Predictors of technical difficulty during endoscopic submucosal dissection of superficial esophageal cancer

More efficient endoscopic submucosal dissection with deep endotracheal intubation for superficial cervical esophageal carcinoma: a dual-center, prospective, randomized controlled study

BACKGROUND AND AIMS

Deep endotracheal intubation (DET) has been proposed to improve cervical esophageal endoscopic submucosal dissection (ESD) because of the limited space and visibility. We aimed to evaluate the efficacy and safety of DET.

METHODS

In the current dual-center trial, patients were randomized into DET or conventional endotracheal intubation (CET) groups. Complete resection rate, operation time, and adverse events were measured and compared.

RESULTS

Fifty-nine patients (60 lesions) were assigned to the groups, showing comparable baseline characteristics. The complete resection rates were similarly high in both groups. However, DET significantly reduced ESD operation time (52.2 minutes vs 71.1 minutes, P < .001) and postoperative pain scores (3.1 vs 4.7, P < .01). Severe stenosis occurred more frequently in the CET patients (20% vs 0%, P = .035). No significant differences were observed in other adverse events.

CONCLUSIONS

DET can overcome technical challenges to improve therapeutic efficiency and safety. (Clinical trial registration number: NCT06420258.).

Safety and efficacy of endoscopic submucosal dissection with gel immersion technique for superficial esophageal neoplasms

BACKGROUND AND AIM

Gel immersion (GI) endoscopy provides a good visual field in endoscopic submucosal dissection (ESD); however, its clinical outcomes are poorly understood. This study aimed to compare the treatment outcomes between esophageal gel immersion endoscopic submucosal dissection (GI-ESD) and conventional ESD (C-ESD) to determine the safety and efficacy of GI-ESD.

METHODS

The data of 71 consecutive patients who underwent esophageal ESD between April 2021 and March 2023 at a Japanese tertiary center were retrospectively reviewed. GI was achieved using an additional irrigation tube. The treatment outcomes between the GI-ESD and C-ESD groups were compared using inverse probability of treatment weighting (IPTW) to control for confounding factors.

RESULTS

A total of 75 superficial esophageal epithelial neoplasms (41 in the C-ESD and 34 in the GI-ESD groups) were treated using ESD. The mean procedure time in the GI-ESD group was significantly shorter than that in the C-ESD group (59.2 ± 36.2 vs 85.3 ± 45.7 min, P = 0.008). After IPTW adjustment, the mean procedural times were 62.6 ± 36.6 and 82.9 ± 41.7 min in the GI-ESD and C-ESD groups, respectively (P = 0.037), and the incidence rate of muscle layer damage was 4.2% in the GI-ESD group and 30.6% in the C-ESD group (P = 0.001). In the multivariate analysis, specimen size ≥ 30 mm (odds ratio [OR]: 9.44, 95% confidence interval [CI]: 2.46-36.30, P = 0.001) was positively correlated with longer procedural time (≥ 90 min), whereas GI-ESD (OR: 0.19, 95%CI: 0.05-0.68, P = 0.011) showed a negative association.

CONCLUSIONS

Esophageal GI-ESD may be useful in terms of safety and time efficiency. The GI technique could be an option for esophageal ESD.

Endoscopic submucosal dissection for superficial ultra-low rectal tumors: outcomes and predictive factors for procedure difficulty

BACKGROUND

Ultra-low rectal endoscopic submucosal dissection (ESD) presents technical challenges due to anatomical features. The objective of this research was to determine the risk factors linked to unsuccessful curative resections and to create a nomogram predictive model to assess the likelihood of encountering technical challenges.

METHODS

Patients with ultra-low rectal tumors received ESD form June 2017 to December 2022 were retrospectively enrolled. An ESD procedure exceeding 30 min was deemed difficult. A logistic regression analysis was performed to pinpoint important factors and predictors. The effectiveness of the nomogram, which incorporated the identified predictors, was evaluated by employing receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).

RESULTS

A total of 300 patients with ultra-low rectal tumors were enrolled, with a curative resection rate of 82.0%. Multivariate logistic regression revealed that poor lifting sign (OR = 3.282, P = 0.026), non-granular type laterally spreading tumors (LST-NG, OR = 2.230, P = 0.042) and procedure time ≥ 60 min (OR = 6.976, P = 0.010) contributed to non-curative resection. Predictors for ESD difficulty included tumor diameter ≥ 30 mm (compared with < 30 mm, 30-50 mm, OR = 2.450, P = 0.044; ≥ 50 mm, OR = 5.047, P = 0.009), ≥ 1/2 circumference involvement (OR = 3.183, P = 0.038); dentate line invasion (OR = 3.881, P = 0.026) and less colorectal ESD experience (OR = 3.415, P = 0.032). The nomogram performed well in both train and validation sets (area under the curve (AUC) = 0.873 and 0.810, respectively). Calibration plots exhibited satisfactory agreement between predicted and observed outcomes, and DCA showed superior clinical benefit of the model than individual predictors.

CONCLUSIONS

Poor lifting sign, LST-NG and procedure time ≥ 60 min were associated with non-curative resection for ultra-low rectal ESD. By including factors such as tumor size, location, and the operator's experience with ESD, the nomogram can predict the complexity of the procedure before surgery.

Characteristics of Esophageal Squamous Cell Carcinomas Based on Circumferential Localization

BACKGROUND AND AIM

In terms of their longitudinal positioning, esophageal squamous cell carcinoma (ESCC) commonly arises in the middle segment of the esophagus. However, limited attention has been given to the circumferential aspect. This study aimed to investigate the prevalence and characteristics of ESCC lesions resected via endoscopic submucosal dissection (ESD), taking into consideration both longitudinal and circumferential positions.

