Snare Tip Soft Coagulation vs Argon Plasma Coagulation vs No Margin Treatment After Large Nonpedunculated Colorectal Polyp Resection: a Randomized Trial.

BACKGROUND & AIMS: Thermal treatment of the defect margin after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions reduces the recurrence rate. Both snare tip soft coagulation (STSC) and argon plasma coagulation (APC) have been used for thermal margin treatment, but there are few data directly comparing STSC with APC for this indication. METHODS: We performed a randomized 3-arm trial in 9 US centers comparing STSC with APC with no margin treatment (control) of defects after EMR of colorectal nonpedunculated lesions ≥15 mm. The primary end point was the presence of residual lesion at first follow-up. RESULTS: There were 384 patients and 414 lesions randomized, and 308 patients (80.2%) with 328 lesions completed ≥1 follow-up. The proportion of lesions with residual polyp at first follow-up was 4.6% with STSC, 9.3% with APC, and 21.4% with control subjects (no margin treatment). The odds of residual polyp at first follow-up were lower for STSC and APC when compared with control subjects (P = .001 and P = .01, respectively). The difference in odds was not significant between STSC and APC. STSC took less time to apply than APC (median, 3.35 vs 4.08 minutes; P = .019). Adverse event rates were low, with no difference between arms. CONCLUSIONS: In a randomized trial STSC and APC were each superior to no thermal margin treatment after EMR. STSC was faster to apply than APC. Because STSC also results in lower cost and plastic waste than APC (APC requires an additional device), our study supports STSC as the preferred thermal margin treatment after colorectal EMR. (Clinicaltrials.gov, Number NCT03654209.).

Safety of first surveillance colonoscopy at 12 months after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal lesions.

BACKGROUND AND AIMS: After piecemeal endoscopic mucosal resection (pEMR) of nonpedunculated colorectal lesions ≥ 20 mm, guidelines recommend first endoscopic surveillance at 6 months. However, initial surveillance at 12 months may be adequate for selected low-risk lesions, and could save the cost, risk and inconvenience of one surveillance examination. METHODS: We retrospectively examined a prospectively collected database of all colorectal lesions referred to our center for endoscopic resection between August 2019 and April 2023. We report recurrence rates of colorectal lesions ≥ 20 mm removed by pEMR who were assigned to 6-month first surveillance or assigned to 12-month first surveillance (or assigned to 6-month but did not return until after 10 months). RESULTS: There were 561 nonpedunculated lesions ≥ 20 mm that underwent first follow-up, including 490 lesions in 443 patients assigned to 6-month, and 71 lesions in 65 patients assigned to 12-month surveillance. Lesions assigned to 12-month surveillance were smaller (mean size 25.9 ± 6.1mm vs. 37.0 ± 17.4mm), more likely serrated (63.4% vs. 9.6%), and more often removed by cold pEMR (74.6% vs 20.4%). Twenty-nine lesions in 24 patients assigned 6-month surveillance presented after 10 months and their recurrence data were included in the group assigned 12-month surveillance. Overall recurrence rates at 6 months and 12 months were 10.0% (46/461) and 9.0% (9/100), respectively. Mean recurrence sizes at 6 and 12 months were 10.9 ± 6.2mm and 4.2 ± 1.9mm, respectively. One patient in the 6-month surveillance group had cancer at the pEMR site, but no other recurrences at 6 or 12 months had either cancer or high-grade dysplasia. CONCLUSION: Twelve-month surveillance appears acceptable for selected colorectal lesions ≥ 20 mm removed by pEMR. A randomized trial comparing initial 6-month to 12-month surveillance is warranted for selected lesions.

One-device colonoscopy: feasibility, cost savings, and plastic waste reduction by procedure indication, when performed by a high detecting colonoscopist.

