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Han L, Li J, Liang C, Chu Y, Wang Y, Lv L, Liu D, Tan Y. Risk factors for positive resection margins after endoscopic resection for gastrointestinal neuroendocrine tumors. Surg Endosc 2024; 38:2041-2049. [PMID: 38429572 DOI: 10.1007/s00464-024-10706-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/18/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND In recent years, the incidence of gastrointestinal neuroendocrine tumors (GI-NETs) has remarkably increased due to the widespread use of screening gastrointestinal endoscopy. Currently, the most common treatments are surgery and endoscopic resection. Compared to surgery, endoscopic resection possesses a higher risk of resection margin residues for the treatment of GI-NETs. METHODS A total of 315 patients who underwent surgery or endoscopic resection for GI-NETs were included. We analyzed their resection modality (surgery, ESD, EMR), margin status, Preoperative marking and Prognosis. RESULTS Among 315 patients included, 175 cases underwent endoscopic resection and 140 cases underwent surgical treatment. A total of 43 (43/175, 24.57%) and 10 (10/140, 7.14%) patients exhibited positive resection margins after endoscopic resection and surgery, respectively. Multivariate regression analysis suggested that no preoperative marking and endoscopic treatment methods were risk factors for resection margin residues. Among the patients with positive margin residues after endoscopic resection, 5 patients underwent the radical surgical resection and 1 patient underwent additional ESD resection. The remaining 37 patients had no recurrence during a median follow-up of 36 months. CONCLUSIONS Compared with surgery, endoscopic therapy has a higher margin residual rate. During endoscopic resection, preoperative marking may reduce the rate of lateral margin residues, and endoscopic submucosal dissection may be preferred than endoscopic mucosal resection. Periodical follow-up may be an alternative method for patients with positive margin residues after endoscopic resection.
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Affiliation(s)
- Liu Han
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China
| | - Jianglei Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410000, Hunan, China
| | - Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China
| | - Yi Chu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China
| | - Yongjun Wang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China.
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China.
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China.
- Clinical Research Center for Digestive Diseases in Hunan Province, Changsha, 410011, Hunan, China.
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Maan ADI, Sharma P, Koch AD. Curative criteria for endoscopic treatment of oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol 2024; 68:101886. [PMID: 38522884 DOI: 10.1016/j.bpg.2024.101886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/23/2024] [Indexed: 03/26/2024]
Abstract
The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.
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Affiliation(s)
- Annemijn D I Maan
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas and VA Medical Centre, 4801 E Linwood Blvd, Kansas City, USA.
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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Ramai D, Clement B, Maida M, Previtera M, Brooks OW, Wang Y, Chandan S, Dhindsa B, Deliwala S, Facciorusso A, Khashab M, Ofosu A. Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023:00004836-990000000-00248. [PMID: 38227846 DOI: 10.1097/mcg.0000000000001958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND There is increasing evidence that cold endoscopic mucosal resection (c-EMR) can effectively treat large colorectal polyps. We aim to appraise the current literature and evaluate outcomes following c-EMR for nonpedunculated colonic polyps ≥20 mm. METHODS Major databases were searched. Primary outcomes included recurrence rate and adverse events. Meta-analysis was performed using a random-effects model. RESULTS Nine articles were included in the final analysis, which included 817 patients and 1077 colorectal polyps. Average polyp size was 28.8 (±5.1) mm. The pooled recurrence rate of polyps of any histology at 4 to 6 months was 21.0% (95% CI: 9.0%-32.0%, P<0.001, I2=97.3, P<0.001). Subgroup analysis showed that recurrence was 10% for proximal lesions (95% CI: 0.0%-20.0%, P=0.054, I2=93.7%, P=0.054) and 9% for distal lesions (95% CI: 2.0%-21.0%, P=0.114, I2=95.8%, P=0.114). Furthermore, subgroup analysis showed that recurrence was 12% for adenoma (95% CI: 4.0%-19.0%, P=0.003, I2=98.0%, P=0.003), and 3% for sessile serrated polyps (95% CI: 1.0%-5.0%, P=0.002, I2=34.4%, P=0.002). Post-polypectomy bleeding occurred in 1% (n=8/817) of patients, whereas abdominal pain occurred in 0.2% (n=2/817) of patients. CONCLUSIONS C-EMR for nonpedunculated colorectal polyps ≥20 mm shows an excellent safety profile with a very low rate of delayed bleeding as well as significantly less recurrence for sessile serrated polyps than adenomas.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology and Endoscopy Unit, S. Elia Hospital, Caltanissetta, Italy
| | | | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta
| | - Melissa Previtera
- University of Cincinnati Libraries, Donald C. Harrison Health Sciences Library, Cincinnati, OH
| | - Olivia W Brooks
- Internal Medicine Residency, University of Connecticut, Farmington, CT
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, MA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, NE
| | - Smit Deliwala
- Gastroenterology & Hepatology, Emory University Hospital, Atlanta, GA, USA
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Andrew Ofosu
- Faculty of Medicine, "Kore" University of Enna, Enna, Italy
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Bas-Cutrina F, Loras C, Pardo A, Ballester-Clau R, Huertas C, Guarner-Argente C, Colan-Hernandez J, Consiglieri CF, Andujar X, Vilanova-Serra M, González-Huix F, Pardo-Grau L, Maisterra S, Ruiz-Ramírez P, Garcia-Sumalla A, Tebé C, Videla S, Gornals JB. Management of small subepithelial tumors by endoscopic banding without resection and single-incision needle-knife-assisted biopsy sampling: a prospective multicenter study. Gastrointest Endosc 2023; 98:911-921.e8. [PMID: 37263361 DOI: 10.1016/j.gie.2023.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND AIMS Endoscopic band ligation (EBL) without resection combined with single-incision needle-knife (SINK) biopsy sampling may have a positive impact on small GI subepithelial tumor (SET) management, but the method needs to be tested. The aim was to evaluate the feasibility of this strategy in small-sized SETs. METHODS This prospective multicenter observational cohort study in 7 centers included patients with SETs ≤15 mm (confirmed by EUS) between March 2017 and March 2020. The primary outcome was clinical success at 4 weeks, defined as complete SET disappearance on EUS. Secondary outcomes were long-term (1-year) clinical success, technical difficulty level, clinical impact, yield pathology, and safety. RESULTS Of 273 patients screened, 122 (62.3% women; mean age, 60.9 ± 13.2 years) were included with SETs (mean size, 9 ± 2.8 mm; gastric location, 77%; superficial layer dependence, 63%). The primary endpoint was achieved in 73.6% of patients (95% confidence interval [CI], 64.8-81.2). At the 1-year follow-up, the success rate was 68.4% (95% CI, 59.1-76.8). A favorable clinical impact was observed in 97 cases (79.5%; 95% CI, 71.3-86.3). Pathology diagnosis was known in 70%. Potentially malignant lesions were present in 24.7%. The related adverse events rate was 4.1% (95% CI, 1.3-9.3; all mild: 2 bleeding, 2 abdominal pain). On multivariable analysis, the ≤10-mm SET group was associated with a greater success rate (1 year, 87%; relative risk, 5.07; 95% CI, 2.63-9.8) and clinical impact rate (92.7%; relative risk, 6.15; 95% CI, 2.72-13.93). CONCLUSIONS EBL plus SINK biopsy sampling seems to be feasible and safe, and it may offer a favorable clinical impact in small-sized SETs. In particular, SETs ≤10 mm are the best candidates. (Clinical trial registration number: NCT03247231.).