METHODS

We retrospectively evaluated 193 ESD-resected ESCC lesions and compared the occurrence rate of ESCC development and the degree of histopathological invasion across various circumferential and longitudinal positions. We scrutinized lesion characteristics by location, with a particular focus on the proportion of early-stage small lesions in each site.

RESULTS

Regarding lesion location, 27 were situated on the anterior wall, 62 on the left, 66 on the posterior, and 38 on the right. Among the four circumferential positions, the anterior wall group had the smallest median tumor size. Additionally, the anterior wall group had the highest proportions of lesions with invasion depths limited to the epithelial layer and sizes < 10 mm, at 44.4% and 25.9%, respectively. Furthermore, a significant difference was noted among the four circumferential positions with respect to the proportion of ESCC lesions satisfying both criteria, with the highest proportion observed in the anterior wall group (p = 0.049).

CONCLUSIONS

Our findings suggest that while ESCC occurrence on the anterior wall is less frequent, these lesions may present as small lesions with superficial invasion depths.

Assessment of predictive factors associated with the technical difficulty of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: Japanese multicenter retrospective study

OBJECTIVES

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) is performed for the treatment of lesions with varied backgrounds and factors. However, the predictive factors associated with the technical difficulty of ESD remain unknown in patients with varied lesions. Therefore, this study aimed to identify the predictive factors associated with the technical difficulty of ESD for ESCC using a retrospective cohort.

METHODS

This multicenter, retrospective study was conducted in 10 hospitals in Japan. Consecutive patients who underwent esophageal ESD between January 2013 and December 2019 were enrolled. Lesions of subepithelial tumors, adenocarcinoma, and adenoma were excluded. Difficult lesions were defined as ESD requiring a long procedure time (≥120 min), perforation development, piecemeal resection, or discontinued ESD. In the present study, the clinical factors were assessed to identify the technical difficulty of ESD using univariate and multivariate analyses.

RESULTS

Among 1708 lesions treated with esophageal ESD, eight subepithelial tumors, 44 adenocarcinomas, and two adenomas were excluded. Finally, 1505 patients with 1654 lesions were analyzed, and 217 patients with 217 lesions (13.1%) were classified as patients with difficult lesions. In multivariate analysis, the predictive factors associated with the technical difficulty of ESD were as follows: tumors with varices, tumors with diverticulum, antiplatelet use (discontinued), circumference of tumor (≥1/2), preoperative tumor size ≥30 mm, trainee, and nonhigh-volume center.

CONCLUSION

This multicenter retrospective study identified the predictive factors associated with the technical difficulty of ESD for ESCC with varied backgrounds and factors.

Predictive factors associated with technical difficulty in colorectal endoscopic submucosal dissection: A Honam Association for the Study of Intestinal Disease (HASID) multicenter study

Colorectal endoscopic submucosal dissection (ESD) is a promising but challenging procedure. It is not widely performed due to its technical difficulty. We aimed to find the predictive factors associated with technical difficulty in colorectal ESD before the procedure. Clinical data from patients who underwent ESD for colorectal tumors in 5 hospitals in Honam province of South Korea between 2015 and 2020 were reviewed retrospectively. Technically difficult colorectal ESD procedure was defined in 3 points. Long procedure time (longer than 60 minutes), occurrence of perforation, and failure of en bloc resection. Factors associated with technically difficult ESD were included as main outcome measure. 1446 patients were identified and their data were analyzed. Median procedure time was 30.0 minutes and median long axis of the tumor was 20.1 mm. Technically difficult procedures including long procedure time were 231 cases (16.0%), perforation occurred in 34 cases (2.3%), and en bloc resection was done in 1292 cases (89.3%). Tumor size larger than 35 mm (odd ratio [OR]: 1.474, P = .047), central depression or ulceration in the lesion (OR: 1.474, P = .013), previous endoscopic mucosal resection (EMR) or polypectomy procedure (OR: 2.428, P = .020) were associated with technically difficult ESD. Descending colon-located tumor (OR: 5.355, P < .001), and use of IT knife (OR: 4.157, P = .003) were associated with perforation. Recognizing factors associated with technically difficult ESD can help in planning the ESD procedure beforehand.

Validation and update of a clinical score model to predict technical difficulty of colorectal endoscopic submucosal dissection: a multicenter prospective cohort study

BACKGROUND AND AIMS

The Zhongshan colorectal endoscopic submucosal dissection (CR-ESD) score model was proposed to grade the technical difficulty of CR-ESD. The objective of this study was to prospectively validate and update the score model.

METHODS

A multicenter prospective cohort analysis of CR-ESD was conducted. Individual data on patients, lesions, and outcomes of CR-ESD were used to validate the original model and further refine the difficulty of the prediction model. Data were randomly divided into discovery and internal validation cohorts. A multivariate Cox regression analysis was conducted on the discovery cohort to develop an updated risk-scoring system, which was then validated.

RESULTS

Five hundred forty-eight patients with 565 colorectal lesions treated by ESD from 4 hospitals were included. In the prospective validation cohort, the area under the receiver-operating characteristic (ROC) curve for the original model was .707. Six risk factors were identified and assigned point values: tumor size (2 points for 30-50 mm, 3 points for ≥50 mm), at least two-thirds circumference of the lesion (3 points), tumor location in the cecum (2 points) or flexure (2 points), laterally spreading tumor-nongranular lesions (1 point), preceding biopsy sampling (1 point), and NBI International Colorectal Endoscopic type 3 (3 points). The updated model had an area under the ROC curve of .738 in the discovery cohort and of .782 in the validation cohort. Cases were categorized into easy (score = 0-1), intermediate (score = 2-3), difficult (score = 4-6), and very difficult (score ≥7) groups. Satisfactory discrimination and calibration were observed.