BACKGROUND: Cold forceps and snares are each effective for removing polyps of 1-3 mm, while snares are more effective for polyps of 4-10 mm in size. If, in the same patient, polyps of 1-3 mm are removed with forceps and those of 4-10 mm with snares, two devices are used. If cold snares are used to resect all lesions of 1-10 mm (one-device colonoscopy), there is a potential for lower costs and less plastic waste. METHODS: A single high detecting colonoscopist prospectively measured the feasibility of cold snaring all colorectal lesions of ≤10 mm in size, along with the associated costs and plastic waste reduction. RESULTS: 677 consecutive lower gastrointestinal endoscopies (not for inflammatory bowel disease) were assessed. Of 1430 lesions of 1-3 mm and 1685 lesions of 4-10 mm in size, 1428 (99.9%, 95%CI 99.5%-100%) and 1674 (99.3%, 95%CI 98.8%-99.7%), respectively, were successfully resected using cold snaring. Among 379 screening and surveillance patients, universal cold snaring of lesions ≤10 mm saved 35 and 47 cold forceps per 100 screening and surveillance patients, respectively. CONCLUSION: Cold snare resection of all lesions ≤10 mm (one-device colonoscopy) was feasible, and reduced costs and plastic waste.

Impact of margin thermal treatment after EMR of giant (≥40 mm) colorectal lateral spreading lesions.

BACKGROUND AND AIMS: Increasing lesion size is a risk factor for recurrence after piecemeal EMR (pEMR). Snare-tip soft coagulation (STSC) treatment of the normal-appearing margin after pEMR of lesions ≥ 20 mm has been shown to reduce recurrence rates by 75% to 80%. We sought to evaluate the impact of STSC on giant (≥ 40 mm) lateral spreading lesions treated by pEMR. We describe the relative risk and absolute risks of recurrence with and without STSC margin treatment after EMR of ≥ 40-mm lesions. METHODS: We performed a retrospective evaluation of a prospectively collected database on large lesions describing lesion size, location, and methods of resection. We excluded lesions < 40 mm in maximum dimension, those that did not undergo follow-up care at our center, and those in which argon plasma coagulation was used for either ablative treatment of residual polyp or margin treatment. Propensity score analysis was used to account for potential differences between patients treated with and without STSC. RESULTS: There were 68 lesions ≥ 40 mm removed by pEMR without STSC treatment and 133 removed and treated with STSC. There were no differences between groups in demographics, polyp size, location, histologic features, and mean follow-up time. The recurrence rate in the no-treatment group was 35% versus 9% with STSC (P < .00001 by direct comparison and P = .008 by using the propensity score analysis). CONCLUSION: STSC treatment after pEMR of large lateral spreading lesions in the colorectum reduced recurrences by 75%. However, the absolute recurrence rate of 9% remained clinically significant in the STSC-treated group. Short-term follow-up care after STSC of lesions ≥ 40 mm is still warranted, and additional study of technical factors that eliminate recurrence after pEMR of giant lateral spreading lesions is warranted.

Characterization of endoscopic features and histology of a distinct mucosal transition zone on the ileocecal valve (with video).

BACKGROUND AND AIMS: We have endoscopically encountered a zone of transitional mucosa between the colonic and ileal mucosa located in a 3- to 10-mm-wide ring around the ileocecal valve (ICV) orifice. We aimed to describe the features of the ICV transitional zone mucosa. METHODS: We used videos and photographs from normal ICVs and biopsy samples from normal colonic mucosa, transitional zone mucosa, and normal ileal mucosa to characterize the endoscopic and histologic features of the ICV transitional zone mucosa. RESULTS: The ICV transitional zone is identifiable on every ICV without a circumferential adenoma or inflammation that obliterates the zone. The zone is characterized endoscopically by an absence of villi, which distinguishes it from the ileal mucosa, but the pits are more tubular and with more prominent blood vessels compared with normal colonic mucosa. Histologically, the villi of the transitional zone are blunted, and the amount of lymphoid tissue is intermediate between the colonic mucosa and ileal mucosa. CONCLUSIONS: This is the first description of the normal transitional zone of mucosa on the ICV. This zone has unique endoscopic features that should be recognized by colonoscopists and that can potentially create difficulty in identifying the margins of adenomas located on the ICV.

Prevalence of synchronous neoplasia in patients with large pedunculated colorectal polyps.