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Affiliation(s)
- Francesc Bas-Cutrina
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; Digestive Diseases Unit, Hospital General de Granollers, Barcelona, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Albert Pardo
- Department of Digestive Diseases, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Raquel Ballester-Clau
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Carlos Huertas
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Carlos Guarner-Argente
- Endoscopy Unit, Digestive Pathology Service, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Colan-Hernandez
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Claudia F Consiglieri
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Xavi Andujar
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Ferran González-Huix
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Laura Pardo-Grau
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Sandra Maisterra
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Pablo Ruiz-Ramírez
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Albert Garcia-Sumalla
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Cristian Tebé
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Statistics Advisory Service, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Sebastià Videla
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; Clinical Research and Clinical Trial Unit (UICEC-IDIBELL), Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Spain
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Stojic V, Zdravkovic N, Nikolic-Turnic T, Zdravkovic N, Dimitrijevic J, Misic A, Jovanovic K, Milojevic S, Zivic J. Using of endoscopic polypectomy in patients with diagnosed malignant colorectal polyp - The cross-sectional clinical study. Open Med (Wars) 2023; 18:20230811. [PMID: 37873541 PMCID: PMC10590616 DOI: 10.1515/med-2023-0811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 10/25/2023] Open
Abstract
The aim of this study was to evaluate the efficacy of endoscopic polypectomy as a therapeutic treatment for malignant alteration of colorectal polyps. In a 5-year research, 89 patients were included, who were tested and treated at the University Clinical Center Kragujevac, Kragujevac, Serbia, with the confirmed presence of malignant alteration polyps of the colon by colonoscopy, which were removed using the method of endoscopic polypectomy and confirmed by the histopathological examination of the entire polyp. After that, the same group of patients was monitored endoscopically within a certain period, controlling polypectomy locations and the occurrence of a possible remnant of the polyp, in the period of up to 2 years of polypectomy. We observed that, with an increasing size of polyps, there is also an increase in the percentage of the complexity of endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer. The highest percentage of incomplete endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer were shown at malignant altered polyps in the field of tubulovillous adenoma. Eighteen patients in total underwent the surgical intervention. In conclusion, our data support the high efficacy of endoscopic polypectomy for the removal of the altered malignant polyp.
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Affiliation(s)
- Vladislava Stojic
- Department of Medical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Natasa Zdravkovic
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Tamara Nikolic-Turnic
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Nebojsa Zdravkovic
- Department of Medical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Jelena Dimitrijevic
- Department of Medical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Aleksandra Misic
- Department of Dentistry, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Kristijan Jovanovic
- Department of Anatomy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Stefan Milojevic
- Faculty of Business Economics, EDUCONS University, Sremska Kamenica, Serbia
| | - Jelena Zivic
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Chandan S, Bapaye J, Khan SR, Mohan BP, Ramai D, Dahiya DS, Bilal M, Draganov PV, Othman MO, Rodriguez Sánchez J, Kochhar GS. Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs. Endosc Int Open 2023; 11:E768-E777. [PMID: 37593155 PMCID: PMC10431976 DOI: 10.1055/a-2117-8327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/20/2023] [Indexed: 08/19/2023] Open
Abstract
Background and study aims Conventional endoscopic mucosal resection (C-EMR) is limited by low en-bloc resection rates, especially for large (> 20 mm) lesions. Underwater EMR (U-EMR) has emerged as an alternative for colorectal polyps and is being shown to improve en-bloc resection rates. We conducted a systematic review and meta-analysis comparing the two techniques. Methods Multiple databases were searched through November 2022 for randomized controlled trials (RCTs) comparing outcomes of U-EMR and C-EMR for colorectal polyps. Meta-analysis was performed to determine pooled proportions and relative risks (RRs) of R0 and en-bloc resection, polyp recurrence, resection time, and adverse events. Results Seven RCTs with 1458 patients (U-EMR: 739, C-EMR: 719) were included. The pooled rate of en-bloc resection was significantly higher with U-EMR vs C-EMR, 70.17% (confidence interval [CI] 46.68-86.34) vs 58.14% (CI 31.59-80.68), respectively, RR 1.21 (CI 1.01-1.44). R0 resection rates were higher with U-EMR vs C-EMR, 58.1% (CI 29.75-81.9) vs 44.6% (CI 17.4-75.4), RR 1.25 (CI 0.99-1.6). For large polyps (> 20 mm), en-bloc resection rates were comparable between the two techniques, RR 1.24 (CI 0.83-1.84). Resection times were comparable between U-EMR and C-EMR, standardized mean difference -1.21 min (CI -2.57 to -0.16). Overall pooled rates of perforation, and immediate and delayed bleeding were comparable between U-EMR and C-EMR. Pooled rate of polyp recurrence at surveillance colonoscopy was significantly lower with U-EMR than with C-EMR, RR 0.62 (CI 0.41-0.94). Conclusions Colorectal U-EMR results in higher en-bloc resection and lower recurrence rates when compared to C-EMR. Both techniques have comparable resection times and safety profiles.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology & Hepatology, Creighton University School of Medicine, Omaha, NE, United States, Omaha, United States
| | - Jay Bapaye
- Department of Medicine, Rochester General Health System, Rochester, NY, United States, Rochester, United States
| | - Shahab R. Khan
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States, Boston, United States
| | - Babu P. Mohan
- Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah Health, Salt Lake City, UT, United States, Tucson, United States
| | - Dushyant S. Dahiya
- Department of Medicine, Central Michigan University, Mount Pleasant, MI, United States, Saginaw, United States
| | - Mohammad Bilal
- Department of Gastroenterology, Minneapolis VA Health Care System, Minneapolis, MN, United States, Minneapolis, United States
| | - Peter V. Draganov
- Department of Gastroenterology, University of Florida, Gainesville, FL, United States, Gainesville, United States
| | - Mohamed O. Othman
- Department of Gastroenterology, Baylor College of Medicine, Houston, TX, United States, Houston, United States
| | - Joaquin Rodriguez Sánchez
- Endoscopy Unite, Hospital Universitario 12 de Octubre, Madrid, Comunidad de Madrid, Spain, Ciudad Real, Spain
| | - Gursimran S. Kochhar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, United States, Pittsburgh, United States
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7
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Esposito G, Dell'Unto E, Ligato I, Marasco M, Panzuto F. The meaning of R1 resection after endoscopic removal of gastric, duodenal and rectal neuroendocrine tumors. Expert Rev Gastroenterol Hepatol 2023; 17:785-793. [PMID: 37497604 DOI: 10.1080/17474124.2023.2242261] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/26/2023] [Accepted: 07/25/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Well-differentiated gastric, duodenal, and rectal neuroendocrine neoplasms (NETs) are rare diseases usually managed by endoscopic treatment. Although several endoscopic techniques are available, the number of patients with incomplete (R1) resection is significant. AREAS COVERED This review focuses on the meaning of incomplete R1 findings after endoscopic resection in type I gastric NETs; nonfunctioning, non-ampullary duodenal NETs; and small rectal NETs. Data were identified by MEDLINE database search without publication date limitation. EXPERT OPINION An incomplete R1 finding may have no significant impact on a patient's clinical outcome, particularly in small G1 type I gastric NETs, which have an indolent course. A 'stepwise approach,' which uses more advanced endoscopic techniques, or minimally invasive surgery may be justified to achieve complete margin-free resection. This approach must balance the tumor features and the procedure-related risk of complications, particularly in the duodenum, where the role of deep endoscopic resections is limited due to the thin duodenal wall. Gastric and rectal NETs that are incompletely removed after initial resection are more easily amenable to deep endoscopic techniques. However, this might not be necessary for patients with comorbidities, elderly, or both due to the uncertainty of how R1 finding impacts a patient's clinical outcome.