CONCLUSIONS

The original model achieved an acceptable level of prediction in the prospective cohort. The updated model exhibited superior performance and can be used in place of the previous version. (Clinical trial registration number: ChiCTR2100047087.).

Endoscopic resection of giant esophageal subepithelial lesions: experience from a large tertiary center

BACKGROUND AND AIMS

Increased reports on endoscopic resection (ER) of esophageal giant subepithelial lesions (g-SELs) have emerged in recent years. The aim of this study was to evaluate the efficacy, technical difficulty, and safety through our single-center experience.

METHODS

Seventy-five patients with g-SELs undergoing endoscopic resection were included in the training set. Clinicopathologic features, procedure-related characteristics, postprocedural outcomes, and follow-up data were analyzed. A predictive nomogram model for procedural difficulty was proposed based on the multivariable logistic regression analysis. Internal and external validations were conducted to verify the model performance.

RESULTS

The overall en bloc resection rate was 93.3%. Intraoperative and postoperative adverse events occurred in 7 (9.3%) and 13 (17.3%) patients, respectively. No recurrence or metastasis was observed. Thirty-two (42.7%) patients underwent a difficult procedure. Age (adjusted odds ratio [aOR], .915; P = .004), maximal tumor diameter ≥8 cm (aOR, 9.896; P = .009), irregular shape (aOR, 4.081; P = .053), extraluminal growth pattern (aOR, 5.419; P = .011), and submucosal tunneling endoscopic resection (aOR, .109; P = .042) were found to be statistically or clinically significant factors for predicting endoscopic resection difficulty, based on which a nomogram model was developed. Internal and external validations of the nomogram via receiver-operating characteristic curves and calibration curves achieved favorable results.

CONCLUSIONS

Endoscopic resection serves as a promising therapeutic option for esophageal g-SELs. A younger patient age, large tumor size, irregular shape, and extraluminal growth may indicate increased endoscopic resection difficulty, whereas a submucosal tunneling endoscopic resection procedure tends to be of lower difficulty. Our nomogram model performs well for predicting endoscopic resection difficulty for esophageal g-SELs.

Predictors of technical difficulty for trainees in esophageal endoscopic submucosal dissection

BACKGROUND

Esophageal endoscopic submucosal dissection (ESD) is technically challenging, especially for trainees, and requires a safe training system. This study aimed to identify predictors of technical difficulty facing trainees performing esophageal ESD to establish such system.

METHODS

This was a single-center retrospective study of patients with esophageal cancer who underwent ESD performed by trainees between January 2010 and August 2022. Technical difficulties were defined as muscularis propria exposure and long procedure time (≥ 90 min). Factors associated with these technical difficulties were investigated.

RESULTS

A total of 798 lesions in 721 patients were evaluated. Muscularis propria exposure occurred in 298 lesions (37.3%), including 10 perforations (1.3%). The procedure time was ≥ 90 min in 134 lesions (16.8%). In the multivariate analysis, tumor size ≥ 20 mm, tumors ≥ 1/2 of the circumference, and those close to previous treatment scars significantly increased the incidence of both difficulties, whereas tumors in the upper esophagus significantly decreased this incidence. Furthermore, female sex and tumors in the left wall were independent predictors of muscularis propria exposure, and elevated morphology was an independent predictor of long procedure time. Muscularis propria exposure and long procedure time occurred in more than half of the cases with three or more predictors of each difficulty.

CONCLUSIONS

Large tumors and tumors close to previous treatment scars increase technical difficulties for trainees in esophageal ESD. Conversely, tumors in the upper esophagus reduce these difficulties. These results enable us to predict the difficulty level preoperatively and select appropriate cases in stepwise training.

Predictive Factors for the Outcome of Unsupervised Endoscopic Submucosal Dissection During the Initial Learning Curve with Prevalence-Based Indication

BACKGROUND

For an adequate educational strategy of ESD in non-Asian settings with prevalence-based indication it is essential to define adequate lesions, suitable for the beginner without on-site expert-supervision.

AIMS

We analyzed possible predictors for outcome parameters of effectiveness and safety during the initial learning curve.

METHODS

The first 120 ESDs of four operators (n = 480), performed between 2007 and 2020 in four tertiary hospitals, were enrolled. Uni-/multivariable regression analysis was done with sex, age, pretreated lesion, lesion size, organ, and organ-based localization as possible independent predictors for en bloc resection (EBR), complication, and resection speed.

RESULTS

Rates of EBR, complication, and resection speed were 84.5%, 14.2%, and 6.20 (± 4.45) cm2/h. Independent predictors for EBR were pretreated lesion (OR 0.27 [0.13-0.57], p < 0.001) and non-colonic ESD (OR 2.29 [1.26-4.17] (rectum)/5.72 [2.36-13.89] (stomach)/7.80 [2.60-23.42] (esophagus), p < 0.001), for complication pretreated lesion (OR 3.04 [1.46-6.34], p < 0.001) and lesion size (OR 1.02 [1.004-1.04], p = 0.012) and for resection speed pretreated lesion (RC - 3.10 [- 4.39 to - 1.81], p < 0.001), lesion size (RC 0.13 [0.11-0.16], p < 0.001) and male patient (RC - 1.11 [- 1.85 to - 0.37], p < 0.001). We found no significant difference in the incidence of technically unsuccessful resections in esophageal (1/84), gastric (3/113), rectal (7/181), and colonic (3/101) ESDs (p = 0.76). Technical failure was mainly caused by complication and fibrosis/pretreatment.