BACKGROUND: Large (≥ 20 mm) nonpedunculated colorectal lesions have high rates of synchronous neoplasia and advanced neoplasia. Synchronous neoplasia prevalence in patients with large pedunculated lesions is uncertain. We describe synchronous neoplasia in patients with large pedunculated colorectal polyps, using a cohort of patients with large nonpedunculated lesions as controls. METHODS: This study was a retrospective assessment of a prospectively recorded database listing synchronous findings in patients with ≥ 20 mm colorectal lesions referred to a tertiary center for endoscopic resection. RESULTS: At least one synchronous precancerous lesion was identified in 66/78 patients with large pedunculated index lesions (84.6 %, 95 %CI 74.9-91.1) and 726/814 patients with large nonpedunculated index lesions (89.2 %, 95 %CI 87.1-91.3). Patients with a large pedunculated index lesion had mean of 4.8 synchronous conventional adenomas, 56.4 % had ≥ 1 synchronous high risk lesion (advanced adenoma or advanced serrated lesion), 48.7 % had ≥ 1 synchronous advanced conventional adenoma, and 19.2 % had a synchronous neoplastic lesion ≥ 20 mm. Compared with patients with nonpedunculated index lesions, patients with large pedunculated index lesions had comparable rates of synchronous polyps, adenomas, and sessile serrated lesions, and higher rates of synchronous adenomas with villous elements (15.6 % [95 %CI 13.3-18.3] vs. 26.9 % [95 %CI 18.3-37.7]; P = 0.01) and synchronous pedunculated polyps (9.5 % [95 %CI 7.6-11.7] vs. 33.3 % [95 %CI 23.8-44.4]; P < 0.001). CONCLUSION: In patients with large (≥ 20 mm) pedunculated colorectal lesions, rates of synchronous neoplasia and advanced synchronous neoplasia were high and comparable to or higher than rates of synchronous neoplasia in patients with large nonpedunculated colorectal lesions.

2021 Patient Perceptions Regarding Colonoscopy Experience.

GOAL: We sought to document patient perceptions in 2021 regarding colonoscopy experience and potential deterrents to repeat colonoscopy. BACKGROUND AND AIM: Bowel preparation has been previously considered by patients to be the worst part of a colonoscopy. MATERIALS AND METHODS: We conducted a prospective survey of consecutive patients age 18 years and older who had just completed colonoscopy at 2 outpatient endoscopy centers at a tertiary academic hospital. The short survey was conducted in the recovery area. The main outcome measure was patient perceptions of the worst part of their colonoscopy experience and which factor would most deter them from a future colonoscopy. RESULTS: Four hundred patients completed the survey of 405 approached. Average patient age was 64 years, and 48% were women. Seventy-five percent of patients used low-volume preparations. Bowel preparation was considered the worst part of colonoscopy by 71% of patients. Women were more likely to choose laxatives as the worst part of a colonoscopy. Bowel preparation was chosen most often (55%) as the most likely deterrent to a future colonoscopy. There were minimal differences in responses between those receiving low-volume versus high-volume (4 L) preparations. CONCLUSION: Bowel preparation remains the worst part of the colonoscopy experience for patients, and the most likely deterrent to future colonoscopy.

Impact of including epinephrine in the submucosal injectate for colorectal EMR on postprocedural pain: a randomized controlled trial.

BACKGROUND AND AIMS: EMR is first-line therapy for colorectal laterally spreading lesions. Some colonoscopists include epinephrine in the submucosal injectate, which we observed increased postprocedure discomfort. Our aim was to determine whether inclusion of epinephrine in the submucosal injectate increases postprocedure pain after EMR. METHODS: We performed a randomized, controlled, double-blind trial comparing epinephrine in submucosal injectate versus injectate alone for abdominal pain at 30 and 60 minutes after EMR. RESULTS: Mean polyp diameter in both arms was >40 mm. There were no differences in procedure times or amounts of fluid injected. Mean pain was higher on a visual analog scale in the epinephrine group at 30 minutes (47 vs 14, P = .022) and at 60 minutes (44 vs 13, P = .035). Recovery room stay was longer in the epinephrine group (68 vs 53 minutes, P = .034). CONCLUSIONS: Epinephrine in the submucosal injectate for EMR increases postprocedural pain, which could cause diagnostic confusion and prolong observation time in the recovery area. (Clinical trial registration number: NCT04065451.).

Assessment of submucosal distortion and mass effect seen at follow-up after colorectal EMR with ORISE (with video).