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Affiliation(s)
- Gianluca Esposito
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Elisabetta Dell'Unto
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Irene Ligato
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Matteo Marasco
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Francesco Panzuto
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
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8
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Keating E, Leyden J, O'Connor DB, Lahiff C. Unlocking quality in endoscopic mucosal resection. World J Gastrointest Endosc 2023; 15:338-353. [PMID: 37274555 PMCID: PMC10236981 DOI: 10.4253/wjge.v15.i5.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.
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Affiliation(s)
- Eoin Keating
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Jan Leyden
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Donal B O'Connor
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Conor Lahiff
- Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
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9
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Cheema HI, Tharian B, Inamdar S, Garcia-Saenz-de-Sicilia M, Cengiz C. Recent advances in endoscopic management of gastric neoplasms. World J Gastrointest Endosc 2023; 15:319-337. [PMID: 37274561 PMCID: PMC10236974 DOI: 10.4253/wjge.v15.i5.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/12/2023] [Accepted: 04/06/2023] [Indexed: 05/16/2023] Open
Abstract
The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.
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Affiliation(s)
- Hira Imad Cheema
- Department of Internal Medicine, Baptist Health Medical Center, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Interventional Endoscopy/Gastroenterology, Bayfront Health, Digestive Health Institute, St. Petersberg, FL 33701, United States
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Mauricio Garcia-Saenz-de-Sicilia
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Cem Cengiz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR 72205, United States
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, TOBB University of Economics and Technology, Ankara 06510, Turkey
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Sun D, Yi J, Gong L, Wu Y, Liu X. Prognostic analysis and nomogram establishment in patients with early esophageal cancer receiving endoscopic therapy: a population-based study. Therap Adv Gastroenterol 2023; 16:17562848231170470. [PMID: 37163166 PMCID: PMC10164252 DOI: 10.1177/17562848231170470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/01/2023] [Indexed: 05/11/2023] Open
Abstract
Background The growing numbers of early esophageal cancer (EEC) have increased the demand for endoscopic therapy. Objectives To clarify the influential factors for the prognosis of patients with EEC receiving endoscopic surgery, and to construct a nomogram to evaluate the prognostic value of endoscopic therapy. Design Prognostic analysis study. Methods Clinical data of EEC patients who received endoscopic therapy between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results database and used to construct the nomogram. The prognosis was analyzed by R language; the nomogram was constructed by Cox survival analysis; and the accuracy of the nomogram was verified by C index and the receiver operating characteristic (ROC) and calibration curves. X-Tile software was used to stratify the risk of patients. Results Our study constructed the nomogram of the prognosis of patients with EEC treated by endoscopic surgery, including 1118 patients and 5 independent prognostic factors of esophageal cancer-specific survival. The C index and the area under the ROC curve (AUC) of the training and verification cohorts were all >0.75. The calibration curve also reflected the good consistency of the model in predicting survival. Significant difference in the risk of patients from different stratifications with the same T staging existed, and the model had a better C index than that of the T staging. Conclusion Our study reports potential influential factors affecting the prognosis of EEC patients who received endoscopic therapy and establishes a reliable nomogram to predict the risk and prognosis, which has certain advantages compared with traditional TNM staging system.
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Affiliation(s)
- Danping Sun
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jun Yi
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha, Hunan, China
| | - Lingqi Gong
- Department of Gastroenterology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Yu Wu
- Department of Gastroenterology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, Hunan 410000 China
- Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha, Hunan, China
| | - Xiaowei Liu
- Department of Gastroenterology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, Hunan 410000, China
- Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, China
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11
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João M, Areia M, Pinto-Pais T, Gomes LC, Saraiva S, Alves S, Elvas L, Brito D, Saraiva S, Teixeira-Pinto A, Claro I, Dinis-Ribeiro M, Cadime AT. Can white-light endoscopy or narrow-band imaging avoid biopsy of colorectal endoscopic mucosal resection scars? A multicenter randomized single-blind crossover trial. Endoscopy 2023. [PMID: 36690030 DOI: 10.1055/a-2018-1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND : Current guidelines suggest that routine biopsy of post-endoscopic mucosal resection (EMR) scars can be abandoned, provided that a standardized imaging protocol with virtual chromoendoscopy is used. However, few studies have examined the accuracy of advanced endoscopic imaging, such as narrow-band imaging (NBI) vs. white-light endoscopy (WLE) for prediction of histological recurrence. We aimed to assess whether NBI accuracy is superior to that of WLE and whether one or both techniques can replace biopsies. METHODS : The study was a multicenter, randomized, pathologist-blind, crossover trial, with consecutive patients undergoing first colonoscopy after EMR of lesions ≥ 20 mm. Computer-generated randomization and opaque envelope concealed allocation. Patients were randomly assigned to scar examination with NBI followed by WLE (NBI + WLE), or WLE followed by NBI (WLE + NBI). Histology was the reference method, with biopsies being performed for all tissues. RESULTS : The study included 203 scars (103 in the NBI + WLE group, 100 in the WLE + NBI group). Recurrence was confirmed histologically in 29.6 % of the scars. The diagnostic accuracy of NBI was not statistically different from that of WLE (95 % [95 %CI 92 %-98 %] vs. 94 % [95 %CI 90 %-97 %]; P = 0.48). The negative predictive values (NPVs) were 96 % (95 %CI 93 %-99 %) for NBI and 93 % (95 %CI 89 %-97 %) for WLE (P = 0.06). CONCLUSIONS : The accuracy of NBI for the diagnosis of recurrence was not superior to that of WLE. Endoscopic assessment of EMR scars with WLE and NBI achieved an NPV that would allow routine biopsy to be avoided in cases of negative optical diagnosis.
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Affiliation(s)
- Mafalda João
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Miguel Areia
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Teresa Pinto-Pais
- RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto / Porto Comprehensive Cancer Center, Porto, Portugal
| | - Luís Correia Gomes
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Sofia Saraiva
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Susana Alves
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Luís Elvas
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Daniel Brito
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Sandra Saraiva
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | | | - Isabel Claro
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Mário Dinis-Ribeiro
- RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto / Porto Comprehensive Cancer Center, Porto, Portugal.,Department of Community Medicine, Health Information and Decision, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Teresa Cadime
- Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
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12
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ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions. Am J Gastroenterol 2023; 118:46-58. [PMID: 36602835 DOI: 10.14309/ajg.0000000000002100] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/29/2022] [Indexed: 01/06/2023]
Abstract
Subepithelial lesions (SEL) of the GI tract represent a mix of benign and potentially malignant entities including tumors, cysts, or extraluminal structures causing extrinsic compression of the gastrointestinal wall. SEL can occur anywhere along the GI tract and are frequently incidental findings encountered during endoscopy or cross-sectional imaging. This clinical guideline of the American College of Gastroenterology was developed using the Grading of Recommendations Assessment, Development, and Evaluation process and is intended to suggest preferable approaches to a typical patient with a SEL based on the currently available published literature. Among the recommendations, we suggest endoscopic ultrasound (EUS) with tissue acquisition to improve diagnostic accuracy in the identification of solid nonlipomatous SEL and EUS fine-needle biopsy alone or EUS fine-needle aspiration with rapid on-site evaluation sampling of solid SEL. There is insufficient evidence to recommend surveillance vs resection of gastric gastrointestinal stromal tumors (GIST) <2 cm in size. Owing to their malignant potential, we suggest resection of gastric GIST >2 cm and all nongastric GIST. When exercising clinical judgment, particularly when statements are conditional suggestions and/or treatments pose significant risks, health-care providers should incorporate this guideline with patient-specific preferences, medical comorbidities, and overall health status to arrive at a patient-centered approach.