CONCLUSION

During the initial learning curve of an unsupervised ESD program with prevalence-based indication, pretreated lesions and colonic ESDs should be avoided. In contrast, lesion size and organ-based localizations have less predictive value for the outcome.

Development and validation of a preoperative difficulty scoring system for endoscopic resection of gastric gastrointestinal stromal tumor: a multi-center study

BACKGROUND

Endoscopic resection (ER) is a promising technique for resecting gastric gastrointestinal stromal tumors (gGISTs); however, ER is technically challenging. This study aimed to develop and validate a difficulty scoring system (DSS) to determine the difficulty for ER of a gGIST.

METHODS

This retrospective study enrolled 555 patients with gGISTs in multi-centers from December 2010 to December 2022. Data on patients, lesions, and outcomes of ER were collected and analyzed. A difficult case was defined as an operative time ≥ 90 min, or the occurrence of severe intraoperative bleeding, or conversion to laparoscopic resection. The DSS was developed in the training cohort (TC) and validated in the internal validation cohort (IVC) and external validation cohort (EVC).

RESULTS

The difficulty occurred in 97 cases (17.5%). The DSS comprised the following: tumor size ≥ 3.0 cm (3 points) or 2.0-3.0 cm (1 point); location in the upper third of the stomach (2 points); invasion depth beyond the muscularis propria (2 points); lack of experience (1 point). The area under the curve (AUC) of DSS in IVC and EVC was 0.838 and 0.864, respectively, and the negative predictive value (NPV) was 0.923 and 0.972, respectively. The proportions of difficult operation in easy (score 0-3), intermediate (score 4-5), and difficult (score 6-8) categories were 6.5%, 29.4%, and 88.2% in the TC, 7.7%, 45.8%, and 85.7% in the IVC, and 7.0%, 29.4%, and 85.7% in the EVC, respectively.

CONCLUSIONS

We developed and validated a preoperative DSS for ER of gGISTs based on tumor size, location, invasion depth, and endoscopists' experience. This DSS can be used to grade the technical difficulty before surgery.

Automated machine learning to predict the difficulty for endoscopic resection of gastric gastrointestinal stromal tumor

Background

Accurate preoperative assessment of surgical difficulty is crucial to the success of the surgery and patient safety. This study aimed to evaluate the difficulty for endoscopic resection (ER) of gastric gastrointestinal stromal tumors (gGISTs) using multiple machine learning (ML) algorithms.

Methods

From December 2010 to December 2022, 555 patients with gGISTs in multi-centers were retrospectively studied and assigned to a training, validation, and test cohort. A difficult case was defined as meeting one of the following criteria: an operative time ≥ 90 min, severe intraoperative bleeding, or conversion to laparoscopic resection. Five types of algorithms were employed in building models, including traditional logistic regression (LR) and automated machine learning (AutoML) analysis (gradient boost machine (GBM), deep neural net (DL), generalized linear model (GLM), and default random forest (DRF)). We assessed the performance of the models using the areas under the receiver operating characteristic curves (AUC), the calibration curve, and the decision curve analysis (DCA) based on LR, as well as feature importance, SHapley Additive exPlanation (SHAP) Plots and Local Interpretable Model Agnostic Explanation (LIME) based on AutoML.

Results

The GBM model outperformed other models with an AUC of 0.894 in the validation and 0.791 in the test cohorts. Furthermore, the GBM model achieved the highest accuracy among these AutoML models, with 0.935 and 0.911 in the validation and test cohorts, respectively. In addition, it was found that tumor size and endoscopists' experience were the most prominent features that significantly impacted the AutoML model's performance in predicting the difficulty for ER of gGISTs.

Conclusion

The AutoML model based on the GBM algorithm can accurately predict the difficulty for ER of gGISTs before surgery.

Safety and efficacy of endoscopic submucosal dissection for superficial esophageal cancer with esophageal varices

BACKGROUND

Heavy drinking is associated with esophageal cancer and esophageal varices. However, there are limited reports of endoscopic resection for esophageal cancer with esophageal varices. In this multicenter study, we clarified the safety and efficacy of endoscopic submucosal dissection for superficial esophageal cancer with esophageal varices.

METHODS

In this multicenter, retrospective, observational study, patients underwent esophageal endoscopic submucosal dissection at 10 referral centers in Japan from January 2013 to December 2019. We analyzed characteristics including backgrounds and varices, treatment outcomes, and adverse events in cases with esophageal varices.

RESULTS

A total of 1708 patients were evaluated, 27 (1.6%) of whom had esophageal varices. In patients with esophageal varices, the en bloc resection rate and R0 resection rate were 100% and 77.8%, respectively. Patients with esophageal varices had longer procedure times than patients without esophageal varices (p = 0.015). There was no significant difference in adverse events. There was no significant difference in procedure time and number of adverse events between patients who underwent pretreatment and those who did not. There was no significant difference in these outcomes for patients with lesions on varices compared to those without. Child-Pugh classification and location of the lesions also did not affect these outcomes.

CONCLUSIONS

Esophageal cancer with esophageal varices could be treated endoscopically safely and effectively.

The relationship between the esophageal endoscopic submucosal dissection technical difficulty and its intraoperative process

BACKGROUND

Estimating the esophageal endoscopic submucosal dissection (ESD) technical difficulty is important to reduce complications. Endoscopic duration is one of the related factors to a technical difficulty. The relationship between the esophageal ESD technical difficulty and its intraoperative process was analyzed as a first step toward automatic technical difficulty recognition using artificial intelligence.

METHODS

This study enrolled 75 patients with superficial esophageal cancer who underwent esophageal ESD. The technical difficulty score was established, which consisted of three factors, including total procedure duration, en bloc resection, and complications. Additionally, technical difficulty-related factors, which were perioperative factors that included the intraoperative process, were investigated.