BACKGROUND AND AIMS: ORISE (Boston Scientific, Marlborough, Mass, USA) is a viscous gel used for submucosal injection. We noted anecdotally that ORISE is associated with submucosal distortion of EMR scars at follow-up. METHODS: We blindly reviewed photographs of 30 consecutive EMR scars at follow-up after resections using ORISE and 30 resections using other agents. Distortion was scored on a scale of 0 (no submucosal distortion) to 5 (overt submucosal distortion). RESULTS: The median submucosal distortion score at follow-up in ORISE cases was 3 (range, 0-5) versus 0 (range, 0-2) with other fluids (P < .001, Mann-Whitney U test) by 1 reviewer and 3 (range, 0-5) versus 2 (range, 0-5), respectively, by a second reviewer (P = .018). The kappa value for agreement in the submucosal distortion scores between the 2 experts was .148 for all photographs and .214 for the ORISE cases (overall minimal agreement). CONCLUSIONS: ORISE can cause submucosal distortion in the region of EMR scars when they are viewed at follow-up. Such distortions must not be mistaken for submucosal tumor growth.

Implications of stable or increasing adenoma detection rate on the need for continuous measurement.

BACKGROUND AND AIMS: Measurement of the adenoma detection rate (ADR) is resource intensive, and the benefit of continuous measurement for colonoscopists with high ADR is unclear. We examined the ADR trends at our center to determine whether continuous measurement for consistently high ADR is warranted. METHODS: Among colonoscopies performed between January 1999 and November 2019 at a tertiary center, we analyzed data from colonoscopists performing at least 50 screening colonoscopies annually for 5 consecutive years. ADR trends for individual colonoscopists were examined using Joinpoint regression models. RESULTS: Eleven colonoscopists performed screening colonoscopies on 14,047 patients, and 5912 among them had at least 1 conventional adenoma removed (42.0%). Of 25,829 polyps, 13,585 (52.6%) were conventional adenomas or adenocarcinomas and contributed to ADR calculation. All but 1 colonoscopist included met the recommended minimum threshold ADR of 25% continuously over the study period. Of the 11 colonoscopists, 5 had an increase in their ADR and the remaining 6 had stable ADRs over the study period. CONCLUSIONS: For colonoscopists consistently performing above the minimum threshold, diversion of resources toward improvement of quality measures other than ADR is justified.

Yield of a second right colon examination during colonoscopy after a first examination using a mucosal exposure device.

BACKGROUND AND AIMS: Double right colon examination during colonoscopy has been advocated to reduce the risk of interval cancer in the right colon. Whether 2 examinations are necessary when the first examination is performed with a mucosal exposure device is uncertain. We documented the rates of missed adenomas, sessile serrated lesions, and hyperplastic polyps after an initial right colon examination by a high-level detector using a mucosal exposure device. METHODS: At a single tertiary hospital outpatient practice, we prospectively collected data on the yield of a second examination of the right colon after an initial examination by a single high-detecting colonoscopist using a mucosal exposure device. RESULTS: During the study period, 1331 eligible consecutive patients underwent colonoscopy. Right colon adenoma, sessile serrated lesion, and hyperplastic polyp miss rates were 15.8%, 14.1%, and 16.7%, respectively. Four percent of patients had adenomas detected in the right colon only with a second examination. CONCLUSIONS: A second examination of the right colon is warranted, even when using a distal mucosal exposure device to perform colonoscopy.

Cold versus hot snare resection with or without submucosal injection of 6- to 15-mm colorectal polyps: a randomized controlled trial.

BACKGROUND AND AIMS: Cold snare resection of colorectal lesions has been found to be safe and effective for an expanding set of colorectal lesions. In this study, we sought to understand the efficacy of simple cold snare resection and cold EMR versus hot snare resection and hot EMR for colorectal lesions 6 to 15 mm in size. METHODS: At 3 U.S. centers, 235 patients with 286 colorectal lesions 6 to 15 mm in size were randomized to cold snaring, cold EMR, hot snaring, or hot EMR for nonpedunculated colorectal lesions 6 to 15 mm in size. The primary outcome was complete resection determined by 4 biopsy samples from the defect margin and 1 biopsy sample from the center of the resection defect. RESULTS: The overall incomplete resection rate was 2.4% (95% confidence interval [CI], .8%-7.5%). All 7 incompletely removed polyps were 10 to 15 mm in size and removed by hot EMR (n = 4, 6.2%), hot snare (n = 2, 2.2%), or cold EMR (n = 1, 1.8%). Cold snaring had no incomplete resections, required less procedural time than the other methods, and was not associated with serious adverse events. CONCLUSIONS: Cold snaring is a dominant resection technique for nonpedunculated colorectal lesions 6 to 15 mm in size. (Clinical trial registration number: NCT03462706.).