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13
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Zhang XQ, Sang JZ, Xu L, Mao XL, Li B, Zhu WL, Yang XY, Yu CH. Endoscopic mucosal resection-precutting vs conventional endoscopic mucosal resection for sessile colorectal polyps sized 10-20 mm. World J Gastroenterol 2022; 28:6397-6409. [PMID: 36533110 PMCID: PMC9753056 DOI: 10.3748/wjg.v28.i45.6397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/14/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The optimal method to remove sessile colorectal lesions sized 10-20 mm remains uncertain. Piecemeal and incomplete resection are major limitations in current practice, such as endoscopic mucosal resection (EMR) and cold or hot snare polypectomy. Recently, EMR with circumferential precutting (EMR-P) has emerged as an effective technique, but the quality of current evidence in comparative studies of conventional EMR (CEMR) and EMR-P is limited.
AIM To investigate whether EMR-P is superior to CEMR in removing sessile colorectal polyps.
METHODS This multicenter randomized controlled trial involved seven medical institutions in China. Patients with colorectal polyps sized 10-20 mm were enrolled and randomly assigned to undergo EMR-P or CEMR. EMR-P was performed following submucosal injection, and a circumferential mucosa incision (precutting) was conducted using a snare tip. Primary outcomes included a comparison of the rates of en bloc and R0 resection, defined as one-piece resection and one-piece resection with histologically assessed clear margins, respectively.
RESULTS A total of 110 patients in the EMR-P group and 110 patients in the CEMR group were finally evaluated. In the per-protocol analysis, the proportion of en bloc resections was 94.3% [95% confidence interval (CI): 88.2%-97.4%] in the EMR-P group and 86% (95%CI: 78.2%-91.3%) in the CEMR group (P = 0.041), while subgroup analysis showed that for lesions > 15 mm, EMR-P also resulted in a higher en bloc resection rate (92.0% vs 58.8% P = 0.029). The proportion of R0 resections was 81.1% (95%CI: 72.6%-87.4%) in the EMR-P group and 76.6% (95%CI: 68.8%-84.4%) in the CEMR group (P = 0.521). The EMR-P group showed a longer median procedure time (6.4 vs 3.0 min; P < 0.001). No significant difference was found in the proportion of patients with adverse events (EMR-P: 9.1%; CEMR: 6.4%; P = 0.449).
CONCLUSION In this study, EMR-P served as an alternative to CEMR for removing nonpedunculated colorectal polyps sized 10-20 mm, particularly polyps > 15 mm in diameter, with higher R0 and en bloc resection rates and without increasing adverse events. However, EMR-P required a relatively longer procedure time than CEMR. Considering its potential benefits for en bloc and R0 resection, EMR-P may be a promising technique in colorectal polyp resection.
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Affiliation(s)
- Xue-Qun Zhang
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jian-Zhong Sang
- Department of Gastroenterology, Renmin Hospital of Yuyao City, Yuyao 315499, Zhejiang Province, China
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo 315010, Zhejiang Province, China
| | - Xin-Li Mao
- Department of Gastroenterology, Taizhou Hospital, Taizhou 317099, Zhejiang Province, China
| | - Bo Li
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Wan-Lin Zhu
- Department of Gastroenterology, The Central Hospital of Lishui City, Lishui 323020, Zhejiang Province, China
| | - Xiao-Yun Yang
- Department of Gastroenterology, Jinhua Municipal Central Hospital, Jinhua 321099, Zhejiang Province, China
| | - Chao-Hui Yu
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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14
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Motchum L, Levenick JM, Djinbachian R, Moyer MT, Bouchard S, Taghiakbari M, Repici A, Deslandres É, von Renteln D. EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos). Gastrointest Endosc 2022; 96:840-848.e2. [PMID: 35724695 DOI: 10.1016/j.gie.2022.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR. METHODS Adult patients (aged 18-89 years) undergoing EMR of nonpedunculated colorectal polyps ≥20 mm were enrolled in a prospective multicenter study. h-APC was used to ablate all defect margins and also the resection surface in selected cases. The primary study outcome was recurrence rates found during the first follow-up colonoscopy. Secondary outcomes were technical success and adverse event rates. RESULTS EMR with h-APC ablation was used in 101 polyps (84 patients, 46.4% women). EMR with h-APC ablation was technically successful in all cases (median EMR time, 15 minutes; median h-APC ablation time, 4 minutes). Median polyp size was 30 mm (range, 20-60). Resected polyps were either adenomas (68/101 [67.3%]), sessile serrated lesions (27/101 [27%]), or adenocarcinomas (6/101 [6%]). The post-EMR recurrence rate was 2.2% (2/91) (95% confidence interval, .27-7.71). All 6 patients with cancer (intramucosal cancer, 4; T1sm cancer, 2) were found to have complete eradication of the primary tumor after EMR with h-APC, and none had lymph node metastasis. Four serious adverse events occurred in 3 patients (2 delayed bleeding [2.4%], 1 abdominal pain [1.2%], and 1 microperforation [1.2%]. All serious adverse events resolved with either endoscopic or antibiotic treatment only. CONCLUSIONS EMR with h-APC showed a high technical success rate, low adverse event rate, and very low post-EMR recurrence rates. (Clinical trial registration number: NCT04015765.).
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Affiliation(s)
- Leslie Motchum
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Faculty of Medicine, Montreal University Montreal, Montreal, Quebec, Canada
| | - John M Levenick
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Roupen Djinbachian
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Matthew T Moyer
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Simon Bouchard
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Mahsa Taghiakbari
- Montreal University Medical Research Center, Montreal, Quebec, Canada
| | - Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Érik Deslandres
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Daniel von Renteln
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
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15
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Jakabčin P, Kello M, Záň J, Kolář J, Uličný J. Hetastarch induced volume changes of starving adenoma and suggested mechanism of action. Sci Rep 2022; 12:17988. [PMID: 36289259 PMCID: PMC9606266 DOI: 10.1038/s41598-022-21693-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/30/2022] [Indexed: 01/24/2023] Open
Abstract
Submucosal injection is often required step during endoscopic mucosal resection (EMR). In clinical practice we have observed that the EMR injection solution containing hetastarch (HES) lead to selective increase of the neoplasms volume, facilitating their resection. The aim of this study was to explore the possible mechanisms of such behaviour, which was not reported elsewhere. The HCT116 cell line of human colon cancer was exposed to the same EMR solution in vitro. The significant volume increase of HCT116 cells was observed, but only for starving cell culture, suggesting that the starving is essential for the neoplasms-specific volume change. We suggest, that for the iso-oncotic composition of the EMR submucosa injection solution the HES component is crucial, as it can be subject of the starch hydrolysis followed by facilitated transport of resulting monosaccharides from the submucosa into the neoplastic tissue.