RESULTS

Eight (11%) patients were allocated to high difficulty, whereas 67 patients (89%) were allocated to low difficulty. The intraoperative process, which was shown as the extension of each endoscopic phase, was significantly related to a technical difficulty. The area under the curve (AUC) values were higher at all the phase duration than at the clinical characteristics. Submucosal dissection phase (AUC 0.902; 95% confidence intervals (CI) 0.752-1.000), marking phase (AUC 0.827; 95% CI 0.703-0.951), and early phase which was defined as the duration from the start of marking to the end of submucosal injection (AUC 0.847; 95% CI 0.701-0.992) were significantly related to technical difficulty.

CONCLUSIONS

The intraoperative process, particularly early phase, was strongly associated with esophageal ESD technical difficulty. This study demonstrated the potential for automatic evaluation of esophageal ESD technical difficulty when combined with an AI-based automatic phase evaluation system.

Efficacy of lidocaine injection method for esophageal endoscopic submucosal dissection: single-center, double-blind, randomized controlled trial

BACKGROUND

Intraoperative body movements are one of the causes of difficulty in performing esophageal endoscopic submucosal dissection (ESD) under conscious sedation. The use of local anesthetics as local injection materials during ESD may overcome this difficulty. We clinically evaluated the lidocaine injection method (LIM) in the submucosa during esophageal ESD.

METHODS

This was a single-center, prospective, double-blind, randomized trial. Patients who underwent esophageal ESD under conscious sedation from June 2018 to May 2021 were included in this study. In the LIM group, lidocaine was used for submucosal injection during ESD; in the control group, ESD was performed without lidocaine. The primary outcome was the presence of body movements.

RESULTS

Fifty patients were enrolled and randomized in a 1:1 ratio in two groups. The incidence of body movements was significantly lower in the LIM group (12% [3/25]) than in the control group (48% [12/25]; P = 0.01). The median additional dose of midazolam was 2 mg (interquartile range [IQR]: 0.5-4 mg) in the LIM group and 4 mg (IQR: 3-6 mg) in the control group, which was significantly lower in the LIM group (P < 0.01). The median visual analog scale score for endoscopist satisfaction was 7 (IQR: 5-8) in the LIM group and 5 (IQR: 4-6.5) in the control group, which was significantly higher in the LIM group.

CONCLUSIONS

LIM during esophageal ESD reduced body movements while decreasing the level of sedation. Therefore, LIM during esophageal ESD is an option for maintaining good sedation (UMIN000032804).

Novel image enhancement technology that helps find bleeding points during endoscopic submucosal dissection of gastric neoplasms

BACKGROUND AND AIM

The management of bleeding during endoscopic submucosal dissection (ESD) is critical and related to the procedure time. We collaborated on a new image enhancement algorithm with parameter optimization for clinical use being developed by FUJIFILM Co. and processed white light image data offline to evaluate the effectiveness of this technology. This study aims to evaluate the clinical usefulness of this technology.

METHODS

Eighteen video scenes of bleeding points from five gastric ESDs were selected and processed by the new image enhancement algorithm. The time until a bleeding point was found, visibility of a bleeding point, and color abnormality of the submucosal layer were evaluated by ESD experts, ESD trainees, and endoscopy trainees. The color differences between the bleeding point and the surroundings in CIE-L*a*b* color space were calculated in the original and enhanced images.

RESULTS

The time until a bleeding point was found in the enhanced videos was significantly shorter than that in the original videos (11.10 s vs 13.85 s) (P = 0.017). On a 5-point (-2 to +2) Likert scale of visibility, the enhanced image was slightly superior to the original (+0.45), and the appearance of the submucosa was comparable between images (+0.14). The color difference among the bleeding areas on the enhanced images was significantly larger than that on the original images (10.93 vs 8.36).

CONCLUSION

This novel image enhancement algorithm emphasizes the color difference between a bleeding point and the surrounding area, which would help find bleeding points faster during ESD for the less experienced endoscopists.

Gel immersion endoscopic submucosal dissection: clinical experience with 13 cases of superficial esophageal cancer

Esophageal endoscopic submucosal dissection (ESD) of tumors located on the gravity side is technically challenging. Given that gel immersion ESD (GIESD) is performed by immersing lesions in gel, we hypothesized that it could be used to eliminate the disadvantage associated with submerging the gravity side. Here, we performed GIESD using VISCOCLEAR for superficial esophageal cancer on the gravity side of the esophagus, with monopolar devices. This study aimed to evaluate the short-term outcomes of GIESD for superficial esophageal cancer. Fifteen patients with 16 superficial esophageal cancers underwent GIESD by a single operator, and 13 cases were evaluated. All patients were male, and GIESD was performed in the middle (12/13, 92.3 %) and lower (1/13, 7.7 %) thoracic esophagus. The lesions were located on the left (7/13, 53.8 %), posterior (5/13, 38.5 %), and right (1/13, 7.7 %) esophageal walls. The median procedure time was 27 minutes (interquartile range [IQR], 14-68), and the median dissection speed was 20 mm ² /min (IQR, 14-25.7). The median amount of gel used was 400 mL (IQR, 360-580), and no gel-related adverse events were observed. The median total dose of midazolam was 3 mg (IQR, 2-5). GIESD was completed with en bloc and R0 resections achieved in 100 % of the 13 cases. Delayed adverse events, such as bleeding or perforation, did not occur (0/13, 0 %).

