JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Factors influencing interruption of colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Although colorectal endoscopic submucosal dissection (ESD) has become a standardized procedure worldwide, the difficulty of the procedure is well known. However, there have been no studies assessing the causes of treatment interruption. The present study aimed to evaluate the factors involved in the interruption of colorectal ESD.

METHODS

We retrospectively analyzed 1116 consecutive superficial colorectal neoplasms of 1012 patients who were treated with ESD between August 2008 and September 2018. The clinicopathological characteristics and treatment outcomes were analyzed.

RESULTS

Interrupted ESD was reported in 14 lesions (1.3%) of the total study population. Univariate analysis of clinical characteristics indicated that age, 0-I macroscopic-type tumor, and tumor location on the left side colon were risk factors for interruption. Multivariate analysis revealed that 0-I macroscopic-type tumor was the sole preoperative independent risk factor for interruption. Univariate analysis revealed that the presence of muscle-retracting sign (MRS), deep submucosal tumor invasion, and intermediate invasive growth pattern represented the etiology of interruption. Multivariate analysis indicated that MRS can be a sole key sign for the interruption. Additionally, the resectability and curability of 0-I type tumors were significantly inferior to those of predominantly lateral spreading tumors. Observations of 0-I macroscopic-type tumors, MRS, and submucosal deep invasion were significantly more frequent in interrupted cases. Conventional endoscopic images without magnification endoscopy were more associated with interruption than irregular surfaces or Vi pit patterns in cases with 0-I type tumors.

CONCLUSION

ESD of 0-I type tumors is highly disruptive, and undiagnosable submucosal infiltration can reduce the curability.

Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD)

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation.

AREAS COVERED

This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing.

EXPERT OPINION

As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions.

The Endoscopy Patient as a Vector and Victim

Patient and procedural factors can increase the risk of infectious adverse events during endoscopy. Prophylactic antibiotic use must be judicious and individualized in the era of antibiotic resistance. New and emerging procedures require high-quality studies to elucidate appropriate risk profiles.

Endoscopic submucosal dissection in the treatment of patients with early colorectal carcinoma and precancerous lesions

BACKGROUND

Our study aims to explore the indications and clinical efficacy of endoscopic submucosal dissection (ESD) on the early colorectal carcinoma and precancerous lesions.

METHODS

The clinical data of 29 patients with early colorectal carcinoma and precancerous lesions who were treated with ESD at Nantong First People's Hospital between January 2018 and December 2019 were collected. Then the endoscopic morphology, postoperative pathological classification, tumor resection rate, postoperative complications, and follow-up outcomes were analyzed.

RESULTS

Colorectal carcinoma lesions were distributed in the left colon, accounting for 89.6%. There were 14 cases (48.3%) with protuberant endoscopic tumors, accounting for the highest proportion, while 2 cases (6.9%) of the flat tumors, accounting for the lowest proportion. The average operation time for ESD was 123 minutes, and en-bloc resection was 100% while the curative resection rate was 89.6%. There were 3 cases (10.3%) with delayed hemorrhage after ESD, and 1 case with persistent hemorrhage during the operation was transferred to surgical treatment. No cases with infection or perforation after ESD. For postoperative pathological classification, villous-tubular adenoma with low-grade epithelioma accounted for 31%; tubular adenoma with high-grade epithelioma only accounted for 3.4%. There was no recurrence in the follow-up for 1-20 months.

CONCLUSIONS

Control of surgical indications strictly, improvement of operation skills, attention to postoperative pathological feedback, and close follow-up are necessary guarantees to improve the clinical effectiveness of ESD.

Predicting and managing complications following colonoscopy: risk factors and management of advanced interventional endoscopy with a focus on colorectal ESD

INTRODUCTION

Colorectal endoscopic submucosal dissection (ESD) has been introduced widely in Western and Asian countries. The management of the perforation during ESD is crucial.

AREAS COVERED

The rate of intraprocedural perforation, risk factors, prevention, and management of perforation during ESD and EMR were discussed in this review. The perforation rate in ESD and EMR depending on the lesion size is also discussed.

EXPERT OPINION

The knowledge regarding the risk factor and techniques to manage perforation is important during colorectal ESD and EMR. The development of novel suturing techniques devices is key for colorectal ESD in the future.

DNA mismatch repair is not disrupted in stage 0 colorectal cancer resected using endoscopic submucosal dissection

The frequency of deficient mismatch repair (dMMR) or microsatellite instability-high colorectal cancer (CRC) is estimated to be ~15% of all patients with CRC; however, the patients reported are limited to surgical cases, and the frequency of patients exhibiting stage 0 disease is not considered, despite the currently increasing use of endoscopic techniques to cure a number of these patients. In the present study, the DNA MMR status for stage 0 patients with CRC treated using endoscopic submucosal dissection or endoscopic mucosal resection was analyzed via immunohistochemical staining of four types of proteins, namely MutL homolog 1 (MLH1), MutS homolog 2 (MSH2), MSH6 and PMS1 homolog 2 MMR system component, in adenocarcinoma specimens. Notably, none of the endoscopically resected specimens exhibited dMMR among the 41 patients diagnosed with stage 0 CRC. Since tumors harboring dMMR progress more rapidly than tumors with chromosomal instability, the present results highlight the importance of tumor resection during very early phases that exist before the promoter region of MLH1 becomes hypermethylated, resulting in a loss of DNA MMR function.

Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA

Endoscopic submucosal dissection (ESD) is a rigorous and technically sophisticated method for removal of lesions within the gastrointestinal tract. Despite having advantages of en-bloc resection of lesions, regardless of size, and widespread use in Japan and Asia, ESD has not become widely adopted in the USA for a variety of reasons. Based upon Japanese education and the master-apprentice model, modification to the education system and additional techniques designed to facilitate broader adoption are required for trainees in the USA. This article will review the current state of education and training for ESD in the USA.

A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study

BACKGROUND

This study aimed to demonstrate the feasibility of endoscopic hand-suturing (EHS) and attainability of sustained closure after colorectal endoscopic submucosal dissection (ESD).

METHODS

EHS was defined as uninterrupted endoscopic suturing of the mucosal defect after colorectal ESD using an absorbable barbed suture and a through-the-scope needle holder. Following individual EHS training using an ex vivo porcine colonic model, two experienced endoscopists performed EHS. Repeat colonoscopy was performed on the third or fourth day after ESD to examine the EHS site. The primary end point was the complete EHS closure rate, and secondary end points were sustained closure and post-ESD bleeding rates.

RESULTS

11 lesions were included. Median size of the mucosal defect was 38 mm (range 25 - 55 mm) and the lesion characteristics were as follows: lower rectum/upper rectum/ascending colon/cecum = 3/3/2/3, and 0-IIa/0-Is + IIa/others = 5/4/2. EHS was not attempted in two patients owing to difficulty in colonoscope reinsertion after ESD and intraoperative perforation, respectively. EHS was performed for nine lesions, and the complete EHS closure rate was 73 %. Median procedure time for suturing was 56 minutes (range 30 - 120 minutes) and median number of stitches was 8 (range 6 - 12). Sustained closure and post-ESD bleeding rates were 64 % and 9 %, respectively.