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Affiliation(s)
- P. Jakabčin
- grid.4491.80000 0004 1937 116XDepartment of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Prague, Czech Republic
| | - M. Kello
- grid.11175.330000 0004 0576 0391Department of Pharmacology, Faculty of Medicine, Pavol Jozef Šafárik University in Košice, Košice, Slovakia
| | - J. Záň
- grid.454915.80000 0004 0413 3011Department of Gastroenterology, Central Military Hospital-Faculty Hospital, Ružomberok, Slovakia
| | - J. Kolář
- grid.4491.80000 0004 1937 116XDepartment of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Prague, Czech Republic
| | - Jozef Uličný
- grid.11175.330000 0004 0576 0391Department of Biophysics, Institute of Physics, Faculty of Science, Pavol Jozef Šafárik University in Košice, Jesenná 5, 040 01 Košice, Slovakia
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16
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Ko CY, Yao CC, Li YC, Lu LS, Chou YP, Hu ML, Chiu YC, Chuah SK, Tai WC. Clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms: A single-center experience in Southern Taiwan. PLoS One 2022; 17:e0275723. [PMID: 36206286 PMCID: PMC9543958 DOI: 10.1371/journal.pone.0275723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022] Open
Abstract
Background and aims Endoscopic submucosal dissection (ESD) as an advanced endoscopic procedure can be considered for the removal of colorectal lesions with high suspicion of limited submucosal invasion or cannot be optimally removed by snare-based techniques. We aimed to analyze the clinical outcomes of ESD for colorectal neoplasms in our hospital. Methods We retrospectively enrolled 230 patients with 244 colorectal neoplasms who received ESD procedures from April 2012 to October 2020 at Kaohsiung Chang Gung Memorial Hospital. Clinicopathological data were collected by chart review. We also recorded ESD-related complications and clinical outcomes. Results The average age was 64 years old, with a mean follow-up time of 22.59 months. There was a loss of follow-up in 34 lesions. Most lesions were lateral spreading tumors of the non-granular type. The average ESD time was 51.9 minutes. Nine cases (3.7%) had procedure-related complications, including two intra-procedure perforations (0.8%) and seven delayed bleeding (2.9%) without procedure-related mortality. 241 lesions (98.8%) achieved en-bloc resection, while 207 lesions (84.8%) achieved R0 resection. Most lesions were tubulo-(villous) adenoma. Malignancy included 35 adenocarcinomas and 5 neuroendocrine tumors. No local recurrence was developed during follow-up. Multivariate analysis for long ESD time revealed significance in size ≥ 10 cm2 and endoscopist’s experience < 3 years. Pre-ESD endoscopic ultrasound revealed good prediction in discrimination of mucosal (sensitivity: 0.90) and submucosal lesion (specificity: 0.67). Conclusions ESD for colorectal neoplasms is an effective and safe technique. Size ≥ 10 cm2 and endoscopist’s experience < 3 years were significantly associated with long procedure time. Pre-ESD EUS provided a good prediction for colorectal neoplasms in invasion depth.
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Affiliation(s)
- Chen-Yu Ko
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Chien Yao
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Chi Li
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Lung-Sheng Lu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yeh-Pin Chou
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ming-Luen Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Seng-Kee Chuah
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- * E-mail:
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17
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Chandan S, Deliwala S, Khan SR, Ramai D, Mohan BP, Bilal M, Facciorusso A, Kassab LL, Kamal F, Dhindsa B, Perisetti A, Adler DG. Advanced Endoscopic Resection Techniques in Cirrhosis-A Systematic Review and Meta-Analysis of Outcomes. Dig Dis Sci 2022; 67:4813-4826. [PMID: 34993682 DOI: 10.1007/s10620-021-07364-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS While safety and effectiveness of advanced endoscopic resection techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) has been well established in general population, data regarding their utility in patients with cirrhosis is limited. METHODS We searched multiple databases from inception through July 2021 to identify studies that reported on outcomes of EMR and/or ESD in patients with cirrhosis. Meta-analysis was performed to determine pooled rates of immediate and delayed bleeding, perforation, death as well as rates of successful en bloc and R0 resection. Pooled relative risk (RR) was calculated for each outcome between patients with and without cirrhosis. RESULTS Ten studies with a total of 3244 patients were included in the final analysis. Pooled rates of immediate & delayed bleeding, perforation, and death during EMR and/or ESD in patients with cirrhosis were 9.5% (CI 4.0-21.1), 6.6% (CI 4.2-10.3), 2.1% (CI 1.1-3.9) and 0.6% (CI 0.2-1.7), respectively. Pooled rates of successful en bloc and R0 resection were 93% (CI 85.9-96.7) and 90.8% (CI 86.5-93.8), respectively. While incidence of immediate bleeding was higher in patients with cirrhosis, there was no statistically significant difference in any of the other outcomes between the patient groups. CONCLUSIONS Our study shows that performing EMR and ESD for gastrointestinal lesions in patients with cirrhosis is both safe and effective. The risks of procedural complications parallel those reported in general population.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE, USA
| | - Smit Deliwala
- Internal Medicine, Hurley Medical Center, Flint, MI, USA
| | - Shahab R Khan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota & Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Faisal Kamal
- Division of Gastroenterology, University of California-San Francisco, San Francisco, CA, USA
| | - Banreet Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, CO, USA.
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Bulking agents in gastrointestinal endoscopy: present applications and future advances. Curr Opin Gastroenterol 2022; 38:472-480. [PMID: 35881970 DOI: 10.1097/mog.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Bulking agents are inert materials injected into an organ to affect the physical properties of the organ for a therapeutic purpose. Various agents have been developed to aid in the treatment of diseases like gastroesophageal reflux disease (GERD), fecal incontinence, obesity, malignancy, hemostasis, and tissue dissection. Here, we review the state of the art in bulking agents in gastrointestinal endoscopy, past failures, current limitations, and where we see the field heading in the future. RECENT FINDINGS Though bulking agents have been trialed for various different gastrointestinal diseases, there are currently limited uses in gastrointestinal endoscopy. Though various agents have been trialed for GERD, numerous complications and adverse events have limited its current use. However, for the treatment of fecal incontinence endoscopic bulking agent therapy is a reasonable option. Though in early stages of exploration, bulking agent therapy for enteric protection from radiotherapy may be a promising tool to improve treatment of pancreatic cancer. Bulking agents for tissue dissection have substantially improved lifting agents and complex polyp removal. Bulking agent therapy has not really been explored for endoscopic bariatric therapy or hemostasis but may be a fruitful area for exploration in the future. SUMMARY Bulking agent therapy has been trialed for various gastrointestinal diseases with mixed success. There is currently a therapeutic roll in the endoscopic management of fecal incontinence and tissue dissection. A future role in the treatment of GERD, obesity, malignancy, and hemostasis seem feasible.
