Best endoscopic approach for large rectal adenomas remains unclear

Last Updated: 2017-08-30

By Will Boggs MD

NEW YORK (Reuters Health) - Endoscopic mucosal resection (EMR) might offer advantages over trans-anal endoscopic microsurgery (TEM) for large rectal adenomas, but noninferiority of recurrence rates with EMR could not be demonstrated in the TREND study.

Existing evidence suggests that EMR for large rectal adenomas is less effective but safer than TEM after a single intervention; however, firm recommendations cannot be made given the lack of comparative studies.

Dr. Renee M. Barendse from Academic Medical Center, Amsterdam, the Netherlands, and colleagues from 17 Dutch centers and one Belgian center compared the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas.

They conducted a noninferiority trial of 209 patients, with 176 in the final analysis. The report appears in Gut, online August 16.

At 3 months, endoscopic removal of adenoma remnants was required significantly more often after EMR (19%) than after TEM (5%). The recurrence rate was 15% after EMR and 11% after TEM, a difference that did not meet the criteria for noninferiority.

Postprocedural complications affected nonsignificantly fewer EMR patients (18%) than TEM patients (26%).

The two groups did not differ in health-related quality-of-life scores after their procedures. Overall survival was 100% after follow-up of more than 4 years.

Total costs associated with EMR were 3,003 euros (US$3,544) less than those associated with TEM, but both procedures yielded comparable quality-adjusted life-years.

"Therefore," the researchers note, "from a health economic perspective, EMR is the preferable treatment."

But "under the statistical assumptions of this study, noninferiority could not be demonstrated," they write. "However, EMR may have potential due to a tendency of lower complication rates and a better cost-effectiveness ratio."

Dr. Monica Ortenzi from Universita Politecnica delle Marche, Ancona, Italy, recently found TEM to be an important therapeutic option for rare rectal lesions. She told Reuters Health by email, "Maybe, in the future we will be able to treat rectal lesions endoscopically, but now a lot of issues have to be clarified to consider endoscopy or even TEM suitable in some cases."

"I worked in a center with a huge experience in TEM procedure before, and now (I am at) a center where endoscopic techniques are being developed and highly performed," she said. "My perspectives changed after my recent experience, and I would recommend performing EMR in patients with medium-size adenomas (3-4 cm), especially if they are unsuitable for general anesthesia."

"However, I have several concerns about this technique," Dr. Ortenzi said. "The first one is about the time required to do EMR for larger polyps. EMR can be quite demanding and may be not so well tolerated by patients; sometimes it may even require deep sedation or general anesthesia as well. However, in the case of older patients with comorbidities that can contraindicate a surgical approach, EMR could be an appealing alternative to TEM even for larger polyps."

"Another concern is about recurrence," she said. "The TREND study failed to demonstrate the noninferiority of EMR for recurrence. TEM is a (surgically) safe technique with low rates of recurrence even for polyps >5 cm. Even in terms of costs, it may be more expensive as a first approach but more manageable if you can spare another excision-avoiding recurrence. Furthermore, TEM technique evolved throughout the years, and nowadays it can be performed using instruments already supplied without purchasing specific equipment, being cheaper and more affordable."

Dr. Ortenzi added, "I was surprised by the high postprocedural complication rate observed in this study in both groups, and I believe that it can be lowered with higher experience, but both techniques are technically demanding and require a long learning curve and period of training. This is not a secondary issue, because I believe that is the main issue preventing the diffusion of both the approaches in the Western world."

Dr. Barendse did not respond to a request for comment.

SOURCE: http://bit.ly/2wnTRUe

Gut 2017.