CONCLUSIONS

EHS achieved complete and sustained closure in the colorectum. However, EHS is not currently clinically applicable given the long procedure time. Further modifications of the technique and devices are desirable.

Delayed perforation after endoscopic resection of a colonic laterally spreading tumor: A case report and literature review

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely used for the treatment of early gastrointestinal cancer. Endoscopic piecemeal mucosal resection (EPMR) is derived from the combination of EMR and ESD. Delayed perforation with peritonitis after colonic EPMR is a rare but severe complication, sometimes requiring surgery. There are some associated risk factors, including patient- (location, diameter, and presence of fibrosis) and procedure-related factors. Early recognition and timely treatment are crucial for its management.

CASE SUMMARY

We report a case in which delayed perforation with peritonitis was treated using endoscopic closure. A 54-year-old man was diagnosed with a 30-mm-diameter laterally spreading tumor in the colonic hepatic curvature. Fifteen hours after endoscopic resection, peritonitis caused by delayed perforation occurred and gradually aggravated. Conservative treatment was ineffective and no obvious perforation was observed. After timely endoscopic closure, the patient was discharged on postoperative day 4.

CONCLUSION

In occasion of localized peritonitis aggravating without macroscopic perforation, endoscopic closure is an effective treatment for delayed perforation with stable vital signs in the early stage.

Clinical outcomes of laparoscopic versus open surgery for repairing colonoscopic perforation: a multicenter study

PURPOSE

We conducted this study to compare the perioperative outcomes of laparoscopic surgery (LS) vs. open surgery (OS) for repairing colonoscopic perforation, and to evaluate the possible predictors of complications.

METHOD

We reviewed the medical records of patients who underwent surgical repair of colonoscopic perforation by LS or OS between January 2005 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify the predictors of postoperative complications.

RESULTS

Of the total 99 patients, 40 underwent OS and 59 underwent LS. The postoperative hospital stay and the time to resuming a soft diet were shorter in the LS group than in the OS group (P = 0.017 and 0.026, respectively). The complication rate and Clavien-Dindo classification were not significantly different between the two groups. Multivariable analysis revealed that an American Society of Anesthesiologists score (ASA) ≥ 3 and switching from non-operative management to surgical treatment were independently associated with complications (P = 0.025 and 0.010, respectively).

CONCLUSION

LS may be a safe alternative to OS for repairing colonoscopic perforation with a shorter postoperative hospital stay and time to resuming a soft diet. Patients with an ASA score ≥ 3 and those with changes to their planned treatment should be monitored carefully to minimize their risk of complications.

Double-endoscope assisted endoscopic submucosal dissection for treating tumors in rectum and distal colon by expert endoscopists: a feasibility study

Background

Colorectal endoscopic submucosal dissection (ESD) is an effective but challenging procedure. To facilitate ESD, several methods that apply traction are available; however, the optimal one remains to be established. The aim of this study was to evaluate the feasibility and safety of the double-endoscope assisted ESD (DEA-ESD) by improving traction to treat complex colorectal lesions.

Methods

Naïve or previously treated lesions in the rectum and sigmoid colon were included. A grasping forceps advanced through a small-caliber endoscope (GIF-XP190N, Olympus Medical Systems, Tokyo, Japan, 5.4 mm outer diameter) was used to apply traction to the mucosal flap. Lesions were deemed complex when they exceeded a total of nine points on the SMSA scoring system (size, morphology, site, and access) and recurrent when they were previously treated with endoscopic mucosal resection (EMR). Outcome measures included procedural success, total procedure time, complications, and recurrence rate at 3-month follow-up.

Results

Nine patients (mean age 62.3 ± 14.5 years) were included; five had rectal and four had tumors in the sigmoid colon. The median SMSA score was 14 (SMSA Level IV—complex polyp), while three patients were pre-treated with EMR. DEA-ESD was technically feasible in all cases. En bloc resection and R0 resection rates were 100%, respectively, with a mean procedure time of 128.4 ± 54.1 min. No immediate or delayed complications occurred.

Conclusions

DEA-ESD is a feasible and safe method for treating complex or recurrent tumors in the rectum and distal colon.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02308-4) contains supplementary material, which is available to authorized users.

Endoscopic mucosal resection vs endoscopic submucosal dissection for superficial non-ampullary duodenal tumors

BACKGROUND

The selection of endoscopic treatments for superficial non-ampullary duodenal epithelial tumors (SNADETs) is controversial.

AIM

To compare the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for SNADETs.

METHODS

We retrospectively analyzed the data of patients with SNADETs from a database of endoscopic treatment for SNADETs, which included eight hospitals in Fukuoka, Japan, between April 2001 and October 2017. A total of 142 patients with SNADETs treated with EMR or ESD were analyzed. Propensity score matching was performed to adjust for the differences in the patient characteristics between the two groups. We analyzed the treatment outcomes, including the rates of en bloc/complete resection, procedure time, adverse event rate, hospital stay, and local or metastatic recurrence.

RESULTS

Twenty-eight pairs of patients were created. The characteristics of patients between the two groups were similar after matching. The EMR group had a significantly shorter procedure time and hospital stay than those of the ESD group [median procedure time (interquartile range): 6 (3-10.75) min vs 87.5 (68.5-136.5) min, P < 0.001, hospital stay: 8 (6-10.75) d vs 11 (8.25-14.75) d, P = 0.006]. Other outcomes were not significantly different between the two groups (en bloc resection rate: 82.1% vs 92.9%, P = 0.42; complete resection rate: 71.4% vs 89.3%, P = 0.18; and adverse event rate: 3.6% vs 17.9%, P = 0.19, local recurrence rate: 3.6% vs 0%, P = 1; metastatic recurrence rate: 0% in both). Only one patient in the ESD group underwent emergency surgery owing to intraoperative perforation.

CONCLUSION

EMR has significantly shorter procedure time and hospital stay than ESD, and provides acceptable curability and safety compared to ESD. Accordingly, EMR for SNADETs is associated with lower medical costs.

Reduction in the procedure time of hybrid endoscopic submucosal dissection for early gastric neoplasms: a multi-center retrospective propensity score-matched analysis

BACKGROUND

Endoscopic submucosal dissection (ESD) for early gastric neoplasms is still a technically difficult and time-consuming procedure. Hybrid ESD (H-ESD) involves circumferential incision with partial submucosal dissection combined with subsequent mucosal resection by snaring, wherein the newly developed device allows us to perform H-ESD using a single device. This study aimed to determine the clinical outcomes of H-ESD compared with conventional ESD (C-ESD) for early gastric neoplasms.

METHODS

In this multi-center, retrospective study, using propensity score-matched analysis, we reviewed the charts of patients with early gastric neoplasms smaller than 20 mm treated with H-ESD or C-ESD at three hospitals between January 2017 and October 2018. The primary outcome was the procedure time, and the secondary outcomes were other factors, including the en bloc resection rate, complete resection rate, curative resection rate, and rate of adverse events.

RESULTS

Among 215 patients, 29 underwent H-ESD and 186 underwent C-ESD; 29 pairs were created by propensity score matching. In the H-ESD group, 82.8% of lesions met the absolute indication [mucosal lesions limited to 20-mm diameter, dominated by differentiated adenocarcinoma without ulcer (scar)] for endoscopic resection (ER). As a result, the procedure time of H-ESD was significantly shorter than that of C-ESD [20 (interquartile range, 12-27) min versus 40 (30-50) min; p < 0.001]. There was no significant difference in the secondary outcomes between the two groups.