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McKechnie T, Govind S, Lee J, Lee Y, Hong D, Eskicioglu C. Endoscopic Full-Thickness Resection for Colorectal Lesions: A Systematic Review and Meta-Analysis. J Surg Res 2022; 280:440-449. [PMID: 36054955 DOI: 10.1016/j.jss.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Endoscopic full-thickness resection (EFTR) with an over-the-scope full-thickness resection device is a relatively new technique for the resection of colorectal lesions. Multiple centers have published the results of case series and observational cohorts regarding the use of this technique for managing difficult polyps. This study aims to aggregate the results of these studies to determine the effectiveness and safety of this technique in the resection of these technically challenging colonic lesions. METHODS MEDLINE, EMBASE, and CENTRAL were searched. Articles were included if they reported technical success rate for EFTR of colonic lesions. The primary outcome was technical success rate and secondary outcomes included rate of R0 resection and overall 30-d morbidity. DerSimonian and Laird random-effects meta-analysis of proportions was used to generate effect sizes for pooled outcomes. RESULTS From 2211 citations, 21 studies with 1539 patients (mean age 67.2 y, 39.5% female) undergoing 1551 procedures were included. Difficult to resect benign lesions were the most commonly excised lesions (hyperplastic: 35.9%; adenomas: 30.2%), followed by T1 adenocarcinomas (25.6%) and neuroendocrine tumors (6.1%). Technical success rate was 89% (95% confidence interval [CI] 87-92), and R0 resection rate was 79% (95% CI 76-82). Mean procedure time was 53.5 min and mean specimen size was 17.5 mm. Overall 30-d morbidity was 11% (95% CI 7-13), and incidences of perforation and postpolypectomy bleeding were 2% (95% CI 1-2) and 5% (95% CI 3-7), respectively. Lesion recurrence at 3-mo follow-up was 8%. CONCLUSIONS EFTR requires further large sample size, comparative studies with reporting of long-term oncologic data. However, preliminary findings indicate that it is a safe and effective technique with high rates of technical success and acceptable rates of R0 resection when employed by experienced endoscopists for high-risk colonic lesions.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shaylan Govind
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jay Lee
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Siggens K, Aslam SP, Htet H, Abdelrahim M, Bhandari P. Managing perforations during endoscopic resection of gastrointestinal lesions. Endoscopy 2022; 54:E1015. [PMID: 36002014 PMCID: PMC9736836 DOI: 10.1055/a-1884-8931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Katie Siggens
- Gastroenterology Unit, Queen Alexandra Hospital, Portsmouth Hospital University NHS Trust, Portsmouth, United Kingdom
| | - Shahila Perveen Aslam
- Gastroenterology Unit, Queen Alexandra Hospital, Portsmouth Hospital University NHS Trust, Portsmouth, United Kingdom
| | - Hein Htet
- Gastroenterology Unit, Queen Alexandra Hospital, Portsmouth Hospital University NHS Trust, Portsmouth, United Kingdom
| | - Mohamed Abdelrahim
- Gastroenterology Unit, Queen Alexandra Hospital, Portsmouth Hospital University NHS Trust, Portsmouth, United Kingdom
| | - Pradeep Bhandari
- Gastroenterology Unit, Queen Alexandra Hospital, Portsmouth Hospital University NHS Trust, Portsmouth, United Kingdom
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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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Mehta N, Ayazi S, Landau M, Eriksson S, Jobe BA. Esophageal retention cyst: Esophagogastric junction outflow obstruction (EGJOO) as a potential etiology and management with endoscopic mucosal resection (EMR). Int J Surg Case Rep 2022; 95:107194. [PMID: 35569311 PMCID: PMC9112123 DOI: 10.1016/j.ijscr.2022.107194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/04/2022] [Accepted: 05/08/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Esophageal retention cysts are acquired cysts with no known etiology. They are characterized by dilation of the submucosal glands. Symptomatic cysts are traditionally managed by surgical resection. CASE PRESENTATION We present a case of progressive dysphagia and chest pain secondary to esophageal retention cysts in the mid and distal esophagus with associated esophagogastric junction outflow obstruction (EGJOO) and jackhammer esophagus on high resolution manometry (HRM). The patient underwent staged endoscopic mucosal resection (EMR) with subsequent improvement in her symptoms. However, EGJOO persisted after resection, suggesting it was the primary pathology and not a consequence of the obstruction from the cysts. CLINICAL DISCUSSION Esophageal retention cysts are rarely reported in the literature with most descriptions coming from incidental post-mortems. The presented case suggests EGJOO as a potential etiology of retention cysts. The proposed mechanism is that a significant rise in esophageal intraluminal pressure creates a state of stasis in the esophagus, ideal for the development of these cysts. Symptomatic or malignant retention cysts should be resected. We demonstrate the feasibility of EMR as an alternative to surgical resection. CONCLUSION Esophageal retention cyst is a rare entity, which may arise as a result of EGJOO. The natural history and malignant potential of these cysts are unknown, and no formal guidelines have been established for follow-up for patients with asymptomatic retention cysts. Endoscopic mucosal resection can be used to successfully manage these cysts.
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Affiliation(s)
- Nisarg Mehta
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, United States
| | - Shahin Ayazi
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, United States; Department of Surgery, Drexel University, Philadelphia, PA, United States.
| | - Michael Landau
- Department of Pathology, Allegheny Health Network, Pittsburgh, PA, United States
| | - Sven Eriksson
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, United States
| | - Blair A Jobe
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, United States; Department of Surgery, Drexel University, Philadelphia, PA, United States
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Yang H, Mou Y, Hu B. Safety and efficacy of common endoscopic treatments in patients with decompensated liver cirrhosis. Ann Hepatol 2022; 27:100689. [PMID: 35192965 DOI: 10.1016/j.aohep.2022.100689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The safety and efficacy have always been a concern, when patients with decompensated liver cirrhosis (DLC) receive endoscopic treatments. METHODS To evaluate the safety and efficacy of common endoscopic treatments including endoscopic resection (ER) and endoscopic retrograde cholangiopancreatography (ERCP) applying to patients with DLC, we performed a retrospective study finally including 81 patients receiving ER (43 endoscopic mucosal resection (EMR) and 38 endoscopic submucosal dissection (ESD)) and 131 patients treated by ERCP. RESULTS There were no significant differences in the rate of degeneration and invariability of Child-Pugh (CP) class and the overall rate of adverse events between two groups (93.8%/8.6% ER vs. 96.2%/15.3% ERCP). Both the degeneration rate of CP class (35.4%) and the rate of adverse events (27.1%) in subgroup CP class C of ERCP group were significantly higher (P=0). The rate of poor outcomes was higher in ERCP group (12.2%) than that in ER group (2.5%) (P=0.02). And subgroup CP class C of ERCP group had a higher poor outcome rate (27.1%) (P=0). CONCLUSION ER and ERCP could remove focal lesions or relieve symptoms induced by targeted diseases without significant changes of CP class. Significant benefits and risks coexisted in CP class C patients with DLC when receiving ERCP.
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Affiliation(s)
- Hang Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Wu Hou District, Chengdu 610041, China
| | - Yi Mou
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Wu Hou District, Chengdu 610041, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Wu Hou District, Chengdu 610041, China.
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Matsueda K, Takeuchi Y, Kitamura M, Yamashina T, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, Kawamura T, Fujii S, Kusaka T, Shimokawa T, Uedo N. Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post-hoc analysis of a randomized study. J Gastroenterol Hepatol 2022; 37:741-748. [PMID: 34978107 DOI: 10.1111/jgh.15769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/14/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM A multicenter randomized controlled trial reported a better R0 resection rate for intermediate-sized (10-20 mm) colorectal polyps with underwater endoscopic mucosal resection (UEMR) than conventional endoscopic mucosal resection (CEMR). To clarify whether UEMR removes enough submucosal tissue in the removal of unpredictable invasive cancers, we investigated the cutting plane depth with UEMR versus CEMR. METHODS This was a post-hoc analysis of a randomized controlled trial in which 210 intermediate-sized colorectal polyps were removed in five Japanese hospitals. One pathologist and two gastroenterologists independently reviewed all resected specimens and measured the cutting plane depth. The cutting plane depth was evaluated as (i) maximum depth of submucosal layer and (ii) mean depth of submucosal layer, calculated using a virtual pathology system. RESULTS We identified 168 appropriate specimens for the evaluation of the cutting plane depth, resected by UEMR (n = 88) and CEMR (n = 80). The median resection depth was not significantly different between UEMR and CEMR specimens, regardless of the measurement method ([i] 1317 vs 1290 μm, P = 0.52; [ii] 619 vs 545 μm, P = 0.32). All specimens in the UEMR and CEMR groups contained substantial submucosa and no muscularis propria. CONCLUSIONS The cutting plane depth with UEMR was comparable with that with CEMR. UEMR can be a viable alternative method that adequately resects the submucosal layer for the histopathological assessment of unpredictable submucosal invasive cancers.