Intelligent Identification of Early Esophageal Cancer by Band-Selective Hyperspectral Imaging

In this study, the combination of hyperspectral imaging (HSI) technology and band selection was coupled with color reproduction. The white-light images (WLIs) were simulated as narrow-band endoscopic images (NBIs). As a result, the blood vessel features in the endoscopic image became more noticeable, and the prediction performance was improved. In addition, a single-shot multi-box detector model for predicting the stage and location of esophageal cancer was developed to evaluate the results. A total of 1780 esophageal cancer images, including 845 WLIs and 935 NBIs, were used in this study. The images were divided into three stages based on the pathological features of esophageal cancer: normal, dysplasia, and squamous cell carcinoma. The results showed that the mean average precision (mAP) reached 80% in WLIs, 85% in NBIs, and 84% in HSI images. This study's results showed that HSI has more spectral features than white-light imagery, and it improves accuracy by about 5% and matches the results of NBI predictions.

Clinical benefit of tunnel endoscopic submucosal dissection for esophageal squamous cancer: a multicenter, randomized controlled trial

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is widely accepted as a primary treatment modality for dysplastic and early cancerous lesions of the GI tract. However, prolonged procedure time and life-threatening adverse events remain obstacles to the successful treatment of esophageal cancer. This study aimed to compare the efficacy and safety of tunnel ESD (T-ESD) with conventional ESD (C-ESD) for superficial esophageal squamous neoplasms.

METHODS

A prospective, multicenter trial was conducted at 5 hospitals in China. Patients with esophageal squamous neoplasms were enrolled and randomly assigned to undergo C-ESD or T-ESD. Randomization was stratified by tumor location and circumference extent (<1/2 or ≥1/2). The primary endpoint was procedure time.

RESULTS

Between January and July 2018, 160 patients were enrolled. One hundred fifty-two patients (76 in the C-ESD group and 76 in the T-ESD group) were included in the final analysis. The median procedure time was 47.3 minutes (interquartile range, 31.7-81.3) for C-ESD and 40.0 minutes (interquartile range, 30.0-60.0) for T-ESD (P = .095). However, T-ESD specifically reduced the median procedure time 34.5% (29.5 minutes) compared with C-ESD for lesions ≥1/2 circumference (P < .001). Among the multiple secondary outcomes, muscular injury was less frequent in the T-ESD group compared with the C-ESD group (18.4% vs 38.2%, P = .007), but complete healing of artificial mucosal defect in 1-month follow-up was more common in the T-ESD group than the C-ESD group (95.9% vs 84.7%, P =.026).

CONCLUSIONS

Our study suggests that T-ESD results in shorter procedure time, specifically for lesions ≥1/2 circumference of the esophagus. In addition, T-ESD has a better safety profile indicated by less frequent muscular injury and improved healing of artificial mucosal defects caused by ESD procedures. (Clinical trial registration number: NCT03404921.).

Associated risk factor analysis and the prognostic impact of positive resection margins after endoscopic resection in early esophageal squamous cell carcinoma

Endoscopic resection for early esophageal cancer has a risk of residual margins. The risk these residual margins pose have not been fully evaluated. The present study aimed to investigate the associated risk factors and prognosis of residual margins following the endoscopic resection of early esophageal squamous cell carcinoma. In total, 369 patients (381 lesions) with early esophageal squamous cell carcinoma treated in the Fourth Hospital of Hebei Medical University (Shijiazhuang, China) with endoscopic resection were retrospectively analyzed. Sex, age, location, tumor diameter, depth of tumor invasion, endoscopic treatment, endoscopic ultrasonography (EUS) before resection, work experience of endoscopists and the degree of tumor differentiation were all evaluated as potential risk factors. In addition, the prognosis of patients with positive margins were analyzed. A total of 73 patients (73/381, 19.2%) had positive margins after endoscopic resection. Amongst the 65 patients who were successfully followed up, five patients succumbed to cardiovascular and cerebrovascular diseases, one patient received radiotherapy, two patients received radiotherapy and chemotherapy whilst one patient received chemotherapy. By contrast, 12 patients received surgery and 20 patients received additional endoscopic mucosal resection or endoscopic submucosal dissection. The other 29 patients were followed up regularly and no recurrence could be found. Univariate analysis revealed that tumor diameter, endoscopic treatment, depth of invasion, EUS before resection, degree of tumor differentiation and direction of invasion were all associated with the positive margin. Multivariate logistic regression analysis then found that EUS before resection, degree of tumor differentiation and depth of tumor invasion are independent risk factors for positive margins after endoscopic resection. These results suggest that poorly differentiated lesions and deeper invasion depth can increase the risk of positive margin after endoscopic resection. As a result, EUS evaluation before resection may reduce the risk of invasion depth. In addition, for poorly differentiated lesions, more aggressive treatment regimens may be recommended for preventing recurrence.

Propensity-score matched analysis to evaluate efficacy of endoscopic submucosal dissection for superficial esophageal cancer in gastrectomized patients

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for superficial esophageal cancer (SEC) with high rates of complete resection. However, limited research exists on the efficacy of ESD for SEC in gastrectomized patients. This study aimed to evaluate the efficacy of ESD for SEC in gastrectomized patients. We included 318 patients of SEC treated at our institution between April 2005 and October 2021. To minimize bias between the gastrectomized and non-gastrectomized groups, we conducted a propensity-score matched analysis and compared the ESD outcomes for SEC of the two groups. Of the 318 patients included in the study, 48 and 270 patients were in the gastrectomized and non-gastrectomized groups, respectively. After 1:2 propensity-score matching, we matched 44 patients in the gastrectomized group to 88 patients in the non-gastrectomized group, and found no significant differences in the baseline clinicopathological characteristics. Regarding the ESD outcomes, there were no significant differences in the complete resection rate, procedure time, hospitalized period, and recurrence rates between the two groups. Multivariate analysis also cofirmed that the history of gastrectomy was not a risk factor of the difficult case of esophageal ESD. In conclusion, history of gastrectomy might not negatively affect the ESD outcomes of SECs.

