Safety and efficacy of underwater endoscopic mucosal resection for non-pedunculated colorectal polyps larger than 10 mm
DOI:
https://doi.org/10.47892/rgp.2025.453.1933Keywords:
Colonic Polyps, Endoscopic Mucosal Resection, Postoperative Complications, RecurrenceAbstract
Introduction: Colorectal cancer (CRC) is one of the leading causes of cancer-related death in Peru. Endoscopic resection of colorectal polyps has been shown to reduce the incidence and mortality of CRC. Underwater endoscopic mucosal resection (UEMR) has emerged as a safe and effective technique for the management of non-pedunculated polyps. Objectives: To evaluate the efficacy and safety of UEMR for non-pedunculated colorectal polyps larger than 10 mm in a high-complexity hospital in Lima, Peru. Materials and methods: Observational, retrospective, and descriptive study of patients aged ≥18 years who underwent UEMR between January and December 2023. En bloc resection, R0 resection, recurrence, and complication rates were analyzed. Clinical, endoscopic, and histopathological data were collected. Results: A total of 119 UEMRs were performed in 91 patients, with a median age of 72 years. 60.5% of lesions were located in the right colon, and most measured between 10–19 mm. The en bloc resection rate was 80%, and the R0 resection rate was 78%. The complication rate was 15%, including one perforation and two delayed bleeding events. Most complications occurred in the right colon. Recurrence was 3.1%, observed only in piecemeal resections. Histopathological findings included low-grade (47.9%) and high-grade (28.6%) adenomas, as well as 7 carcinomas (5.8%). Conclusions: UEMR is an effective and safe technique for the treatment of non-pedunculated colorectal polyps larger than 10 mm, particularly for lesions ≤20 mm. Its advantages include a high en bloc resection rate, low complication risk, and low cost.
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Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA A Cancer J Clinicians. 2024;74(3):229-263. doi: 10.3322/caac.21834.
Schoen RE, Pinsky PF, Weissfeld JL, Yokochi LA, Church T, Laiyemo AO, et al. Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med. 2012;366(25):2345-2357. doi: 10.1056/NEJMoa1114635.
Brenner H, Chang-Claude J, Rickert A, Seiler CM, Hoffmeister M. Risk of colorectal cancer after detection and removal of adenomas at colonoscopy: population-based case-control study. J Clin Oncol. 2012;30(24):2969-2976. doi: 10.1200/ JCO.2011.41.3377.
Nishihara R, Wu K, Lochhead P, Morikawa T, Liao X, Qian ZR, et al. Long-Term Colorectal-Cancer Incidence and Mortality after Lower Endoscopy. N Engl J Med. 2013;369(12):1095-1105. doi: 10.1056/NEJMoa1301969.
Palacios Salas F, Benites Goñi H. [Efficacy and safety of endoscopic resection in patients with large non-pedunculated colorectal polyps]. Rev Gastroenterol Peru. 2017;37(4):305- 316.
Takeuchi Y, Shichijo S, Uedo N, Ishihara R. Underwater endoscopic mucosal resection for colorectal lesions: Can it be an “Underwater” revolution? DEN Open. 2022;2(1):e84. doi: 10.1002/deo2.84.
Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024. Endoscopy. 2024;56(07):516-545. doi: 10.1055/a-2304-3219.
Wang X, Wang Y, Cao X, Zhang C, Miao L. Underwater versus conventional endoscopic mucosal resection for ≥10 mm sessile or flat colorectal polyps: A systematic review and metaanalysis. PLoS One. 2024;19(3):e0299931. doi: 10.1371/journal. pone.0299931.
Binmoeller KF, Weilert F, Shah J, Bhat Y, Kane S. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointestinal Endoscopy. 2012;75(5):1086-1091. doi: 10.1016/j.gie.2011.12.022.