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Affiliation(s)
- Katsunori Matsueda
- Department of Gastrointestinal Oncology, and Department of Genetic Oncology, Division of Hereditary Tumors, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, and Department of Genetic Oncology, Division of Hereditary Tumors, Osaka International Cancer Institute, Osaka, Japan
| | - Masanori Kitamura
- Department of Diagnostic Pathology and Cytology, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Yamashina
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Tomofumi Akasaka
- Department of Gastroenterology and Hepatology, National Hospital Organization, Osaka National Hospital, Osaka, Japan.,Akasaka Family Clinic, Osaka, Japan
| | - Taro Iwatsubo
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yasuki Nakatani
- Department of Gastroenterology and Hepatology, Japanese Red Cross Wakayama Medical Center and Cancer Center, Wakayama, Japan
| | - Takuji Akamatsu
- Department of Gastroenterology and Hepatology, Japanese Red Cross Wakayama Medical Center and Cancer Center, Wakayama, Japan
| | - Takuji Kawamura
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Shigehiko Fujii
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshihiro Kusaka
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshio Shimokawa
- Department of Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, and Department of Genetic Oncology, Division of Hereditary Tumors, Osaka International Cancer Institute, Osaka, Japan
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Kwok K, Tran T, Lew D. Polypectomy for Large Polyps with Endoscopic Mucosal Resection. Gastrointest Endosc Clin N Am 2022; 32:259-276. [PMID: 35361335 DOI: 10.1016/j.giec.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.
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Affiliation(s)
- Karl Kwok
- Interventional Endoscopy, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, 1526 North Edgemont Street, 7th Floor, Los Angeles, CA 90027, USA.
| | - Tri Tran
- Department of Medicine, Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Daniel Lew
- Division of Gastroenterology, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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Rex DK, Lahr RE, Peterson MM, Vemulapalli KC. Impact of including epinephrine in the submucosal injectate for colorectal EMR on postprocedural pain: a randomized controlled trial. Gastrointest Endosc 2022; 95:535-539.e1. [PMID: 34896443 DOI: 10.1016/j.gie.2021.11.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EMR is first-line therapy for colorectal laterally spreading lesions. Some colonoscopists include epinephrine in the submucosal injectate, which we observed increased postprocedure discomfort. Our aim was to determine whether inclusion of epinephrine in the submucosal injectate increases postprocedure pain after EMR. METHODS We performed a randomized, controlled, double-blind trial comparing epinephrine in submucosal injectate versus injectate alone for abdominal pain at 30 and 60 minutes after EMR. RESULTS Mean polyp diameter in both arms was >40 mm. There were no differences in procedure times or amounts of fluid injected. Mean pain was higher on a visual analog scale in the epinephrine group at 30 minutes (47 vs 14, P = .022) and at 60 minutes (44 vs 13, P = .035). Recovery room stay was longer in the epinephrine group (68 vs 53 minutes, P = .034). CONCLUSIONS Epinephrine in the submucosal injectate for EMR increases postprocedural pain, which could cause diagnostic confusion and prolong observation time in the recovery area. (Clinical trial registration number: NCT04065451.).
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Merritt M Peterson
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Shah SC, Itzkowitz SH. Colorectal Cancer in Inflammatory Bowel Disease: Mechanisms and Management. Gastroenterology 2022; 162:715-730.e3. [PMID: 34757143 PMCID: PMC9003896 DOI: 10.1053/j.gastro.2021.10.035] [Citation(s) in RCA: 180] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/14/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022]
Abstract
Patients with inflammatory bowel disease (IBD) are at increased risk of developing colorectal cancer (CRC), despite decreases in CRC incidence in recent years. Chronic inflammation is the driver of neoplastic progression, resulting in dysplastic precursor lesions that may arise in multiple areas of the colon through a process of field cancerization. Colitis-associated CRC shares many molecular similarities with sporadic CRC, and preclinical investigations have demonstrated a potential role for the microbiome in concert with the host immune system in the development of colitis-associated colorectal cancer (CAC). Some unique molecular differences occur in CAC, but their role in the pathogenesis and behavior of inflammation-associated cancers remains to be elucidated. Nonconventional types of dysplasia have been increasingly recognized, but their natural history is not well defined, and they have not been incorporated into surveillance algorithms. The concept of cumulative inflammatory burden highlights the importance of considering histologic inflammation over time as an important risk factor for CAC. Dysplasia is arguably the most important risk factor for developing CAC, and advances have been made in the endoscopic detection and removal of precancerous lesions, thereby deferring or avoiding surgical resection. Some of the agents used to treat IBD are chemopreventive. It is hoped that by gaining better control of the underlying inflammation with newer medications and better endoscopic detection and management, a more sophisticated appreciation of clinicopathologic risk factors, and growing awareness of the genetic, immunologic, and environmental causes of colitis- associated neoplasia, that colitis-associated colorectal neoplasia will become even more predictable and manageable in the coming years.
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Affiliation(s)
- Shailja C. Shah
- Division of Gastroenterology, University of California San Diego, GI Section, VA San Diego Healthcare Center, San Diego, CA
| | - Steven H. Itzkowitz
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Endoscopic mucosal resection of colorectal polyps: results, adverse events and two-year outcome. Acta Gastroenterol Belg 2022; 85:47-55. [PMID: 35304993 DOI: 10.51821/85.1.9207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is the first-line treatment for large sessile and flat colorectal polyps in Western centres, however recurrence after EMR continues to be a challenge. The aim of this study is to assess efficacy, safety and recurrence rate of EMR in a tertiary centre and to identify risk factors for recurrence at first surveillance endoscopy (SE1). Patients and methods We performed a retrospective study of 165 sessile and flat colorectal lesions ≥15 mm, treated by EMR between 2017-2019. We used multivariate logistic regression to identify independent risk factors for recurrence at SE1. Results EMR was performed for 165 colorectal polyps in 142 patients with technical success in 158 cases (95,2%). SE1 data for 117 of 135 eligible cases (86,7%) showed recurrent adenoma in 19 cases (16,2%) after a median time of 6,2 months (IQR 5-9,9). This was primarily treated endoscopically (78,9%). Independent risk factors for recurrence at SE1 were lesion size ≥40 mm (OR 4,03; p=0,018) and presence of high-grade dysplasia (HGD) (OR 3,89; p=0,034). Early adverse event occurred in 4 patients (2,4%), with 3 bleeding complications and one perforation. Twelve patients (7,2%) presented with delayed bleeding of which 3 required transfusion, with radiological intervention in one case. All other complications were managed either conservatively (n=8) or endoscopically (n=5). Conclusions EMR is a safe and effective treatment for large sessile and flat colorectal lesions with low recurrence rates. Lesion size ≥40 mm and presence of HGD were identified as risk factors for early recurrence, highlighting the importance of compliance to follow-up in these cases.