Predictors of the difficulty for endoscopic resection of gastric gastrointestinal stromal tumor and follow-up data

BACKGROUND AND AIM

Gastrointestinal stromal tumors (GISTs) are among the most common submucosal tumors in the stomach that require therapeutic intervention. We aim to identify the predictors of technical difficulty during endoscopic resection of gastric GIST and to investigate follow-up outcomes.

METHODS

Patients with gastric GISTs were reviewed from June 2009 to June 2020 at Zhongshan Hospital. Clinical and pathological features, endoscopic procedure information, and follow-up data were collected and analyzed. A nomogram was developed and validated internally and externally.

RESULTS

A total of 628 GISTs were finally analyzed. The difficulty was experienced in 66 cases. GISTs size (2-3 cm: OR 2.431 P = 0.018 and > 3 cm: OR 9.765 P < 0.001), invasion depth beyond submucosal (MP: OR 2.280, P = 0.038 and MP-ex: OR 4.295, P = 0.002), and lack of experience (OR 2.075, P = 0.016) were independent risk factors of difficulty. The nomogram prediction model showed a bias-corrected C-index value of 0.778 and acquired an area under curve (AUC) of 0.756 on the external validation cohort. At the cut-off of 0.15, the nomogram's negative predictive value (NPV) and accuracy (ACC) were 94.9% and 79.8% in identifying non-difficult GISTs. Follow-up results showed that only five GIST patients had local recurrence after endoscopic resection.

CONCLUSIONS

Tumor size, invasion depth, and endoscopists' experience were risk factors for the difficulty of endoscopic GIST resection. Our nomogram provided a valuable tool for screening non-difficult GIST resection.

Predictors for Submucosal Fibrosis in Patients With Superficial Squamous Esophageal Neoplasia Undergoing Endoscopic Submucosal Dissection

INTRODUCTION

Submucosal fibrosis greatly hinders the success of endoscopic submucosal dissection (ESD). This study determined ESD outcomes in patients with esophageal submucosal fibrosis and further explored the predictors.

METHODS

We retrospectively analyzed 163 patients with superficial squamous esophageal neoplasia. The degree of submucosal fibrosis was classified as follows: F0, none; F1, mild; and F2, severe. ESD outcomes as a function of the degree of submucosal fibrosis and biopsy were determined. The potential predictors of submucosal fibrosis were analyzed.

RESULTS

En bloc resection, R0 resection, and procedure time were significantly different between the F0-F2 groups (P = 0.009, P = 0.002, and P < 0.001, respectively). Perforation and immediate bleeding rates of F2 were significantly higher than the F0/F1 groups (P < 0.001 and P < 0.001, respectively). However, the nonbiopsy group vs the biopsy group and the delayed ESD group (postbiopsy >21 days) vs the early ESD group (postbiopsy ≤21 days) showed no statistical differences regarding the en bloc resection, R0 resection, and ESD complications (all P > 0.05). Further analysis indicated that it was not the biopsy history and delayed ESD (both P > 0.05), rather submucosal invasion vs intramucosal tumor (odds ratio = 4.534, P = 0.003) and current smoker vs nonsmoker (odds ratio = 2.145, P = 0.043) were independent risk factors for endoscopic submucosal fibrosis.

DISCUSSION

Esophageal submucosal fibrosis was shown to be closely related to unsatisfactory ESD outcomes. Biopsy history and delayed ESD had no adverse effect on submucosal fibrosis and ESD outcomes. Submucosal invasion and current cigarette smoking were predictors of submucosal fibrosis.

Prediction of technically difficult endoscopic submucosal dissection for large superficial colorectal tumors: a novel clinical score model

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a promising technique for removing superficial GI tumors, but ESD is technically difficult. The aim of this study was to establish a clinical score model for grading technically difficult colorectal ESD.

METHODS

Data on patients, lesions, and outcomes of colorectal ESD at 2 centers were analyzed. The objective parameter of successful ESD within 60 minutes was set as an endpoint to evaluate the difficulty. Independent predictors of difficulty in the derivation cohort were identified by multiple logistic regression analysis and used to develop a clinical score. We validated the score model in the validation cohort.

RESULTS

The clinical score comprised tumor size of 30 to 50 mm (1 point) or ≥50 mm (2 points), at least two-thirds circumference of the lesion (2 points), location in the cecum (1 point), flexure (2 points) or dentate line (1 point), and laterally spreading tumor nongranular lesions (1 point). Areas under the receiver operator characteristic curves for the score model were comparable (derivation [.70] vs internal validation [.69] vs external validation [.69]). The probability of successful ESD within 60 minutes in easy (score = 0), intermediate (score = 1), difficult (score = 2-3), and very difficult (score ≥4) categories were 75.0%, 51.3%, 35.6%, and 3.4% in the derivation cohort; 73.3%, 47.9%, 31.8%, and 16.7% in the internal validation cohort; and 79.5%, 66.7%, 43.3%, and 20.0% in the external validation cohort, respectively.

CONCLUSIONS

This clinical score model accurately predicts the probability of successful ESD within 60 minutes and can be applied to grade the technical difficulty before the procedure.

Predictive factors for difficult endoscopic submucosal dissection for esophageal neoplasia including failure of en bloc resection or perforation

BACKGROUND

Endoscopic submucosal dissection (ESD) is accepted as the standard treatment for early-stage esophageal neoplasia. However, esophageal perforation may occur, leading to mediastinitis and pneumothorax, which occasionally require emergency surgery. Moreover, failure of en bloc resection causes local recurrence. However, studies on the predictors of such difficulties during ESD are limited. Hence, we evaluated the predictors associated with the difficulty of ESD for esophageal neoplasia including failure of en bloc resection or perforation.

