Endoscopic submucosal tunnel dissection for superficial esophageal neoplastic lesions: a meta-analysis

Comparison of traction vs. snare as rescue methods for challenging colorectal endoscopic submucosal dissection: Propensity score-matched study

Background and study aims

To address the challenges of difficult colorectal endoscopic submucosal dissection (ESD), conversion to snare resection (rescue-snare ESD: rSnare), a variant of hybrid ESD, is commonly proposed. However, rSnare is associated with a lower en bloc resection rate compared with conventional ESD. Traction-assisted ESD has emerged as a technique to facilitate dissection, but its effectiveness as a rescue method remains unclear. This study was the first to compare the effectiveness of rSnare and rescue-traction-assisted ESD (rTraction).

Patients and methods

This retrospective study involved 1464 consecutive lesions from 1372 patients with superficial colorectal neoplasms across eight institutions. Among these, 162 lesions required rescue methods of rSnare or rTraction. After propensity score matching, 88 lesions treated with either rSnare or rTraction were analyzed.

Results

The rTraction group exhibited significantly higher en bloc resection and R0 resection rates (93.2% and 77.3%, respectively) compared with the rSnare group (45.5% and 38.6%, respectively). However, average procedure time was significantly longer in the rTraction group (122.3 ± 72.5 min) compared with the rSnare group (92.2 ± 54.2 min). In the rTraction group, univariable and multivariable analyses identified traction initiation time > 75 minutes as the only independent predictor of procedure durations exceeding 120 minutes.

Conclusions

Utilizing a traction device as a rescue technique in difficult colorectal ESD resulted in higher en bloc and R0 resection rates compared with conversion to snare resection. Initiating traction within 75 minutes may contribute to reducing overall procedure time for challenging colorectal ESD cases.

Muscular Injury Is a Risk Factor for Post-Entire Circumferential Esophageal Endoscopic Submucosal Dissection Stricture

INTRODUCTION

Endoscopic submucosal dissection (ESD) has become a widely adopted treatment for early esophageal cancer. However, extensive mucosal defects resulting from ESD pose a significant risk of post-procedural strictures. Despite efforts to prevent strictures through various means, including steroid administration, they remain a challenge, significantly impacting patients' quality of life and healthcare costs. Thus, identifying risk factors for refractory strictures following entire circumferential esophageal ESD (EC-E-ESD) is imperative.

METHODS

Between July 2013 and September 2023, 49 patients who underwent EC-E-ESD were retrospectively analyzed. Patients were classified based on the presence of refractory or non-refractory strictures. A refractory stricture was defined as requiring six or more endoscopic balloon dilation procedures before stricture improvement. Clinicopathological features and outcomes were examined using multivariate logistic regression analysis.

RESULTS

Refractory strictures were observed in 51% of patients. A comparison showed that the refractory group had a significantly higher percentage of muscular injury (52% vs. 8%, p = 0.002) and mucosal defect length ≥50 mm (68% vs. 37%, p = 0.047) than the non-refractory group. Multivariate analysis showed that muscular injury (odds ratio 16.2; 95% confidence interval: 2.04-129.1) was an independent risk factor for refractory strictures after EC-E-ESD.

CONCLUSIONS

Muscular injury during EC-E-ESD is a risk factor for refractory strictures. Strategies to prevent injury, such as meticulous dissection techniques and effective steroid administration, may mitigate this risk. However, current prophylactic measures are inadequate, highlighting the need for further research into preventive strategies.

INTRODUCTION

Endoscopic submucosal dissection (ESD) has become a widely adopted treatment for early esophageal cancer. However, extensive mucosal defects resulting from ESD pose a significant risk of post-procedural strictures. Despite efforts to prevent strictures through various means, including steroid administration, they remain a challenge, significantly impacting patients' quality of life and healthcare costs. Thus, identifying risk factors for refractory strictures following entire circumferential esophageal ESD (EC-E-ESD) is imperative.

METHODS

Between July 2013 and September 2023, 49 patients who underwent EC-E-ESD were retrospectively analyzed. Patients were classified based on the presence of refractory or non-refractory strictures. A refractory stricture was defined as requiring six or more endoscopic balloon dilation procedures before stricture improvement. Clinicopathological features and outcomes were examined using multivariate logistic regression analysis.