Impact of Expanding Screening Colonoscopy Interval on Providers Choice of Prescribing Colonoscopy for Colorectal Cancer Screening.

GOALS: We investigated if increasing the colonoscopy screening interval from 10 to 15 years would increase provider preferences for colonoscopy as a screening test. We further examined whether having colonoscopy performed at a 15-year interval by an endoscopist with a high adenoma detection rate would influence preferences. BACKGROUND: Colonoscopy is recommended every 10 years in average risk individuals without polyps for colorectal cancer (CRC) screening. The use of a 15-year interval offers substantial protection, increases cost-effectiveness, and might make colonoscopy more attractive to patients and health care providers who order CRC screening tests. STUDY: An anonymous online survey of health care providers across a health care system that serves a single US state and encompasses both academic and community physicians was conducted. Physicians and nurse practitioners in family medicine, obstetrics-gynecology, and internal medicine were included. Providers were asked to indicate their preference for CRC screening tests as a proportion of tests they prescribe among 5 common screening tools. Responses were compared for current colonoscopy screening intervals and if the screening intervals are increased to 15 years. RESULTS: One hundred and twelve (34%) responded of 326 providers. Colonoscopy was the most frequently ordered test for CRC screening. Increasing screening interval from 10 to 15 years increased the choice of colonoscopy from 75.2% to 78.6% ( P =0.003). CONCLUSIONS: Expanding colonoscopy screening interval to 15 years could produce an increase in physicians and nurse practitioners choice of using colonoscopy for CRC screening, but the clinical impact appears minor. Additional surveys of patients and providers are needed.

Impact of water filling on terminal ileum intubation with a distal-tip mucosal exposure device.

BACKGROUND AND AIMS: Endocuff improves detection at colonoscopy but seems to impede terminal ileal (TI) intubation. We assessed the impact of Endocuff Vision (EV) on TI intubation using adult or pediatric colonoscopes and evaluated whether filling the cecum with gas versus water affected the impact of EV on TI intubation. METHODS: Using a prospectively recorded quality control database, we explored the impact of EV on TI intubation in ≤1 minute. We used adult and pediatric colonoscopes and tested the effect of filling the cecum with gas versus water. If the initial attempt failed, then the alternative (water vs gas) was tried as a rescue method. RESULTS: TI intubation in ≤1 minute occurred in 91% of colonoscopies without EV versus 65% with EV, but the use of the pediatric colonoscope with EV had a higher success rate for TI intubation in ≤1 minute compared with the adult colonoscope with EV (73% vs 57%, P = .043). TI intubation in ≤1 minute was more successful with EV when the cecum was filled with water rather than gas (74% vs 56%, P = .019), but the benefit of water filling was limited to the adult colonoscope with EV. When EV was in place, water filling was more successful as a rescue method of TI intubation (58% vs 21%, P = .011). CONCLUSIONS: EV adversely affects TI intubation, particularly for adult colonoscopes. Water filling of the cecum mitigates the impact of EV on TI intubation with adult colonoscopes.

Impact of a ring-fitted cap on insertion time and adenoma detection: a randomized controlled trial.

BACKGROUND AND AIMS: Devices for flattening colon folds can improve polyp detection at colonoscopy. However, there are few data on the endoscopic ring-fitted cap (EndoRings; EndoAid, Caesarea, Israel). We sought to compare adenoma detection with EndoRings with that of standard high-definition colonoscopy. METHODS: This was a single-center, randomized controlled trial of 562 patients (284 randomized to EndoRings and 278 to standard colonoscopy) at 2 outpatient endoscopy units in the Indiana University Hospital system. Adenoma detection was the primary outcome measured as adenoma detection rate (ADR) and adenomas per colonoscopy (APC). We also compared sessile serrated polyp detection rate, insertion times, withdrawal times, and ease of passage through the sigmoid colon. RESULTS: EndoRings was superior to standard colonoscopy in terms of APC (1.46 vs 1.06, P = .025), but there were no statistically significant differences in ADR or sessile serrated polyp detection rate. Mean withdrawal time (in patients with no polyps) was shorter and insertion time (all patients) was longer in the EndoRings arm by 1.8 minutes and 0.75 minutes, respectively. One provider had significantly higher detection with Endo-Rings and contributed substantially to the overall results. CONCLUSIONS: EndoRings can increase adenoma detection without a significant increase in procedure time, but the effect varies between operators. The use of EndoRings slows colonoscope insertion. (Clinical trial registration number: NCT03418662.).