Binmoeller KF. Underwater EMR without submucosal injection: Is less more? Gastrointest Endosc. 2019;89(6):1117-1119. doi: 10.1016/j.gie.2019.02.011.
Uedo N, Nemeth A, Johansson GW, Toth E, Thorlacius H. Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy. 2015;47(2):172-174. doi: 10.1055/s-0034- 1390749.
Tziatzios G, Gkolfakis P, Triantafyllou K, Fuccio L, Facciorusso A, Papanikolaou IS, et al. Higher rate of en bloc resection with underwater than conventional endoscopic mucosal resection: A meta-analysis. Dig Liver Dis. 2021;53(8):958-964. doi: 10.1016/j.dld.2021.05.001.
Leung FW, Leung JW, Mann SK, Friedland S, Ramirez FC. The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy. Endoscopy. 2011;43(9):816-821. doi: 10.1055/s-0030-1256407.
Oka S, Tanaka S, Saito Y, Iishi H, Kudo SE, Ikematsu H, et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol. 2015;110(5):697-707. doi: 10.1038/ajg.2015.96.
Yamashina T, Uedo N, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, et al. Comparison of Underwater vs Conventional Endoscopic Mucosal Resection of Intermediate-Size Colorectal Polyps. Gastroenterology. 2019;157(2):451-461.e2. doi: 10.1053/j.gastro.2019.04.005.
Nagl S, Ebigbo A, Goelder SK, Roemmele C, Neuhaus L, Weber T, et al. Underwater vs Conventional Endoscopic Mucosal Resection of Large Sessile or Flat Colorectal Polyps: A Prospective Randomized Controlled Trial. Gastroenterology. 2021;161(5):1460-1474.e1. doi: 10.1053/j.gastro.2021.07.044.
Chandan S, Bapaye J, Khan SR, Mohan BP, Ramai D, Dahiya DS, et al. Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs. Endosc Int Open. 2023;11(8):E768-E777. doi: 10.1055/a-2117-8327.
Tanaka S, Kashida H, Saito Y, Yahagi N, Yamano H, Saito S, et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Digestive Endoscopy. 2020;32(2):219-239. doi: 10.1111/den.13545.
Tate DJ, Desomer L, Klein A, Brown G, Hourigan LF, Lee EY, et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc. 2017;85(3):647-656.e6. doi: 10.1016/j.gie.2016.11.027.
Sidhu M, Tate DJ, Desomer L, Brown G, Hourigan LF, Lee EYT, et al. The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy. 2018;50(7):684-692. doi: 10.1055/s-0043-124081.
Forbes N, Gupta S, Frehlich L, Meng ZW, Ruan Y, Montori S, et al. Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials. Gastrointest Endosc. 2022;96(5):721-731.e2. doi: 10.1016/j.gie.2022.05.020.
Choi AY, Moosvi Z, Shah S, Roccato MK, Wang AY, Hamerski CM, et al. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc. 2021;93(2):378-389. doi: 10.1016/j.gie.2020.10.009.
Radadiya D, Desai M, Patel H, Srinivasan S, Chandrasekar VT, Hassan C, et al. Analyzing methods for reducing recurrence rates after EMR of large nonpedunculated colorectal polyps: an indirect pairwise comparison. Gastrointest Endosc. 2024;99(3):326-336.e6. doi: 10.1016/j.gie.2023.11.060.
Wang AY, Flynn MM, Patrie JT, Cox DG, Bleibel W, Mann JA, et al. Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc. 2014;28(4):1348-1354. doi: 10.1007/s00464-013-3297-5.
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Copyright (c) 2025 Harold Benites-Goñi, Diego Berrospi-Castillo, Paulo Bardalez-Cruz, Bryan Medina-Morales, Jairo Asencios-Cusihuallpa, Luis Marin-Calderón
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Revista de Gastroenterología del Perú by Sociedad Peruana de Gastroenterología del Perú is licensed under a Licencia Creative Commons Atribución 4.0 Internacional..
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