Surgical Endoscopy

, Volume 32, Issue 6, pp 2656–2663 | Cite as

Feasibility and outcomes of underwater endoscopic mucosal resection for ≥ 10 mm colorectal polyps

  • Keith Siau
  • Sauid Ishaq
  • Sergio Cadoni
  • Toshio Kuwai
  • Abdulkani Yusuf
  • Noriko Suzuki



Underwater endoscopic mucosal resection (UEMR) is an emerging strategy for the management of colorectal polyps. We aimed to evaluate the efficacy and safety of UEMR for clinically significant (≥ 10 mm) colorectal polyps.


We performed a prospective dual-centre study of polyps ≥ 10 mm undergoing UEMR between June 2014 and March 2017. Outcomes measured comprised: (1) completeness of resection at index UEMR, (2) intraprocedural and 30-day complications, (3) rates and predictors of submucosal lift, en bloc resection, polyp/adenoma recurrence and (4) pain score. Endoscopy records were correlated with histology.


85 patients underwent UEMR of 97 polyps. Resection was endoscopically complete at index UEMR in 97.9%. The median pain score was 0 (no pain). Submucosal lift was required in 29.9% and correlated with polyp size ≥ 30 mm (p = 0.03) and clip placement (p = 0.004). En bloc resection was achieved in 45.4%, and inversely correlated with polyp size ≥ 20 mm (p < 0.001). 30-day complications (4.1%) were minor and consisted of intraprocedural bleeding (n = 2) and delayed bleeding (n = 2). 60.8% attended endoscopy post-UEMR after a median interval of 6 months, with 20.3% polyp and 13.6% adenoma recurrence. Polyp recurrence was associated with piecemeal resection (p = 0.04), recurrent polyp (p = 0.02), female sex (p = 0.01) and poor access (p = 0.005). Predictors for adenoma recurrence included female gender (p = 0.01) and difficult access (p < 0.001). Recurrence rates did not differ with polyp size, site, morphology, dysplasia status, submucosal injection, patient age, or study centre.


UEMR is an effective, safe and well tolerated option for significant colorectal polyps. Piecemeal resection, recurrent polyp, female gender, and difficult access are predictors of post-UEMR polyp recurrence.


EMR Underwater Polypectomy Outcomes 


Compliance with ethical standards


Prof. Sauid Ishaq and Drs. Keith Siau, Sergio Cadoni, Toshio Kuwai, Abdulkani Yusuf and Noriko Sukuzi have no conflicts of interest or financial ties to disclose.