Room temperature water infusion during colonoscopy insertion induces rectosigmoid colon mucus production.

BACKGROUND: Water filling during colonoscopy improves several colonoscopy outcomes. We evaluated an anecdotal observation that room temperature water filling during colonoscope insertion results in mucus production in the left colon, which may impair mucosal visualization during withdrawal. METHODS: We performed 55 colonoscopies with either water or saline filling during insertion, and video recorded the examinations. Three blinded observers scored the amount of mucus visible on the video recordings. RESULTS: 29 patients had water filling and 26 patients had saline filling during insertion. Demographic features, procedure indications, volume of infused fluid, and insertion time to the cecum were similar in the two groups. All three blinded observers rated the mucus as greater after water filling than after saline (median 3 out of 5 vs. 1 out of 5; P < 0.001), with a kappa value for interobserver agreement of 0.364 (P < 0.001). CONCLUSION: Room temperature water filling is associated with mucus production by the rectosigmoid colon, requiring additional cleansing during withdrawal.

A comparison of 2 distal attachment mucosal exposure devices: a noninferiority randomized controlled trial.

BACKGROUND AND AIMS: Endocuff (Arc Medical Design, Leeds, UK) and Endocuff Vision (Arc Medical Design, Leeds, UK) are effective mucosal exposure devices for improving polyp detection during colonoscopy. AmplifEYE (Medivators Inc, Minneapolis, Minn, USA) is a device that appears similar to the Endocuff devices but has received minimal clinical testing. METHODS: We performed a randomized controlled clinical trial using a noninferiority design to compare Endocuff Vision with AmplifEYE. RESULTS: The primary endpoint of adenomas per colonoscopy was similar in AmplifEYE at 1.63 (standard deviation 2.83) versus 1.51 (2.29) with Endocuff Vision (P = .535). The 95% lower confidence limit was 0.88 for ratio of means, establishing noninferiority of AmplifEYE (P = .008). There was no difference between the arms for mean insertion time, and mean inspection time (withdrawal time minus polypectomy time and time for washing and suctioning) was shorter with AmplifEYE (6.8 minutes vs 6.9 minutes, P = .042). CONCLUSIONS: AmplifEYE is noninferior to Endocuff Vision for adenoma detection. The decision on which device to use can be based on cost. Additional comparisons of AmplifEYE with Endocuff by other investigators are warranted. (Clinical trial registration number: NCT03560128.).

SIC-8000 versus hetastarch as a submucosal injection fluid for EMR: a randomized controlled trial.

BACKGROUND AND AIMS: Viscous solutions provide a superior submucosal cushion for EMR. SIC-8000 (Eleview; Aries Pharmaceuticals, La Jolla, Calif) is a commercially available U.S. Food and Drug Administration-approved solution, but hetastarch is also advocated. We performed a randomized trial comparing SIC-8000 with hetastarch as submucosal injection agents for colorectal EMR. METHODS: This was a single-center, double-blinded, randomized controlled trial performed at a tertiary referral center. Patients were referred to our center with flat or sessile lesions measuring ≥15 mm in size. The primary outcome measures were the Sydney resection quotient (SRQ) and the rate of en bloc resections. Secondary outcomes were total volume needed for a sufficient lift, number of resected pieces, and adverse events. RESULTS: There were 158 patients with 159 adenomas (SIC-8000, 84; hetastarch, 75) and 57 serrated lesions (SIC-8000, 30; hetastarch, 27). SRQ was significantly better in the SIC-8000 group compared with hetastarch group (9.3 vs 8.1, P = .001). There was no difference in the proportion of lesions with en bloc resections. The total volume of injectate was significantly lower with SIC-8000 (14.8 mL vs 20.6 mL, P = .038). CONCLUSIONS: SIC-8000 is superior to hetastarch for use during EMR in terms of SRQ and total volume needed, although the absolute differences were small. (Clinical trial registration number: NCT03350217.).