Endoscopic mucosal resection (EMR) is a safe, effective, and surgery-sparing technique for removing large colorectal lesions 1 . Although piecemeal EMR is recommended for polyps > 20 mm in size, it remains a suboptimal technique for complete lesion resection, with high rates of residual polyp and recurrence rates reaching 15 % 2 . Hybrid argon plasma coagulation (hAPC) is a novel approach allowing ablation of resection margins and surface after EMR. hAPC combines waterjet injection and argon plasma coagulation (APC) in a single device. On-demand, repeatable saline cushioning without instrument exchange reduces thermal ablative insult to deep tissue structures, allowing for effective destruction of micro-remnants with reduced risk of perforation. High technical success and low recurrence rates (0 %) were shown in a pilot study using EMR in combination with hAPC 3 . A prospective international multicenter study showed that the local recurrence rate was only 2.2 % when using hAPC after EMR 4 . One recent meta-analysis found the local recurrence rate to be 3.3 % after hot EMR and margin ablation at 12-month follow-up 5 .
We present a step-by-step video tutorial demonstrating how hAPC-assisted EMR is performed while providing technical tips to achieve optimal ablation results ( Video 1 ).
Video 1 Video tutorial demonstrating how to perform hybrid argon plasma coagulation-assisted endoscopic mucosal resection in different clinical examples.
hAPC-assisted EMR is done after standard initial assessment of polyp morphology and submucosal invasion. The polyp is removed in piecemeal fashion using a combination of an electrosurgical snare, cold snare, and forceps avulsion techniques ( Fig. 1 ). Following complete resection of the entire visible polyp, the base and margins of the submucosal defect are then lifted using the waterjet function of the hAPC probe and thermal ablation is performed. EMR margin ablation is performed with combinations alternating between 25–40 W pulsed-APC and precise-APC Effect 8–10 (11–21 W), with both modes using a flow of 0.8 L/min. Vessels can be prophylactically ablated; however, the clinical benefit of this is unclear at present.
Fig. 1.
The hybrid argon plasma coagulation (hAPC)-assisted endoscopic mucosal resection (EMR) technique for removal of colon polyps. a EMR is performed. b The resection area post-EMR. c Needless waterjet injection for margin and base lifting prior to hAPC. d Thermal ablation using hAPC.
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Footnotes
Competing interests D. von Renteln has received research funding and speaker honoraria from Erbe.
Endoscopy E-Videos : https://eref.thieme.de/e-videos .
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
References
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