Endoscopic mucosal ablation: a new argon plasma coagulation/injection technique to assist complete resection of recurrent, fibrotic colon polyps (with video)

Background: Incomplete piecemeal EMR of large, sessile/flat colon polyps results in polyp recurrence, with massive submucosal scarring making subsequent attempts at endoscopic resection problematic. Objective: We report our experience with a new endoscopic mucosal ablation (EMA) technique that can be used to complement the eradication of recurrent fibrotic colon polyps. Design: Single-center, retrospective case series. Setting: Tertiary-care referral academic endoscopy unit. Patients: This study involved consecutive patients referred for endoscopic excision of recurrent benign colon polyps with severe submucosal fibrosis (>30% of the entire lesion). Intervention: Application of high-power argon plasma coagulation (APC), preceded by injection of a submucosal fluid cushion (normal saline/diluted adrenaline and/or sodium hyaluronate solution) to protect the muscle layer, was performed to augment further piecemeal EMR and polyp eradication. Main Outcome Measurements: Technical safety and success, complication and recurrence rates. Results: Fourteen patients (mean age 73 years; 9 men, 5 women) with 15 recurrent colon adenomas (mean polyp size 30 mm, 9 proximal/6 distal) were included. EMA with a mean APC power setting of 55 W was applied. Complete polyp eradication was achieved in 9 of 11 patients (82%) at first or second completed follow-up. One patient needed laparoscopic colectomy because of cancer, and 1 underwent transanal endoscopic microsurgery for benign massive recurrence. The other 3 patients with small, easily treatable recurrence (<= 3 mm) were followed by 1-year-surveillance. No perforations and no postpolypectomy syndrome were reported. Limitations: Single-center, nonrandomized case series with short duration follow-up. Conclusion: EMA appears to be a safe and easily applicable technique to assist the complete eradication of recurrent fibrotic colon polyps.