CONCLUSION

H-ESD contributed to reduced procedure time. Therefore, H-ESD could be an alternative endoscopic treatment for gastric neoplasms when the lesion fulfils the absolute indication for ER.

Efficacy of preemptive endoscopic submucosal dissection and surgery for synchronous colorectal neoplasms

BACKGROUND AND AIM

If patients with surgically resectable colorectal cancershave synchronous colorectal neoplasms that are difficult to remove by endoscopic mucosal resection, preemptive endoscopic submucosal dissection (ESD) can avoid excessive colorectal resection. The aim of this study was to evaluate the efficacy of the strategy of preemptive ESD and surgery for synchronous colorectal neoplasms.

METHODS

Patients who underwent preemptive ESD and surgery for synchronous colorectal neoplasms between September 2002 and December 2017 were enrolled in this retrospective cohort study. The proportion of cases in which extended surgery could be avoided following curative ESD was calculated. Clinicopathological characteristics were evaluated for all patients and long-term outcomes were analyzed for patients who underwent curative ESD and surgery.

RESULTS

A total of 45 consecutive patients with 47 endoscopically-resected lesions and 46 surgically-resected lesions were retrospectively evaluated. Curative ESD was achieved in 44 lesions (93.6%) and an extended surgical procedure could be avoided in 42 patients (93.3%). Intraoperative perforation occurred in two lesions (4.3%), delayed perforation in one lesion (2.1%), and delayed bleeding in two lesions (4.3%). Final stages were as follows: stage 0, 3 patients (7.1%); stage I, 23 patients (54.8%); stage II, 3 patients (7.1%); stage III, 12 patients (28.6%); and stage IV, 1 patient (2.4%). The 5-year overall survival rates of patients with all pathological stages, stage 0-II, and stage III-IV were 93.7%, 100%, and 79.1%, respectively.

CONCLUSION

The strategy of preemptive ESD and surgery for synchronous colorectal neoplasms is minimally invasive and has a favorable prognosis.

Learning curve for mastery of colorectal endoscopic submucosal dissection: Perspectives from a large Japanese cohort

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is a challenging procedure. A dissection speed of ≥9 cm2/h has been acknowledged as a mark for expertise, alongside a complication rate of ≤5% and en bloc resection rate of ≥90%. However, there is lack of objective information on whether the three measures correlate with each other. This study aims to evaluate the dissection speed, safety, and efficacy of colorectal ESDs performed by experts and trainees.

METHODS

Consecutive patients undergoing colorectal ESD at a Japanese hospital (2006-2017) were included in a prospectively collected database. Information on patient demographics, proceduralist, and intra-/postprocedure data was retrieved. The primary outcome was the comparison in dissection speed. The secondary outcomes included differences in safety and efficacy. Log-linear regression models adjusted for confounders (e.g. R0 resection) were used to assess the differences in dissection speed.

RESULTS

Five hundred ninety procedures (514 patients) performed by 26 endoscopists were analyzed. Experts performed a higher number of difficult lesions (e.g. F2 fibrosis) but achieved higher dissection speed (10.3 vs 6.7 cm2/h). The difference was statistically significant for both unadjusted and adjusted models (P < 0.0001). The en bloc resection rates were similar for both groups (experts = 95.6%; trainees = 94.7%, P = 0.61). Although nonexperts damaged more of the muscularis propria (18.6 vs 12.5%, P = 0.04), this did not translate into a significant difference in perforation (experts = 3.7%; trainees = 6.9%, P = 0.09) or delayed bleeding (experts = 2.9%; trainees = 4.4%, P = 0.34). The dissection speed steadily increased with expertise.

CONCLUSION

Although dissection speed for colorectal ESD was significantly higher for experts, ESDs could be safely and efficaciously performed by ESD trainees.

Bipolar-current needle-knife with a water jet function (Jet B-knife) shortens the procedure time of endoscopic submucosal dissection for colorectal tumors

BACKGROUND

Endoscopic submucosal dissection (ESD) is a technically difficult and time-consuming procedure for the treatment of large colorectal tumors. In Japan, the ball-tip bipolar-current needle-knife (BB-knife) has been used in ESD as a safe device that minimizes the damage to deeper tissues of colorectal neoplasms. In May 2012, a BB-knife combined with a water jet function (Jet B-knife) was newly developed.

METHODS

This retrospective study was aimed at examining the effectiveness and safety of the Jet B-knife. The BB-knife was used in 276 lesions (BB-knife group), while the Jet B-knife was used in 245 lesions (Jet B-knife group). We evaluated tumor characteristics and the results of the ESD procedures, including the size of the resected tumor, histological diagnosis, time required for resection, frequency of using other electrical devices, en bloc resection rate, and incidence rate of associated complications. Then, the data obtained were compared between the two groups.

RESULTS

The histological evaluation of the resected tumors revealed that the incidence of cancer was not significantly different between the two groups. The median time required for resection was 103 min (45-255) in the BB-knife group and 51 min (28-210) in the Jet B-knife group. The difference was statistically significant (p < 0.05). Furthermore, the median tumor diameters were 23.1 mm (18-50) and 26.2 mm (20-60) in the BB-knife and Jet B-knife groups, respectively, demonstrating a statistically significant difference (p < 0.05). Multivariate logistic regression analysis revealed that short resection time (p < 0.001) and reduced use of hemostatic devices (p < 0.01) were independent favorable features of Jet B-knife. The en bloc resection rate and the perforation rate were not statistically significant between the two groups.

CONCLUSIONS

Use of the Jet B-knife may contribute to the development of a time-saving, cost-effective, and safe procedure for ESD of colorectal tumors.

The effect of non-curative endoscopic resection on cT1N0M0 colorectal carcinoma patients who underwent additional surgery

BACKGROUND AND AIM

Radical surgery is recommended for T1 colorectal cancer with non-curative endoscopic resection. However, there is still insufficient evidence about whether the non-curative endoscopic resection prior to surgical resection affects the short-term and long-term outcomes of patients. The purpose of this study was to investigate the effect of non-curative endoscopic resection before surgical resection on short-term and long-term outcomes in patients with T1 colorectal cancer.

PATIENTS AND METHODS

Patients with clinical T1N0M0 (cT1N0M0) colorectal cancer who underwent direct surgery or additional radical surgery after non-curative endoscopic resection were collected. We evaluated postoperative complications and long-term prognosis between the two groups.

RESULTS

From 2011 to 2017, 779 patients were clinically diagnosed with T1N0M0 colorectal cancer at Zhongshan Hospital. We assessed patients who underwent additional surgery following the prior non-curative endoscopic resection (n = 145) and patients who underwent radical surgery directly (n = 336). There was no significant difference in 5-year OS (99.3% vs. 99.4%, P = 0.866) and 5-year DFS (97.2% vs. 97.3%, P = 0.909) between the two groups. The total complication rate was slightly higher in prior endoscopic resection group (15.2% vs. 9.5%, P = 0.111). The 5-year OS and 5-year DFS of patients who refused additional surgery (n = 95) were significantly lower than ER prior to surgery group (For OS, 92.6% vs. 99.3%, P = 0.017; for DFS, 91.2% vs. 97.2%, P = 0.021).

