Cold Versus Hot Snare Endoscopic Resection of Large Nonpedunculated Colorectal Polyps: Randomized Controlled German CHRONICLE Trial.

BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing. METHODS: In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant. RESULTS: Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor both for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and high-grade dysplasia/cancer for residual adenoma (OR, 2.92). CONCLUSIONS: Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170.

Endoscopic submucosal dissection for early esophageal adenocarcinoma: low rates of metastases in mucosal cancers with poor differentiation.

BACKGROUND AND AIMS: Endoscopic resection is accepted as standard treatment for intramucosal esophageal adenocarcinoma (EAC) that is well or moderately differentiated. Poor differentiation (PD) is judged as a risk factor for lymph node metastasis (LNM), and surgery is recommended. However, the evidence for this recommendation is weak. The aim of this study was to analyze the clinical course of patients after endoscopic resection of EAC with PD. METHODS: Patients undergoing endoscopic submucosal dissection for EAC were included from 16 German centers. Inclusion criteria were PD in the resection specimen, R0 resection, and endoscopic follow-up. Primary outcome was the metastasis rate during follow-up. Analysis was performed retrospectively in a prospectively collected database. RESULTS: Twenty-five patients with PD as single risk factor (group A) and 15 patients with PD and additional risk factors (submucosal invasion and/or lymphovascular invasion) (group B) were included. The metastasis rate was was 1 of 25 (4.0%; 95% CI, .4%-17.2%) in group A and 3 of 15 (20.0%; 95% CI, 6.0%-44.4%) in group B, respectively (P = .293). The rate of EAC-associated deaths was 1 of 25 (4%; 95% CI, .4%-17.2%) versus 3 of 15 (20%; 95% CI, 6.0%-44.4%) in group B (P = .293). The overall death rate was 7 of 25 (28.0%; 95% CI, 13.5%-47.3%) versus 3 of 15 (20%; 95% CI, 6.0%-44.4%) (P = .715). Median follow-up was 30 months (interquartile range, 15-53 months). CONCLUSIONS: During long-term follow-up, the risk of metastasis is low after endoscopic resection of mucosal EAC with PD as a single risk factor. A conservative approach seems justified in this small patient group. However, the treatment strategy must be determined on an individualized basis until further prospective data are available.

Treatment of the Buried Bumper Syndrome​​​​​: A Retrospective Multicenter Study With Inclusion of 160 Cases.

BACKGROUND AND GOALS: The therapy of buried bumper syndrome (BBS) is difficult. The aim of this retrospective multicenter study was to analyze the treatment methods with focus on effectiveness and safety of endoscopic techniques. METHODS: The analysis of all therapies and a comparison of the papillotome technique (PT) and needle knife-based nonpapillotome technique (NPT) were performed. Primary endpoint was technical success in one session, secondary endpoints overall technical success, number and duration of treatment sessions, SAE, and mortality. RESULTS: The primary treatment of 160 BBS cases, diagnosed between 2003 and 2021, was NPT in 60 (37.5%), PT in 43 (26.9%), push/pull technique (PPT) in 40 (25.0%), no removal in 9 (5.6%), laparotomy in 7 (4.4%) cases, and external incision in 1 (0.6%) case. For PT and NPT rates of technical success in one session were 95.5% and 45.0% (P<0.01), rates of overall technical success 100% and 88.3% (P=0.02), and mean number and duration of treatment sessions 1.05 (±0.21) versus 1.70 (±0.91) (P<0.01) and 32.17 (±21.73) versus 98,00 (±62.28) minutes (P<0.01), respectively. No significant differences between PT and NPT were found for SAE (15.9% vs. 25.0%) and mortality (2.3% vs. 1.7%). For PPT, laparotomy and external incision rates of technical success in one session and overall technical success were 100%, rates of SAE 2.5%, 50.0%, and 0% and mortality 0%, 10.0%, and 0%. CONCLUSIONS: Endoscopic therapy of BBS is treatment of choice in most cases with removal of incomplete BB by PPT. In case of complete BB PT appears more effective than NPT.