RESULTS

Refractory strictures were observed in 51% of patients. A comparison showed that the refractory group had a significantly higher percentage of muscular injury (52% vs. 8%, p = 0.002) and mucosal defect length ≥50 mm (68% vs. 37%, p = 0.047) than the non-refractory group. Multivariate analysis showed that muscular injury (odds ratio 16.2; 95% confidence interval: 2.04-129.1) was an independent risk factor for refractory strictures after EC-E-ESD.

CONCLUSIONS

Muscular injury during EC-E-ESD is a risk factor for refractory strictures. Strategies to prevent injury, such as meticulous dissection techniques and effective steroid administration, may mitigate this risk. However, current prophylactic measures are inadequate, highlighting the need for further research into preventive strategies.

Endoscopic removal of gastrointestinal lesions by using third space endoscopy techniques

The concept of submucosal space, or rather the "third space", located between the intact mucosal flap and the muscularis propria layer of the gastrointestinal tract, represents a tunnel that the endoscopist could use to perform interventions in the muscularis propria layer or breech it to enter the mediastinum or the peritoneal cavity without full thickness perforation. The tunnel technique can be used both for the removal of mucosal tumours, called endoscopic submucosal tunnel dissection (ESTD), for the removal of subepithelial tumours (SELs), called submucosal tunnelling endoscopic resection (STER), and for the removal of extra-luminal lesions (for example in the mediastinum or in the rectum), called submucosal tunnelling endoscopic resection for extraluminal tumours (STER-ET). Aim of this updated narrative review, is to summarize the evidences that analyses indications, and outcomes of tunnelling techniques for the treatment of above mentioned lesions.

Risk factors and a predictive nomogram for lymph node metastasis in superficial esophageal squamous cell carcinoma

BACKGROUND

Superficial esophageal squamous cell carcinoma (ESCC) is defined as cancer infiltrating the mucosa and submucosa, regardless of regional lymph node metastasis (LNM). Endoscopic resection of superficial ESCC is suitable for lesions that have no or low risk of LNM. Patients with a high risk of LNM always need further treatment after endoscopic resection. Therefore, accurately assessing the risk of LNM is critical for additional treatment options.

AIM

To analyze risk factors for LNM and develop a nomogram to predict LNM risk in superficial ESCC patients.

METHODS

Clinical and pathological data of superficial ESCC patients undergoing esophagectomy from January 1, 2009 to January 31, 2016 were collected. Logistic regression analysis was used to predict LNM risk factors, and a nomogram was developed based on risk factors derived from multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was used to obtain the accuracy of the nomogram model.

RESULTS

A total of 4660 patients with esophageal cancer underwent esophagectomy. Of these, 474 superficial ESCC patients were enrolled in the final analysis, with 322 patients in the training set and 142 patients in the validation set. The prevalence of LNM was 3.29% (5/152) for intramucosal cancer and increased to 26.40% (85/322) for submucosal cancer. Multivariate logistic analysis showed that tumor size, invasive depth, tumor differentiation, infiltrative growth pattern, tumor budding, and lymphovascular invasion were significantly correlated with LNM. A nomogram using these six variables showed good discrimination with an area under the ROC curve of 0.789 (95%CI: 0.737-0.841) in the training set and 0.827 (95%CI: 0.755-0.899) in the validation set.

CONCLUSION

We developed a useful nomogram model to predict LNM risk for superficial ESCC patients which will facilitate additional decision-making in treating patients who undergo endoscopic resection.

Submucosal Tunneling Techniques for Tumor Resection

The concept of third space endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The mucosal flap safety valve enabled endoscopists to use submucosal space securely. The era of third space endoscopy started with peroral endoscopic myotomy for treatment of achalasia and has expanded to treat various other gastrointestinal disorders, such as mucosal lesions, submucosal tumors, extraluminal tumors, and refractory gastroparesis, Zenker diverticulum, and restoration of the completely obstructed esophageal lumen. Third space endoscopy rapidly emerged as a minimally invasive alternative to conventional surgery. Many studies discovered that this technique is safe and effective with excellent outcomes. Our review focused on the indications, techniques, clinical management, and adverse events of submucosal tunneling techniques for tumor resection.

