复发证据的患者比例明显低于对照组（10/192，5.2%比 37/176，21.0%）（P<.001）。与对照组相比，热消融组的复发相对风险为 0.25（95%置信区间 0.13-0.48）。两组不良事件发生率相似。
在一项多中心随机试验中，与不进行额外治疗相比，EMR 后黏膜缺损边缘热消融显著降低了首次监测结肠镜检查时的息肉复发率。常规实施这种简单且安全的技术可以提高 EMR 的实用性，减轻监测负担，并降低 CRC 的发病率和死亡率。ClinicalTrials.gov 编号：NCT01789749。
