title: Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos).
abstract: OBJECTIVE
  EMR is used widely for treatment of nonpedunculated colorectal adenomas ≥ 2 cm. Recurrence at the resection site occurs in 10% to 30% of cases.
  
  
  METHODS
  Records of consecutive patients referred for endoscopic resection over a 4-year period were reviewed retrospectively. In the first part of the study period, our routine practice was to use argon plasma coagulation (APC) to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. In the second part of the study period, we changed our practice to use avulsion to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. We analyzed the effect of this change in practice on recurrence rates after EMR.
  
  
  RESULTS
  Two hundred twenty-three resected lesions were analyzed. Fifty-nine (26%) were treated with en-bloc EMR, 55 (25%) by piecemeal EMR with complete snare removal of all visible neoplasia, 63 (28%) by piecemeal EMR with APC of visible residual neoplasia, and 46 (21%) by piecemeal EMR with avulsion of visible residual neoplasia. There was no significant difference in adverse event rates among the 4 groups. The recurrence rates on follow-up colonoscopy were 4.2%, 3.0%, 59.3%, and 10.3%, respectively. The recurrence rate for patients treated with avulsion was significantly lower than for those treated with APC (odds ratio, .079; P < .001). Multivariate analysis demonstrated that use of avulsion instead of APC was a significant predictor of no recurrence.
  
  
  CONCLUSIONS
  After exhaustive attempts at snare resection during EMR, avulsion is superior to APC for treatment of residual visible neoplasia. Compared with APC, avulsion significantly decreases the recurrence rate without significantly increasing the risk of the procedure.
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Ian
authors.initials: I
authors.lastname: Holmes
authors.affiliation: Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, South Korea.
authors.forename: Hyun Gun
authors.initials: HG
authors.lastname: Kim
authors.affiliation: Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
authors.forename: Dong-Hoon
authors.initials: DH
authors.lastname: Yang
authors.affiliation: Department of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA.
authors.forename: Shai
authors.initials: S
authors.lastname: Friedland
mesh_terms: D000236:Adenoma / Q000601:surgery*; D000368:Aged; D057908:Argon Plasma Coagulation; D003111:Colonic Polyps / Q000601:surgery*; D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000601:surgery*; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000000981:diagnostic imaging*; D018365:Neoplasm, Residual; D012189:Retrospective Studies