METHODS

Data of 549 consecutive patients who were treated with ESD between May 2004 and March 2016 at a single institution were retrospectively studied. Exclusion criteria were the presence of metachronous esophageal neoplasia or missing data. The primary outcome was determining the predictors associated with the difficulty of ESD for esophageal neoplasia including failure of en bloc resection or perforation.

RESULTS

Altogether, 543 patients with 736 lesions were evaluated. Failure of en bloc resection occurred in 6 patients (1.1%) with 6 lesions, and perforation occurred in 11 patients (2.0%) with 11 lesions (1.5%). Multivariate logistic regression analysis showed that large lesion diameter (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.21-1.84; p < 0.001) and previous chemoradiotherapy (OR 5.24; 95% CI 1.52-18.06; p = 0.009) were independent predictive factors.

CONCLUSIONS

Larger lesions and previous chemoradiotherapy for esophageal cancer increased the risk for failure of en bloc resection or perforation in patients who underwent esophageal ESD.

Current status of endoscopic submucosal tunnel dissection for treatment of superficial gastrointestinal neoplastic lesions

INTRODUCTION

With the widespread application of screening endoscopy and development of endoscopy-related instruments, more and more gastrointestinal cancers are detected in an early stage. Endoscopic resection is a preferred method for selected patients with superficial gastrointestinal neoplastic lesions, and endoscopic submucosal dissection (ESD) has become a standard method for its ability to perform en bloc resection regardless of the lesion size. ESD can be performed in a conventional or tunneling way, and the latter is termed endoscopic submucosal tunnel dissection (ESTD).

AREA COVERED

In the present review, we provided a comprehensive review on ESTD for treatment of superficial gastrointestinal neoplastic lesions. We mainly focus on technical details, safety and efficacy of ESTD for esophageal, gastric and colorectal lesions. The present review is expected to provide tips for operators who are going to perform ESTD.

EXPERT OPINION

The best indication of ESTD is large superficial esophageal neoplastic lesions (circumferential extent > 1/3 and longitudinal extent > 3 cm). Although ESTD has shown promising primary results for superficial gastric and colorectal neoplastic lesions, it is technically difficult and should be attempted only in experienced hands. Post-treatment stricture is a major concern, and preventive measures are recommended for patients with high risk of post-ESTD stricture.

Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is widely used as a minimally invasive treatment for large esophageal cancers, but prolonged procedure duration and life-threatening adverse events remain matters of concern. We aimed to determine whether traction-assisted ESD (TA-ESD) is superior to conventional ESD in terms of technical outcomes.

METHODS

A superiority, randomized, phase III trial was conducted at 7 institutions across Japan. Patients with large esophageal cancer (defined as tumor diameter >20 mm) were eligible for this study. Enrolled patients were randomly assigned to undergo conventional ESD or TA-ESD. The primary endpoint was ESD procedure duration.

RESULTS

Two hundred forty-one patients were recruited and randomized. On applying exclusion criteria, 117 and 116 patients who underwent conventional ESD and TA-ESD, respectively, were included in the baseline analysis. In 1 patient, conventional ESD was discontinued because of severe perforation. Thus, the final analysis included 116 patients per group (primary analysis). The ESD procedure duration was significantly shorter for TA-ESD than for conventional ESD (44.5 minutes vs 60.5 minutes, respectively; P < .001). Moreover, no adverse events were noted in the TA-ESD group. The rate of horizontal margin involvement did not differ between the groups (10.3% vs 6.9% for conventional ESD and TA-ESD, respectively; P = .484).

CONCLUSIONS

TA-ESD was superior to conventional ESD in terms of procedure duration and was not associated with any adverse events. TA-ESD should be considered the procedure of choice for large esophageal cancers. (Clinical trial registration number: UMIN000024080.).

Comparison of the therapeutic effects of endoscopic submucosal dissection and minimally invasive esophagectomy for T1 stage esophageal carcinoma

BACKGROUND

In recent years, diagnosis of early squamous cell carcinoma of the esophagus has been increasingly emphasized. The application of endoscopic submucosal dissection (ESD) has enabled safe resection of esophageal lesions. Minimally invasive esophagectomy (MIE) is also safe and feasible for early stages of the cancer. This study aimed to compare the therapeutic effects of early esophageal carcinoma treatment, and find the best predictive factor for the selection of treatment for T1a patients.

METHODS

We performed a retrospective study of early-stage patients admitted to Tianjin Medical University Cancer Institute and Hospital between January 2015 and December 2018. A total of 128 patients underwent MIE, while 78 patients underwent ESD. The depth of the tumor invasion, lymph node metastasis, and complications were compared between the two groups.

RESULTS

In the ESD group, 76.92% of the patients were stage T1a, while 34.38% in the MIE group were stage T1a. The lymph node metastasis rate was 16.41% in the MIE group (6.98% in T1a stage), which related to tumor differentiation, tumor length (≥37.5 mm), depth of invasion, and angiolymphatic invasion. However, the R0 resection rate was only 73.08% in the ESD group. Comprehensive analysis of all T1 patients in the two groups revealed that the positive margin was related to tumor differentiation, tumor width (≥13.5 mm), and depth of invasion (≥3.25 mm).

CONCLUSION

For early-stage cases, lymph node metastasis and positive margins are risk factors affecting long-term survival. Efficient predictive factors mentioned in our study would provide a proper indication for treatment strategy selection.