CONCLUSION

In patients who underwent additional surgery, non-curative endoscopic resection of cT1 colorectal carcinoma did not have adverse effect on short-term and long-term outcomes. Additional surgery should be recommended in patients who received non-curative ER.

Feasibility and learning curve of unsupervised colorectal endoscopic submucosal hydrodissection at a Western Center

OBJECTIVES

Colorectal endoscopic submucosal dissection (CR-ESD) is an evolving technique in Western countries. We aimed to determine the results of the untutored implementation of endoscopic submucosal hydrodissection for the treatment of complex colorectal polyps and establish the learning curve for this technique.

METHODS

This study included data from 80 consecutive CR-ESDs performed by a single unsupervised western therapeutic endoscopist. To assess the learning curve, procedures were divided into four groups of 20 each.

RESULTS

En bloc resection was achieved in 55, 75, 75 and 95% cases in the consecutive time periods (period 1 vs. 4, P = 0.003). Curative resection was achieved in 55, 75, 70 and 95%, respectively (P = 0.037). Overall, series results demonstrated R0 resection in 75% of cases, with 23.7% requiring conversion to endoscopic piecemeal mucosal resection, and 1.25% incomplete resections. Complications included perforations (7.5%) and bleeding (3.7%). Multivariate analysis revealed factors more likely to result in association with non en bloc vs. En bloc resection, where polyp size ≥35 mm [70 vs. 23.4%; odds ratio (OR) 13.2 (1.7-100.9); P = 0. 013], severe fibrosis [40 vs. 11.7%; OR 10.2 (1.2-86.3); P = 0.033] and where carbon dioxide for insufflation was not used [65 vs. 30%; OR 0.09 (0.01-0.53); P = 0.008].

CONCLUSION

CR-ESD by hydrodissection has good safety and efficacy profile and offers well tolerated and effective treatment for complex polyps. As such, this technique may be useful in the West, in centers, where previous gastric ESD is not frequent or Japanese mentoring is not possible.

Blue laser imaging and linked color imaging improve the color difference value and visibility of colorectal polyps in underwater conditions

BACKGROUND AND AIM

Underwater endoscopic mucosal resection (UEMR) has become widespread for treating colorectal polyps. However, which observational mode is best suited for determining polyp margins underwater remains unclear. To determine the best mode, we analyzed three imaging modes: white light imaging (WLI), blue laser imaging (BLI) and linked color imaging (LCI).

METHODS

Images of consecutive colorectal polyps previously examined by these three modes before UEMR were analyzed according to the degree of underwater turbidity (transparent or cloudy). Color differences between the polyps and their surroundings were calculated using the Commission Internationale d'Eclairage Lab color space in which 3-D color parameters were expressed. Eight evaluators, who were blinded to the histology, scored the visibility from one (undetectable) to four (easily detectable) in both underwater conditions. The color differences and visibility scores were compared.

RESULTS

Seventy-three polyps were evaluated. Sixty-one polyps (44 adenomatous, 17 serrated) were observed under transparent conditions, and 12 polyps (seven adenomatous, five serrated) were observed under cloudy conditions. Under transparent conditions, color differences for the BLI (8.5) and LCI (7.9) were significantly higher than that of WLI (5.7; P < 0.001). Visibility scores for BLI (3.6) and LCI (3.4) were also higher than that of WLI (3.1; P < 0.0001). Under cloudy conditions, visibility scores for LCI (2.9) and WLI (2.7) were significantly higher than that of BLI (2.2; P < 0.0001 and P = 0.04, respectively).

CONCLUSIONS

BLI and LCI were better observational modes in transparent water; however, BLI was unsuitable for cloudy conditions.

Comparison of dissection speed during colorectal ESD between the novel Multiloop (M-loop) traction method and ESD methods without traction

Background and study aims  We previously reported on a novel traction method called Multiloop (M-loop) for faster colorectal endoscopic submucosal dissection (ESD). In this study, we retrospectively compared the difference in submucosal dissection time (SDT), and submucosal dissection speed (SDS) between groups of patients who were treated using traction with the M-loop method, and with non-traction methods of colorectal ESD. Patients and methods  We reviewed and timed duration of colorectal ESD by the non-traction method from videos recorded between June 2016 and December 2017. From January 2018 onward, we used the M-loop method during all colorectal ESDs and timed it until August 2018. Outcomes of colorectal ESD with the M-loop method and non-traction methods were compared. The study involved two experts and eight non-experts and was carried out at a tertiary endoscopic center in Japan. Results  The study included 50 patients who treated with the M-loop method and 115 patients treated with the non-traction method. Submucosal dissection time (SDT) was not significantly different (M-loop group, 42.1  ±  4.2 min, non-traction ESD group, 51.9 ± 3.3 min) ( P  = 0.098), but submucosal dissection speed (SDS) was significantly greater (M-loop group, 28.0 ± 2.9 mm ²  /min, non-traction ESD group, 19.9 ± 2.0 mm ² /min) ( P  = 0.0014) in the M-loop method group. Multivariate analysis showed that the M-loop method increased SDS by odds ratio of 1.46 ( P  = 0.001) when compared to the non-traction ESD method. A significant difference was also observed for SDT and SDS when the two methods were compared after propensity score matching ( P  = 0.001). No differences in unfavorable outcomes were observed. Conclusions  The M-loop method improved SDS compared to non-traction methods of ESD. The method is an effective tool to assist colorectal ESD.

EMR/ESD: Techniques, Complications, and Evidence

PURPOSE OF REVIEW

To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

RECENT FINDINGS

EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.

Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review

Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.

Factors involved in endoscopists' choice for prophylactic clipping after colorectal endoscopic mucosal resection: a discrete choice experiment

Background: Delayed bleeding (DB) occurs in ∼10% after colorectal EMR. Prophylactic clipping (PC) was reported to significantly decrease DB-rate in proximal lesions ≥2 cm.Objective: Our aim was to determine which predefined variables contribute to using PC in clinical practice.Methods: We performed an international discrete choice experiment (DCE) among ∼500 endoscopists. Relevant variables for PC use were selected by EMR experts: previous DB, anticoagulants, polyp size, morphology, location, intraprocedural bleeding and visible vessel(s). Respondents answered case scenarios with various variable combinations, each time choosing only one scenario for PC, or the 'none' option. Part-worth utilities and importance weights were calculated using HB regression. Subsequently, a predictive model was created to calculate the likelihood of endoscopists choosing PC in any given case.Results: The survey was completed by 190 EMR endoscopists from 17 countries. In total, 8% would never use PC, whereas 30.9% never chose the 'none' option. All variables except polyp type were significant in decision-making for PC (p < .01). The most important factor was anticoagulant use, accounting for 22.5% in decision-making. Polyps <2 cm were considered eligible for PC by 14% in the presence of high-weighing factors such as anticoagulant use. No significant differences were found between high and low-to-moderately experienced endoscopists.Conclusions: PC after EMR is often considered useful by endoscopists, usually based on risk factors for DB. Anticoagulant use was the most important factor in decision-making for PC, independent of endoscopist experience. Although not considered cost-effective, one in seven endoscopists chose PC for adenomas <2 cm.

Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors

BACKGROUND

In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD).

METHODS

In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors.

RESULTS

A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273).

CONCLUSION

Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

Pathology definitions and resection strategies for early colorectal neoplasia: Eastern versus Western approaches in the post-Vienna era

There is a well-known discrepancy between East and West classifications of colorectal neoplasm, especially "intramucosal carcinoma," categorized as subgroup 4.4 in the Vienna classification, usually recognized as high-grade dysplasia in the United States and as carcinoma in situ in Japan. Focusing on management, in the current National Comprehensive Cancer Network algorithm, high-grade dysplasia, carcinoma in situ, and intramucosal carcinoma are managed similarly, whereas submucosal invasion by carcinoma requires en bloc resection. To bridge the differences with regard to these conceptual problems in the definition and management of carcinoma in situ and intramucosal carcinoma, endoscopists and pathologists from Japan and the United States gathered and discussed from their perspectives how to accurately assess specimens of en bloc/piecemeal resection and to effectively predict lymph node metastasis risk.

Pathologic Evaluation of Large Colorectal Endoscopic Submucosal Dissections: An Analysis of 279 Cases With Emphasis on the Importance of Multidisciplinary Work and Establishing Examination Protocols

Background. Endoscopic submucosal dissections (ESDs) allow removal of large gastrointestinal tumors and help patients avoid major oncologic surgery. In this study, the challenges and development of approaches toward successfully handling ESDs were analyzed in 279 colorectal specimens (114 rectal, 47 left, 118 right colonic; 90% adenoma with/without carcinoma). Methods. Each specimen was processed according to an established protocol including gross photography, mapping, and total submission for histopathologic examination. Results. Mean lesion size was 4.2 cm (range: 0.5-22 cm; 28% ≥5 cm; 6% ≥10 cm). Invasive carcinoma was present in 38 cases (14%), which had a mean overall tumor size of 3.8 cm (range: 1.1-17.5 cm), and mean largest size of the invasive component was 0.93 cm (range: 0.04-3 cm). Fifteen cases were staged as pT1a (submucosal invasion of <1000 µm) and 13 cases as pT1b (submucosal invasion of ≥1000 µm). En-bloc and R0 resection rates were 99.3% and 90.6%, respectively. Conclusion. Various histopathologic challenges were encountered, which were carefully evaluated by dedicated pathologists with familiarity to the subtleties in handling and reporting these specimens. We recommend these specimens to be prepared in the endoscopy suite, submitted to the Pathology Department oriented, pinned, and placed into copious amount of fixative. Total sampling, gross photography, mapping, and proper fixation are crucial components in the histopathologic evaluation. Micromeasurement of invasion depth and substaging per European/Japanese guidelines as well as accurate measurement of the distance from the resection margins are highly recommended. In conclusion, ESD is an adequate method that can be successfully implemented in a tertiary care center to perform en-bloc and margin-free resections of clinically selected large colorectal superficial lesions.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect

BACKGROUND

Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD.

METHODS

We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques.

RESULTS

A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed.

CONCLUSIONS

Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Endoscopic submucosal dissection involving the anal canal presents a risk factor for postoperative stricture

BACKGROUND

Although postoperative strictures after endoscopic submucosal dissection (ESD) in the rectum are relatively rare, some rectal lesions require resection involving the anal canal, which is a narrow tract comprising squamous epithelium. To the best of our knowledge, no studies have investigated narrow anal canals when evaluating post-ESD strictures. This study aimed to evaluate the impact of resections involving the anal canal on postoperative stricture development.

METHODS

Between April 2005 and October 2017, 707 rectal lesions were treated with ESD. We retrospectively investigated 102 lesions that required ≥ 75% circumferential resection. Risk factors for post-ESD stricture and, among patients with strictures, obstructive symptoms, and number of dilation therapies required were investigated.

RESULTS

Post-ESD stricture occurred in 18 of 102 patients (17.6%). In the multivariate analysis, circumferential resection ≥ 90% and ESD involving the anal canal (ESD-IAC) were risk factors for postoperative strictures (P ≤ 0.0001 and 0.0115, respectively). Among the patients with strictures, obstructive symptoms were significantly related to anal strictures compared to rectal strictures (100% vs. 27.2%, P = 0.0041). Furthermore, the number of dilation therapies required was significantly greater among patients with anal strictures compared to those with rectal strictures (6.5 times vs. 2.7 times, P = 0.0263).

CONCLUSION

Not only circumferential resection ≥ 90% but also ESD-IAC was a significant risk factor for the stricture after rectal ESD. Furthermore, anal strictures were associated with a significantly higher frequency of obstructive symptoms and larger number of required dilation therapies than were rectal strictures.

ENDOSCOPIC PIECEMEAL RESECTION OF LARGE BENIGN COLORECTAL NEOPLASIA: RESULTS OF A RUSSIAN MULTICENTER STUDY

AIM: to assess the safety of endoscopic piecemeal mucosal resection (EPMR) of large epithelial colorectal lesions and to identify risk factors for tumor recurrence.

PATIENTS AND METHODS: results of EPMR were evaluated in retrospective study, which was carried out in five regional endoscopic centers. The criterion for inclusion in the study was benign colorectal lesion of 20 mm and larger.

RESULTS: we found that complications of EPMR occurred in 13% of cases. In 9.2% it was intraoperative bleeding, which was stopped endoscopically. Postoperative bleeding was detected in 1.2% of patients, perforation – in 2.4%. Tumor recurrence developed in 12%. We have revealed a direct correlation between tumor recurrence and intraoperative bleeding (p=0.013) and a size of lesion >4 cm (p=0.012); the inverse correlation between the tumor recurrence and the fullness of the lifting during the removal (p=0.008) and the male gender of the patient (p=0.043).

CONCLUSION: significant risk factors of tumor recurrence after endoscopic piecemeal resection of large benign colorectal neoplasia were identified before the procedure (gender and tumor size) and intraoperatively (completeness of lifting and the intraoperative bleeding).

Steerable OCT catheter for real-time assistance during teleoperated endoscopic treatment of colorectal cancer

When detected early, colorectal cancer can be treated with minimally invasive flexible endoscopy. However, since only specialized experts can delineate margins and perform endoscopic resections of lesions, patients still often undergo colon resections. To better assist in the performance of surgical tasks, a robotized flexible interventional endoscope was previously developed, having two additional side channels for surgical instrument. We propose to enhance the imaging capabilities of this device by combining it with optical coherence tomography (OCT). For this purpose, we have developed a new steerable OCT instrument with an outer diameter of 3.5 mm. The steerable instrument is terminated with a 2 cm long transparent sheath to allow three-dimensional OCT imaging using a side-focusing optical probe with two external scanning actuators. The instrument is connected to an OCT imaging system built around the OCT Axsun engine, with a 1310 nm center wavelength swept source laser and 100 kHz A-line rate. Once inserted in one of the side channels of the robotized endoscope, bending, rotation and translation of the steerable OCT instrument can be controlled by a physician using a joystick. Ex vivo and in vivo tests show that the novel, steerable and teleoperated OCT device enhances dexterity, allowing for inspection of the surgical field without the need for changing the position of the main endoscope.