Updates in the Field of Submucosal Endoscopy

Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.

Risk Factors for Fever After Esophageal Endoscopic Submucosal Dissection and Its Derived Technique

BACKGROUND

Fever is one of the postoperative adverse events of endoscopic submucosal dissection and its derived technique, but the probability and risk factors of postoperative fever are still unclear. The aim of the current study was to investigate the incidence and risk factors of postoperative fever after esophageal lesion removal.

METHODS

We conducted a retrospective study of 446 patients who underwent esophageal endoscopic submucosal dissection and its derived technique between January 2014 and January 2020. Cases included in this study were divided into fever and non-fever groups.

RESULTS

Postoperative fever developed in 135 patients (30.3%). The median (range) highest fever temperature was 38 (37.8-38.4)°C, the median (range) duration of fever was 1 (1-2) day, and 127 (94.1%) patients developed fever within 24 h after operation. Through logistic regression analysis, factors associated with postoperative fever were age (OR: 1.740, 95% CI: 1.005-3.013, p = 0.048), lesion size (OR: 2.007, 95% CI: 1.198-3.362, p = 0.008), operation time (OR: 3.007, 95% CI: 1.756-5.147, p < 0.001) and nasogastric tube placement (OR: 1.881, 95% CI: 1.165-3.037, p = 0.010), while prophylactic antibiotics (OR: 0.181, 95% CI: 0.082-0.401, p < 0.001) were negatively associated with fever.

CONCLUSIONS

Age ≥52 years old, lesion size ≥19 mm, operation time ≥37 min, and nasogastric tube placement are risk factors for postoperative fever after esophageal endoscopic submucosal dissection and its derived technique, prophylactic antibiotic use after operation may help reduce fever rate. Attention should be paid to such patients to minimize the risk of postoperative fever.

Endoscopic submucosal dissection: How to be more efficient?

Endoscopic submucosal dissection (ESD) allows an "en bloc" resection with safety margins (R0 resection) regardless of the size of the lesion. However, while R0 brings a real benefit for the patient, it is not considered sufficient by many experts to justify the technical difficulties and the longer procedure time compared to piecemeal mucosectomy. The aims of this review are to provide several technical and strategical tips to help you save time and become comfortable during ESD procedures. ESD is divided into several intertwined phases: injection, incision, access to the submucosae, and submucosal dissection itself. During injection there are some mistakes that should not be made: a superficial injection, or on the contrary, a too deep injection. A good needle and good injection technique are mandatory. Some techniques, such as repeated injection or prolonged lifting solution, can help maintain the lift. After this step, mucosal incision can be made, taking care to have a good margin to allow an R0 resection. Starting the mucosal incision from a small point allows calibration of the depth of the incision and then obtaining a nice incision. Trimming is also very important to widen submucosal access. Then comes the submucosal dissection itself. Strategies such as the tunnel strategy or the pocket creation method can help to facilitate dissection, but more importantly, traction systems have become unavoidable, especially in the stomach and colon. Most common complications are bleeding and perforation, and they usually can be managed endoscopically.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Efficacy of Current Traction Techniques for Endoscopic Submucosal Dissection

This systematic review aimed to assess the efficacy of the current approach to tissue traction during the endoscopic submucosal dissection (ESD) of superficial esophageal cancer, early gastric cancer, and colorectal neoplasms. We performed a systematic electronic literature search of articles published in PubMed and selected comparative studies to investigate the treatment outcomes of tractionassisted versus conventional ESD. Using the keywords, we retrieved 381 articles, including five eligible articles on the esophagus, 13 on the stomach, and 12 on the colorectum. A total of seven randomized controlled trials and 23 retrospective studies were identified. Clip line traction and submucosal tunneling were effective in reducing the procedural time during esophageal ESD. The efficacy of traction methods in gastric ESD varied in terms of the devices and strategies used depending on the lesion location and degree of submucosal fibrosis. Several prospective and retrospective studies utilized traction devices without the need to reinsert the colonoscope. When pocket creation is included, the traction devices and methods effectively shorten the procedural time during colorectal ESD. Although the efficacy is dependent on the organ and tumor locations, several traction techniques have been demonstrated to be efficacious in facilitating ESD by maintaining satisfactory traction during dissection.

