Distal Cap-assisted Endoscopic Mucosal Resection for Non-lifting Colorectal Polyps: An International, Multicenter Study

Background and Aims: Submucosal fibrosis is a commonly encountered problem associated with complex polyps referred for endoscopic mucosal resection (EMR). Previous biopsies, submucosal tattoo injection, and previous unsuccessful attempts at polyp resection have all been shown to induce submucosal fibrosis, which makes subsequent EMR more difficult and increases the risk of recurrence. Methods: We conducted a multicenter, international, retrospective study of 61 distal cap-assisted endoscopic mucosal resection (EMR-DC) cases done for the indication of a non-lifting colorectal lesion occurring after a previous biopsy, tattoo, or attempted resection at 3 tertiary referral centers. Results: EMR-DC was preceded by attempted polypectomy or EMR in 88.5% of cases, submucosal tattoo injection in 2%, previous biopsy in 5%, and both biopsy and tattoo in 5%. Complete macroscopic resection was achieved in 100% of EMR-DC procedures in an average procedure time of 49.5 minutes. The adenoma recurrence rate for these adherent lesions at surveillance (average 6.6 months) was only 9.8%. Two serious adverse events occurred (3.3%) within 30 days of the procedure: one instance of postprocedural bleeding and one episode of post-polypectomy syndrome. Conclusion: This large, multicenter series demonstrates EMR-DC to be a safe, effective, and efficient approach to a difficult and common clinical problem: adherent and non-lifting polyps. It may offer several advantages over more expensive or invasive endoscopic techniques used for this indication. The use of EMR-DC for larger adherent polyps with adjuvant techniques such as hot avulsion or cold forceps avulsion with adjuvant snare tip soft coagulation for smaller adherent sections may represent an ideal approach.