Multimodal Endoscopic Assessment Guides Treatment Decisions for Rectal Early Neoplastic Tumors

BACKGROUND

There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment.

OBJECTIVE

We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions.

DESIGN

This was a retrospective study.

SETTING

The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer.

PATIENTS

A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported.

RESULTS

After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up.

LIMITATIONS

This was a retrospective study from a tertiary referral unit.

CONCLUSIONS

Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.

Clinical usefulness of the S-O clip during colorectal endoscopic submucosal dissection in difficult-to-access submucosal layer

Background and study aims  In colorectal endoscopic submucosal dissection (ESD), the S-O clip improves the accessibility to the submucosal layer of the colon. However, its safety and usefulness in difficult colorectal ESDs are unclear. Thus, in this study, we aimed to assess the effectiveness of the S-O clip in colorectal ESD in the difficult-to-access submucosal layer. Patients and methods  From January 2016 to December 2016, 189 consecutive cases of colorectal ESD were performed at Hiroshima University Hospital before the S-O clip was introduced. Between January 2017 and June 2018, among 271 consecutive colorectal ESD cases, 41 cases were performed colorectal ESD using the S-O clip. We compared outcomes between the two groups (41 cases with S-O clip [use group] and 189 cases without S-O clip [non-use group]) using propensity score matching. Results  Prior to propensity score matching, 41 cases with the S-O clip (use group) and 189 cases without the S-O clip (non-use group) were extracted. The degree of submucosal fibrosis was more severe and the procedure time was longer in the use group than in the non-use group. In the use and non-use groups, en bloc resection (100 % vs. 94.7 %) and complete en bloc resection (100 % vs. 92.6 %) rates were satisfactory. After propensity score matching, 33 cases in each group were extracted. As a result, complete en bloc resection rate was significantly higher in the use group than in the non-use group (100 % vs. 84.9 %). Conclusion  The S-O clip is effective and can be used safely in colorectal ESD in the difficult-to-access submucosal layer.

Efficacy and Safety of Complete Endoscopic Resection of Colorectal Neoplasia Using a Stepwise Endoscopic Protocol with SOUTEN, a Novel Multifunctional Snare

BACKGROUND/AIMS

A multifunctional snare SOUTEN has a sharp tip at the top of the snare loop that enables incision of the mucosa, dissection of the submucosal layer, and snaring of lesion. This study assessed the efficacy and safety of complete endoscopic resection of colorectal neoplasia using SOUTEN.

METHODS

We analyzed the rates of gross en bloc resection and complete resections of 108 consecutive tumors from 69 patients resected by precutting endoscopic mucosal resection (precutting), hybrid endoscopic submucosal dissection (hybrid), or conventional endoscopic submucosal dissection (conventional) using SOUTEN.

RESULTS

Out of the 108 tumors, 50 were resected by precutting, 27 were resected by hybrid after attempting precutting, and the remaining 31 were resected by conventional after attempting precutting and hybrid resections. The median tumor sizes were 14.5 mm for precutting, 16.4 mm for hybrid, and 21.1 mm for conventional. The success rate of gross en bloc resection and histological complete resection were 100% and 94.0% for precutting, 96.4% and 96.4% for hybrid, and 100% and 100% for conventional method, respectively. No procedure-related complication occurred.

CONCLUSION

By using SOUTEN, precutting and hybrid were successfully performed on 10-30 mm tumors with a shorter procedure time than conventional without major complications.

Long-term follow-up after endoscopic submucosal dissection of colorectal lesions in a Spanish cohort

INTRODUCTION

ESD in the colon is an increasingly important technique in Western countries. There are few studies that include long term follow-up.

AIM

to analyze the long term recurrence free survival rate after ESD and to compare recurrence rates according to different variables.

METHODS

this was a prospective observational study of patients with a planned ESD from September 2008 to December 2015. When it was not possible to achieve an ESD, hybrid ESD was performed, either en bloc or piecemeal. Kaplan-Meier survival curves were used to assess the five year local recurrence free survival rate and the recurrence rate. The results were compared according to different factors.

RESULTS

of the 89 patients scheduled for ESD who were initially enrolled in the study, 69 were finally included for follow-up. ESD was performed in 31 (45%) patients, KAR in eleven (16%) and pKAR in 27 (39%). The median follow-up was 27 months (range 6-60). The five year disease free survival rate was 81%. The average number of endoscopies needed to eliminate recurrence was two (range 2-7) and no patient required surgery for this reason. The recurrence rate was significantly higher in piecemeal resections vs en bloc resections (27% vs 15%, p = 0.036) and R1 resections vs R0 resections (26% vs 0%, p = 0.034). The presence of affected or unknown lateral margins in en bloc resections without other poor prognosis factors had higher recurrence rates but the difference was not statistically significant (28% vs 0%, p = 0.09).

CONCLUSIONS

in our study, the five year disease free survival rate was 81% and no patient required surgery during follow-up. Piecemeal and R1 resections had significantly higher recurrence rates, as well as LM involvement, although this was not statistically significant.

Double-tunneling butterfly method for endoscopic submucosal dissection of extensive rectal neoplasms

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is the preferred technique for en bloc resection of superficial colorectal neoplasms. Resection of extensive lesions with ESD can be challenging, owing to loss of orientation in the submucosal space. In this case series, we describe the double-tunneling (DoT) butterfly method for ESD of extensive rectal neoplasms.

METHODS

The key feature of the DoT butterfly method is the creation of 2 tunnels that are transformed into bilateral flaps, leaving a submucosal septum between them.

RESULTS

Four rectal neoplasms measuring (maximum diameter) 7 cm, 8 cm, 9 cm, and 18 cm, respectively, were resected in 4 patients by use of the DoT butterfly method. The lesions included recurrent adenoma (n = 1) and dysplasia (n = 1) in longstanding ulcerative colitis. Curative R0 resection was confirmed in all 4 cases. Histologic examination showed tubular adenomas with low-grade dysplasia in 1 of 4 patients and focal high-grade dysplasia in 3 of 4 patients. One patient experienced postprocedural bleeding that required endoscopic reintervention.

CONCLUSION

The DoT butterfly method appears to be useful for the resection of extensive rectal neoplasms. A prospective study is required to assess whether these results can be reproduced in a large cohort of patients.

Present Status of Endoscopic Submucosal Dissection for Non-Ampullary Duodenal Epithelial Tumors

Prediction of histology by endoscopic examination is important in the clinical management of non-ampullary duodenal epithelial tumors (NADETs), including adenoma and adenocarcinoma. The use of a simple scoring system based on the findings of white-light endoscopy or magnified endoscopy with narrow-band imaging is useful to differentiate between Vienna category 3 (C3) and C4/5 lesions. Less invasive endoscopic resection procedures, such as cold snare polypectomy, are quick to perform and convenient for small (<10 mm) C3 lesions. Neoplasms with higher grade histology, such as C4/5 lesions, should be treated by endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgery. Although EMR often requires piecemeal resection, the complication rate is acceptable. Excellent complete resection rates could be achieved by ESD; however, it remains a challenging method considering the high risk of complications. Shielding or closure of the ulcer after ESD is effective at decreasing the risk of delayed bleeding and perforation. Laparoscopic endoscopic cooperative surgery is an ideal treatment with a high rate of en bloc resection and a low rate of complications, although it is limited to high-volume centers. Patients with NADETs could benefit from a multidisciplinary approach to stratify the optimal treatment based on endoscopic diagnoses.

