Endoscopic mucosal resection (EMR) is a safe and effective alternative to surgery for benign complex colorectal lesions, according to research led by UCSF gastroenterologist Tonya Kaltenbach, MD, who served on the U.S. Multi-Society Task Force on Colorectal Cancer and led the guideline development for the endoscopic removal of colorectal lesions.
“Endoscopic management should be the first-line therapy for benign complex colon lesions,” Kaltenbach said. “We can remove even large or scarred lesions with a minimally invasive outpatient procedure. We can preserve the organ and spare surgery and can do this safely and effectively all through the colonoscope.”
Significantly lower mortality rate with EMR
In their review of the available literature, the task force found that mortality rate is significantly lower with endoscopic (0.08%) compared to surgical (0.7%) resection. Specifically, a review of 6,440 patients treated with EMR found a 0.08% 30-day mortality rate associated with resection of large colorectal lesions, almost 10 times lower than the surgical resection group. In contrast, analysis of data from the 2011-2014 National Surgical Quality Improvement Program, which included 12,732 patients who had elective surgery for benign colorectal lesions, showed a 0.7% 30-day mortality rate. Another prospective study of 1,050 patients with advanced colorectal lesions treated with endoscopic resection reported no deaths.
“To have a death from something that can be managed safely endoscopically is a terrible outcome,” Kaltenbach said.
The task force guideline recommends EMR for non-polyploid or suspected serrated 10-to-19-millimeter noninvasive lesions and all lesions 20 millimeters and larger. In cases of suspected minimal or moderate risk of mucosal invasion, the guideline notes en bloc EMR or endoscopic submucosal dissection should be used if complete resection is feasible and safe.
EMR is safe and cost effective
Kaltenbach was involved in a study that found the U.S. rate of EMR use in all colonoscopies performed increased from 1.62% in 2011 to 2.48% in 2015. Despite the increase in EMR use, the rate of adverse events after EMR remained stable, confirming the safety of EMR.
EMR can also be more cost effective than surgery. Kaltenbach and other researchers published the results of a study comparing the cost effectiveness of EMR with transanal endoscopic microsurgery and transanal minimally invasive surgery in managing complex benign rectal polyps. The researchers modeled the lifetime outcomes and costs of the techniques over 50 years and found that the methods were similarly effective, but EMR had a significantly lower lifetime discounted cost than the surgical approaches.
Expanding the use of EMR
Despite the benefits of EMR, surgical resection of benign polyps is still being performed. Furthermore, there is significant regional variation in EMR use: EMR is performed in 2.4% of colonoscopies in the western United States compared to 2.0% in the southern United States. Some barriers that prevent EMR from being used more broadly include lack of training, experience and commensurate reimbursement, according to an article cowritten by Kaltenbach. Currently, providers are not compensated for learning and performing this procedure.
“Physicians need to be trained in how to perform this procedure, and insurance needs to reimburse for it,” Kaltenbach said. “Alleviating these barriers would allow patients to have more access to providers who can perform this technique and thereby optimize patient outcomes compared to surgical resection. Endoscopic treatment of benign complex colorectal lesions is curative, safe and effective.”
To learn more
UCSF Gastroenterology at Mount Zion
Phone: (415) 502-4444 | Fax: (415) 502-2249
UCSF Gastroenterology at Parnassus
Phone: (415) 502-2112 | Fax: (415) 514-3300