  1. 1.
  2. 2.
    Zauber AG, Winawer SJ, O’Brien MJ et al (2012) Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 366:687–696CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Binmoeller KF, Weilert F, Shah J et al (2012) “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 75(5):1086–1091CrossRefPubMedGoogle Scholar
  4. 4.
    Binmoeller KF (2014) Underwater endoscopic mucosal resection. J Interv Gastroenterol 4(4):113–116CrossRefGoogle Scholar
  5. 5.
    Shenck RJ, Jahann DA, Patrie JT et al (2017) Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc. CrossRefGoogle Scholar
  6. 6.
    Hsieh YH, Binmoeller K, Leung FW (2016) Su1664 Underwater polypectomy: heat-sink effect in an experimental model. Gastrointest Endosc 83(5S):AB385CrossRefGoogle Scholar
  7. 7.
    Hafner S, Zolk K, Radaelli F et al (2015) Water infusion versus air insufflation for colonoscopy. Cochrane Database Syst Rev May26(5):CD009863Google Scholar
  8. 8.
    Amato A, Radaelli F, Spinzi G (2016) Underwater endoscopic mucosal resection: the third way for en bloc resection of colonic lesions. United European Gastroenterol J 4(4): 595–598CrossRefPubMedGoogle Scholar
  9. 9.
    Wang AY, Flynn MM, Patrie JT et al (2014) Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc 28(4):1348–1354CrossRefPubMedGoogle Scholar
  10. 10.
    Curcio G, Granata A, Ligresti D et al (2015) Underwater colorectal EMR: remodeling endoscopic mucosal resection. Gastrointest Endosc 81(5):1238–1242CrossRefPubMedGoogle Scholar
  11. 11.
    Ekkelenkamp VE, Dowler K, Valori RM et al (2013) Patient comfort and quality in colonoscopy. World J Gastroenterol 19(15):2355–2361CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Gupta S, Miskovic D, Bhandari P et al (2013) A novel method for determining the difficulty of colonoscopic polypectomy. Frontline Gastroenterol 4:244–248CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Tate DJ, Klein A, Desomer L et al (2016) 391 Predicting adenoma recurrence after colonic endoscopic mucosal resection; the Sydney EMR Recurrence Tool (SERT). Gastrointest Endosc 83(5 s):AB142CrossRefGoogle Scholar
  14. 14.
    Wang X, Luo H, Xiang Y et al (2015) Left-colon water exchange preserves the benefits of whole colon water exchange at reduced cecal intubation time conferring significant advantage in diagnostic colonoscopy - a prospective, randomized controlled trial. Scand J Gastroenterol 50(7):916 – 23CrossRefPubMedGoogle Scholar
  15. 15.
    Binmoeller KF, Hamerski CM, Shah JN et al (2015) Attempted underwater en bloc resection for large (2–4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc 81(3):713–718CrossRefPubMedGoogle Scholar
  16. 16.
    Uedo N, Nemeth A, Johansson GW et al (2015) Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy 47:172–174CrossRefPubMedGoogle Scholar
  17. 17.
    Burgess NG, Metz AJ, Williams SJ et al (2014) Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 12:651–661CrossRefPubMedGoogle Scholar
  18. 18.
    Hassan C, Repici A, Sharma P et al (2016) Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 65:806–820CrossRefPubMedGoogle Scholar
  19. 19.
    Albéniz E, Fraile M, Ibáñez B et al (2016) A scoring system to determine risk of delayed bleeding after endoscopic mucosal resection of large colorectal lesions. Clin Gastroenterol Hepatol 14(8): 1140–1147CrossRefPubMedGoogle Scholar
  20. 20.
    Ponugoti PL, Rex DK (2016) Perforation during underwater EMR. Gastrointest Endosc 84(3):543–544CrossRefPubMedGoogle Scholar
  21. 21.
    Viel JF, Studer JM, Ottignon Y et al (2012) Predictors of colorectal polyp recurrence after the first polypectomy in private practice settings: a cohort study. PLoS ONE 7(12):e50990CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Kim HG, Thosani N, Banerjee S et al (2014) Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 80(6):1094–1102CrossRefPubMedGoogle Scholar
  23. 23.
    De Ceglie A, Hassan C, Mangiavillano B et al (2016) Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: a systematic review. Crit Rev Oncol/Hematol 104:138–155CrossRefGoogle Scholar
  24. 24.
    Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T et al (2015) Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 47:829–854CrossRefPubMedGoogle Scholar
  25. 25.
    Burgess NG, Bahin FF, Bourke MJ (2015) Colonic polypectomy (with videos). Gastrointest Endosc 81:813–815CrossRefPubMedGoogle Scholar
  26. 26.
    Tanaka S, Kashida H, Saito Y et al (2015) JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Digestive Endosc 27:417–434CrossRefGoogle Scholar
  27. 27.
    Backes Y, Moons LMG, van Bergeijk JD et al (2016) Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial. BMC Gastroenterol 16(1):56CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Keith Siau
    • 1
    • 2
  • Sauid Ishaq
    • 2
    • 3
  • Sergio Cadoni
    • 4
  • Toshio Kuwai
    • 5
  • Abdulkani Yusuf
    • 6
  • Noriko Suzuki
    • 6
  1. 1.Joint Advisory Group on Gastrointestinal EndoscopyRoyal College of PhysiciansLondonUK
  2. 2.Department of GastroenterologyDudley Group Hospitals NHS Foundation TrustDudleyUK
  3. 3.Department of MedicineBirmingham City UniversityBirminghamUK
  4. 4.Digestive Endoscopy UnitCTO HospitalIglesiasItaly
  5. 5.Department of Gastroenterology, National Hospital OrganizationKure Medical Centre and Chugoku Cancer CentreKureJapan
  6. 6.Wolfson Unit for EndoscopySt Mark’s HospitalLondonUK

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