Feasibility of endoscopic submucosal dissection for colorectal neoplasia at anastomotic sites: a retrospective study

BACKGROUND

Metachronous colorectal lesions sometimes occur at anastomotic sites following colorectal surgery, which increases the risk of developing colorectal cancer. However, these lesions are difficult to treat even with minimally invasive methods such as endoscopic submucosal dissection (ESD). Thus, we aimed to evaluate the outcomes of ESD for colorectal lesions at anastomotic sites following colorectal surgery.

METHODS

We retrospectively investigated 11 patients with post-surgical colorectal lesions at anastomotic sites who later underwent ESD from May 2010 to April 2019 at Keio University Hospital, Tokyo, Japan. We examined the patients' background (tumor location, macroscopic type, tumor size, histological type, and depth of invasion) and treatment outcomes (procedure duration, en bloc resection rate, R0 resection rate, and adverse events).

RESULTS

The patients' mean age was 66 years. There were two lesions in the transverse colon, six in the rectum, one in the anal canal, and two in the ileal pouch. The median tumor size was 25 mm. The macroscopic types were the protruded type (1 lesion) and the flat or depressed type (10 lesions). The pathological diagnoses were adenoma (4 lesions), intramucosal cancer (corresponding to high-grade dysplasia) (6 lesions), and muscularis propria cancer (1 lesion). The median procedure duration was 50 min; en bloc resection rate was 88.9% and R0 resection rate was 66.7%. The only adverse event was delayed post-ESD bleeding.

CONCLUSIONS

A high en bloc resection rate without perforation was achieved with ESD for lesions at anastomotic sites. Although ESD for lesions at anastomotic sites is a technically challenging procedure because of severe submucosal fibrosis, this approach could prevent the need for repeated surgical resection.

Inverse Association of Age with Risk of Lymph Node Metastasis in Superficial Colorectal Cancer: A Large Population-Based Study

BACKGROUND

Superficial colorectal cancer (SCRC) is defined as colorectal cancer (CRC) confined to the mucosa or submucosa. Endoscopic resection (ER) is widely used to resect differentiated SCRC from patients without lymph node metastasis (LNM). However, it is unclear whether ER is suitable for use with patients with differentiated early-onset SCRC because early-onset CRC is more aggressive. Therefore, we aimed to investigate the association between age of CRC onset and LNM.

MATERIALS AND METHODS

We retrieved data for patients with surgically resected differentiated-type SCRCs from the Surveillance, Epidemiology, and End Results (SEER) database. Rate of LNM was compared among patients aged 18-39, 40-49, 50-59, 60-69, and ≥70 years. The association between age and LNM was further examined using multivariate logistic regression.

RESULTS

We retrieved 34,506 records of differentiated SCRCs from the SEER database, including 667 patients aged 18-39 years, 2,385 aged 40-49, 8,075 aged 50-59 years, 9,577 aged 60-69 years, and 13,802 aged ≥70 years. Rates of LNM were 15.74%, 14.13%, 10.67%, 8.07%, and 6.76% for patients aged 18-39, 40-49, 50-59, 60-69, and ≥70 years, respectively. We found an inverse correlation between age at diagnosis and risk of LNM from the univariate analysis (p < .001). Compared with patients aged 18-39, the odds ratios with 95% confidence interval (CI) for patients aged 40-49, 50-59, 60-69, and ≥70 years were 0.90 (0.71-1.15, p = .376), 0.69 (0.56-0.87, p = .001), 0.54 (0.43-0.68, p < .001), and 0.47 (0.38-0.60, p < .001), respectively.

CONCLUSION

In differentiated SCRCs, younger age at diagnosis was associated with higher risk of LNM.

IMPLICATIONS FOR PRACTICE

Endoscopic resection (ER) is widely used to resect differentiated superficial colorectal cancer (SCRC) without lymph node metastasis (LNM). However, no study has ever investigated risk of LNM of early-onset SCRC compared with average onset SCRC to explore whether ER is suitable for early-onset SCRC. To the authors' knowledge, this population-based study is the first study to find inverse correlation between age at diagnosis and risk of LNM in differentiated SCRCs. This finding indicates that ER may not be suitable for young patients with differentiated SCRC. Because the 30-day operative mortality after surgery is higher but the risk of LNM is lower in older patients compared with younger patients, ER for differentiated SCRCs may be advantageous over surgery for older patients.

Predictive Factors of Mild and Severe Fibrosis in Colorectal Endoscopic Submucosal Dissection

BACKGROUND AND STUDY AIMS

Varying degrees of fibrosis in colorectal endoscopic submucosal dissection (ESD) make the procedure difficult. Consensus on the predictive factors of fibrosis degree (mild or severe) has not been established. We conducted a study to identify the predictive factors and to examine the feasibility of ESD for fibrotic lesions.

PATIENTS AND METHODS

We included 518 patients who had undergone ESD for 558 lesions from April 2012-September 2018. Patients were classified into fibrosis or no-fibrosis groups, and logistic regression analysis was performed to identify predictive factors of fibrosis. Subgroup analyses were performed for fibrosis degree.

RESULTS

The total incidence of fibrosis was 21.1% (mild: 14.1%; severe: 7.1%). Although the curative resection rate (free margin: invasion depth less than 1000 μm: no lymphatic invasion, vascular involvement) was lower in the fibrosis group compared with the control (80.7% vs. 97.6%), neither the en bloc resection rate (99.1% vs. 100%) nor incidence of perforation (0.9% vs. 0.2%) differed between the two groups. Multivariate analysis revealed that a cecal location, preoperative biopsy, straddling fold, laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) type were predictive of mild fibrosis. The presence of a straddling fold and a protruded lesion were independent predictive factors of severe fibrosis.

CONCLUSIONS

We identified the predictive factors of mild and severe fibrosis. It is preferable that a more experienced physician performs ESD for the lesions with F2 fibrosis.

Complete closure versus simple closure for perforations during colorectal endoscopic submucosal dissection

Background and study aims  The efficacy of complete closure versus simple closure for perforations during endoscopic submucosal dissection (ESD) has never been evaluated. We evaluated the efficacy of complete closure and simple closure for perforations and muscular layer injuries incurred during ESD. Patients and methods  Thirty-four consecutive patients who underwent "complete closure" or "simple closure" for correction of perforations and muscular layer injuries during colorectal ESD were enrolled in this study. Complete closure was performed by the mucosa-submucosa clip closure method using only conventional endo-clips. For simple closure, endo-clips are placed just for perforation or muscular layer injury, while leaving any mucosal defects open. Results  Among the 15 patients in the complete closure group, eight developed perforations and seven developed muscular layer injuries. Among the 19 patients in the simple closure group, six developed perforations and 13 developed muscular layer injuries during the ESD procedure. There were no statistically significant differences between the two groups in inflammatory reactions, adverse events, or length of the hospital stay. Conclusion  Complete closure and simple closure for perforations and muscular layer injuries during ESD seem to have similar efficacy. While simple closure for a perforation during ESD seems sufficient, further study will be required to confirm our results.