Efficacy of endoscopic submucosal tunnel dissection versus endoscopic submucosal dissection for superficial esophageal neoplastic lesions: a systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness of endoscopic submucosal tunnel dissection (ESTD) and endoscopic submucosal dissection (ESD) in superficial esophageal neoplastic lesions (SENL).

METHODS

A comprehensive search for studies investigating the efficacy of ESTD and ESD for SENL was conducted to search for relevant studies through PubMed, Web of Science, Cochrane Library, SinoMed, CNKI, and Wanfang. Weighted pooled rates were calculated for en bloc resection rate, R0 resection rate, operation time, dissection area, dissection speed, and adverse events. The 95% confidence intervals (95%CI) for effect size were used to calculate the pooled value using the fixed- or random-effects model.

RESULTS

A total of seventeen studies with 1161 patients were identified and included in the meta-analysis. The pooled analysis showed that ESTD had significantly higher en bloc resection (OR 3.98; 95% CI 1.74 to 9.12; p = 0.001) and R0 resection rates (OR 2.29; 95% CI 1.54 to 3.46; p < 0.001) than ESD. The operation time in the ESTD group was shorter than that in the ESD group (SMD = - 0.57; 95% CI - 0.95 to - 0.19; p = 0.003). The dissection area of the ESTD group was larger than that in the ESD group (SMD = 0.49; 95% CI 0.16 to 0.83; p = 0.004), and the dissection speed is faster than that in the ESD group (SMD = 1.52; 95%CI 1.09 to 0.83; p < 0.001). There were no significant differences in esophageal stenosis (p = 0.94) between the two techniques. However, ESTD was superior to ESD in other adverse events (p < 0.05).

CONCLUSION

ESTD has a significant advantage over ESD in the treatment of SENL. ESTD has significantly higher en bloc and R0 resection rates and reduced adverse events.

Locoregional Residual Esophageal Cancer after Neo-adjuvant Chemoradiotherapy and Surgery Regarding Anatomic Site and Radiation Target Fields: A Histopathologic Evaluation Study

OBJECTIVE

Neoadjuvant chemoradiotherapy followed by surgery establishes a considerable pathologic complete response (pCR) in EC. The aim was to determine site of residual tumor and its prognostic impact.

SUMMARY BACKGROUND DATA

High rates of residual tumor in the adventitial region even inside the radiation fields will influence current decision-making.

METHODS

We evaluated resection specimens with marked target fields from 151 consecutive EC patients treated with carboplatin/paclitaxel and 41.4Gy between 2009 and 2018.

RESULTS

In radically resected (R0) specimens 19.8% (27/136) had a pCR (ypT0N0) and 14% nearly no response (tumor regression grade: tumor regression grade 4-5). Residual tumor commonly extended in or restricted to the adventitia (43.1%; 47/109), whereas 7.3% was in the mucosa (ypT1a), 16.5% in the submucosa (ypT1b) and 6.4% only in lymph nodes (ypT0N+). Macroscopic residues in R0-specimens of partial responders (tumor regression grade 2-3: N = 90) were found in- and outside the gross tumor volume (GTV) in 33.3% and 8.9%, and only microscopic in- and outside the clinical target volume in 58.9% and 1.1%, respectively. Residual nodal disease was observed proximally and distally to the clinical target volume in 2 and 5 patients, respectively. Disease Free Survival decreased significantly if macroscopic tumor was outside the GTV and in ypT2-4aN+.

CONCLUSIONS

After neoadjuvant chemoradiotherapy, pCR and ypT1aN0 were seen in a limited number of R0 resected specimens (19.8% and 7.3%, respectively), whereas 6.4% had only nodal disease (yT0N+). Disease Free Survival decreased significantly if macroscopic residue was outside the GTV and in responders with only nodal disease. Therefore, we should be cautious in applying wait and see strategies.