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer

The number of deaths from colorectal cancer in Japan continues to increase. Colorectal cancer deaths exceeded 50,000 in 2016. In the 2019 edition, revision of all aspects of treatments was performed, with corrections and additions made based on knowledge acquired since the 2016 version (drug therapy) and the 2014 version (other treatments). The Japanese Society for Cancer of the Colon and Rectum guidelines 2019 for the treatment of colorectal cancer (JSCCR guidelines 2019) have been prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment and to deepen mutual understanding between healthcare professionals and patients by making these guidelines available to the general public. These guidelines have been prepared by consensuses reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. Controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here, we present the English version of the JSCCR guidelines 2019.

Multiloop as a novel traction method in accelerating colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Traction methods have been reported to speed up endoscopic submucosal dissection (ESD). We used the multiloop (M-loop) method as a traction method for colorectal ESD and recorded the submucosal dissection time (SDT) and submucosal dissection speed (SDS).

METHODS

From January to August 2018, we used the M-loop method for colorectal ESD procedures and timed the duration and recorded the outcomes. Two experts and eight nonexperts performed the procedures, which were carried out at a tertiary endoscopic center in Japan.

RESULTS

A total of 50 patients were treated by colorectal ESD using the M-loop method. The mean SDT was 42.1 ± 4.16 minutes and the mean SDS was 28.0 ± 2.89 mm²/minutes. The mean SDS was 38.9 ± 6.9 mm²/minutes for experts and 25.3 ± 3.1 mm²/minutes for nonexperts. En bloc resection was achieved in 100% of cases. There were 3 adverse events and unfavorable outcomes.

CONCLUSIONS

Traction by the M-loop method improved SDS in colorectal ESD. The method can be an effective tool to assist colorectal ESD. Further evaluation of the usefulness of the M-loop method is required in direct comparison with conventional ESD.

The Relationship between Post-colonoscopy Colorectal Cancer and Quality Indicators of Colonoscopy: The Latest Single-center Cohort Study with a Review of the Literature

Objective This study aims to elucidate the association between the clinical characteristics of post-colonoscopy colorectal cancer (PCCRC) and quality indicators (QIs) of colonoscopy. Methods Patients with PCCRC who underwent total colonoscopy (TCS) and were histologically diagnosed with adenocarcinoma within six months to five years of the last examination were included in this study. PCCRC and normally detected cancer (NDC) identified within the same period were compared in terms of their clinicopathological characteristics. Furthermore, the QIs at PCCRC detection were compared to those at the last examination. Results Patients with PCCRC had a significantly higher rate of colon surgery history than those with NDC (PCCRC: 25/76, 32.9%; NDC: 31/1,437, 2.2%; p<0.001), but the invasion depth in these patients was significantly shallower (PCCRC: ≤Tis/≥T1, 37/39; NDC: ≤Tis/≥T1, 416/1,021; p<0.001). Among patients with PCCRC, the T1b group had significantly more non-polypoid growth (NPG)-type cases than PG-type CRC cases (p=0.018). The adenoma detection rate (ADR) of colonoscopists performing TCS was 30.2-52.8%. Furthermore, the ADR of colonoscopists at the time of PCCRC detection (36.7%±5.9%) was significantly higher than that of colonoscopists who performed the last examination (34.9%±4.4%; p=0.034). The withdrawal time for negative colonoscopy (WT-NC) at detection was significantly longer than that at the last examination (at detection: 494.3±253.8 s; at last examination: 579.5±243.6 s; p=0.010). Conclusion Given that these PCCRC cases were post-colon surgery cases, had a long WT-NC, and were detected by colonoscopists with a high ADR, most cases showed lesions that were missed during the previous colonoscopy. Caution should be practiced in order to avoid missing flat, NPG-type tumors.

Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also several types of precarcinomatous adenomas. It is important to establish practical guidelines wherein preoperative diagnosis of colorectal neoplasia and selection of endoscopic treatment procedures are appropriately outlined and to ensure that actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society compiled colorectal endoscopic submucosal dissection/endoscopic mucosal resection guidelines by using evidence-based methods in 2014. The first edition of these guidelines was published 5 years ago. Accordingly, we have published the second edition of these guidelines based on recent new knowledge and evidence.

Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) for superficial gastrointestinal neoplasms has become widespread. However, certain aspects of the procedure remain difficult to manage, such as intraoperative bleeding and perforation. There are two kinds of scissor-type knife: the Clutch Cutter (Fujifilm Co., Tokyo, Japan) and the SB knife (Sumitomo Bakelite Co., Tokyo, Japan). These knives have different features from other types of ESD knives and enable the performance of all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis. The standard approach with scissor-type knives involves first grabbing the tissue and then incising or dissecting it. Theoretically, perforation as a result of unintentional movement should never happen with scissor-type knives compared to needle- or blade-type knives, which may induce perforation through unintentional movement. Moreover, the rates of severe bleeding and self-completion of ESD with scissor-type knives by non-experts were reported to be significantly better than for other knives. Thus, scissor-type knives can resolve these problems and help to further standardize ESD globally. In this review, we summarize reports on the efficacy of such scissor-type knives for ESD of gastrointestinal tumors. We also present the pocket-creation method and the application of traction devices, such as dental floss and S-O clips (Zeon Medical Co., Tokyo, Japan) for improving the performance of ESD with a Clutch Cutter.

Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants

BACKGROUNDS AND AIMS

Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors.

MATERIALS AND METHODS

This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients' clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups.

RESULTS

The rates of POH were 7.9%∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6%∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively (∗ vs. ∗∗, p < 0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2 ± 8.3 vs. 7.2 ± 4.9, p < 0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment.

CONCLUSIONS

Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics.

Outcomes of endoscopic submucosal dissection (ESD) during live endoscopy events (LEE) - a 13-year follow-up

Background and study aims  There are no data showing the outcome of ESD during live endoscopy events (LEE). ESD performed during the Augsburg Endo-Update LEE were compared with matched routine procedures with the aim of demonstrating non-inferiority of LEE ESD. Patients and methods  ESD performed during the Endo-Update between 2006 and 2018 were reviewed. The controls were routine procedures matched according to age, location and lesion size. Resection, recurrence, survival and complication rates, procedure time and propofol sedation were assessed. Clinically relevant margins were assumed for resection and complication rates, procedure time and propofol sedation quantity. Results  Thirty-eight ESD were performed in the given time period, and were compared with 38 matched routine ESD. En bloc and curative resection rates in the LEE group and in the control group were 100 % and 87 % as well as 84 % and 71 % respectively, while procedure times were 135 and 125 minutes, respectively. Non-inferiority was demonstrated for resection rates and procedure time. The complication rate was lower in the LEE group as compared with the control group (5 % vs 13 %) while propofol sedation was similar in both groups (863 mg vs 872 mg). Recurrence and 5-year survival rates for both groups were 4 % vs 0 % and 70 % vs 65% respectively. Conclusions  The resection rate and procedure time of ESD during LEE was non-inferior to those of routine ESD procedures. Comparison of the complication rates, however, was inconclusive owing to the low patient number and complication risk in both groups.