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Rudiman R. Advances in gastrointestinal surgical endoscopy. Ann Med Surg (Lond) 2021; 72:103041. [PMID: 34888040 PMCID: PMC8636781 DOI: 10.1016/j.amsu.2021.103041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/22/2022] Open
Abstract
Surgeons have a role in observing, detect abnormalities, disease, and other deficiencies in function which could be treated. Diagnosing and treating back days were challenging for many reasons. However, technology's innovation enhances surgeons' ability to treat their patients. The term endoscopy refers to the Greek prefix endo- ("within") and the verb skopein ("to view or observe"). Endoscopy is practical both in the diagnosis and treatment of various pathologies. Technological advances, especially in endoscopy, gradually progress and discover many possibilities which allow rapid advancement. Endoscopy development aims to assess human orifice that has not been inspected, probed, and examined over the centuries. Endoscopy over these decades is improving, which led to new problem solving using advanced technological approaches. Thus, a surgeon can solve any issues from examination, diagnosis, and treatment using progressive endoscopy evolution. This review delivers a brief history of advances in surgical endoscopy and describes current endoscopy development.
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Affiliation(s)
- Reno Rudiman
- Division of Digestive Surgery, Department of General Surgery, School of Medicine, Padjadjaran University, Hasan Sadikin General Hospital, Bandung, Indonesia
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31
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Kichler AJ, Diehl DL. Wide-field endoscopic mucosal resection of laterally spreading rectal tumors using a multiband ligation endoscopic mucosal resection technique. VideoGIE 2021; 7:53-57. [PMID: 35146224 PMCID: PMC8819476 DOI: 10.1016/j.vgie.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adam J Kichler
- Department of Gastroenterology, Hepatology, and Nutrition, Geisinger Medical Center, Danville, Pennsylvania
| | - David L Diehl
- Department of Gastroenterology, Hepatology, and Nutrition, Geisinger Medical Center, Danville, Pennsylvania
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32
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Toward safer and more efficacious colonoscopy polypectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Chandan S, Khan SR, Kumar A, Mohan BP, Ramai D, Kassab LL, Draganov PV, Othman MO, Kochhar GS. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021; 94:471-482.e9. [PMID: 33385463 DOI: 10.1016/j.gie.2020.12.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Major limitations with conventional EMR (C-EMR) include high rates of polyp recurrence and low en-bloc resection rates, especially for lesions >20 mm in size. Underwater EMR (U-EMR) has emerged as an alternate technique for en-bloc resection of larger lesions. We conducted a systematic review and meta-analysis comparing the efficacy and safety of the 2 techniques. METHODS Multiple databases were searched through June 2020 for studies that compared outcomes of U-EMR and C-EMR for colorectal lesions. Meta-analysis was performed to determine pooled odds ratios (ORs) of successful R0, en-bloc, and piecemeal resection of colorectal lesions. We compared the rates of polyp recurrence at follow-up, diagnostic accuracy for colorectal cancer, and adverse events with the 2 techniques. RESULTS Eleven studies, including 4 randomized controlled trials (RCTs) with 1851 patients were included in the final analysis. A total of 1071 lesions were removed using U-EMR, and 1049 lesions were removed using C-EMR. Although U-EMR had an overall superior en-bloc resection rate compared with C-EMR (OR, 1.9; 95% confidence interval [CI], 1-3.5; P = .04), both techniques were comparable in terms of polyps >20 mm in size (OR, 0.8; 95% CI, 0.3-2.1; P = .75), R0 resection (OR, 3.1; 95% CI, 0.74-12.6; P = .14), piecemeal resection (OR, 3.1; 95% CI, 0.74-12.6; P = .13), and diagnostic accuracy for colorectal cancer (OR, 1.1; 95% CI, 0.6-1.8; P = .82). There were lower rates of polyp recurrence (OR, 0.3; 95% CI, 0.1-0.8; P = .01) and incomplete resection (OR, 0.4; 95% CI, 0.2-0.5; P = .001) with U-EMR. Both techniques have comparable resection times and safety profiles. CONCLUSIONS Our results support the use of U-EMR over C-EMR for successful resection of colorectal lesions. Further randomized controlled trials are needed to evaluate the efficacy of U-EMR for resecting polyps >20 mm in size.
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Affiliation(s)
- Saurabh Chandan
- Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Shahab R Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anand Kumar
- Gastroenterology & Hepatology, Lenox Hill Hospital, New York, New York, USA
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daryl Ramai
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, New York, USA
| | - Lena L Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter V Draganov
- Gastroenterology, University of Florida Health, Gainesville, Florida, USA
| | - Mohamed O Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Garg S, Inamdar S, Tharian B, Muniraj T, Aslanian HR. Education and gastroenterology fellow knowledge about endoscopic mucosal resection of colon adenomas: a survey-based study. Endosc Int Open 2021; 9:E1227-E1233. [PMID: 34447869 PMCID: PMC8383077 DOI: 10.1055/a-1490-8255] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/26/2021] [Indexed: 10/29/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is an effective way to remove large (> 2 cm) colon adenomas. Training about it has not been standardized in fellowship programs. This study was aimed at evaluating the education and knowledge of gastroenterology fellows about EMR of colorectal adenomas. Methods Participation in this survey was offered to 1730 gastroenterology fellows in the United States during the academic year 2019 to 2020. The survey assessed endoscopic mucosal resection training and knowledge and was approved and administered by the American College of Gastroenterology. Results A total of 163 fellows (9.4 %) completed the survey. Only 85 fellows (52.1 %) reported receiving formal education in endoscopic mucosal resection. Fellow confidence was lowest regarding knowing electrosurgery unit settings. Fewer fellows correctly identified Paris 0-IIb (79, 48.5 %; P < 0.0001) or NICE I (114, 69.9 %; P < 0.01) lesions as compared to other Paris and NICE III lesions, respectively. Only 73 (44.8 %) and 93 fellows (57.1 %) arranged steps of EMR in the correct order and identified the correct type of current used for resection, respectively. Training year, male sex, and provision of advanced endoscopy rotations during fellowship were associated with a higher knowledge score for EMR. Conclusions Nearly half of all fellows reported no formal education in EMR and incorrectly ordered its steps. Adenoma assessment by Paris and NICE classifications and electrosurgery unit settings were the most prominent knowledge deficiencies. Incorporation of standardized training about EMR with inclusion of advanced endoscopy rotations appears to be an important educational opportunity during gastroenterology fellowship.
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Affiliation(s)
- Shashank Garg
- Division of Gastroenterology Department of Medicine, UAMS, Little Rock, Arkansas, United States
| | - Sumant Inamdar
- Division of Gastroenterology Department of Medicine, UAMS, Little Rock, Arkansas, United States
| | - Benjamin Tharian
- Division of Gastroenterology Department of Medicine, UAMS, Little Rock, Arkansas, United States
| | - Thiruvengadam Muniraj
- Division of Gastroenterology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Harry R. Aslanian
- Division of Gastroenterology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States
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Kim H, Kim JW, Park HJ, Kim SY, Kim HS, Baik GH, Park SC, Lee SJ, Go TH. A Novel One-Step Knife Approach Can Reduce the Submucosal Injection Time of Endoscopic Submucosal Dissection: A Single-Blinded Randomized Multicenter Clinical Trials. Gut Liver 2021; 16:gnl210103. [PMID: 34162769 PMCID: PMC8761916 DOI: 10.5009/gnl210103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS : Endoscopic submucosal dissection (ESD) is a curative treatment modality for early gastric neoplasms; however, ESD can be a time-consuming process. To overcome this pitfall, we developed the one-step knife (OSK) approach, which combines an endoscopic knife and injection needle on a single sheath. We aimed to evaluate whether this approach could reduce the ESD procedure time. METHODS This single-blinded randomized multicenter trial at four tertiary hospitals from June 2019 to June 2020 included patients aged 19 to 85 years undergoing ESD. Patients were randomly assigned to two groups (OSK or conventional knife [CK]). The injection time, total procedure time, resected specimen size, submucosal fluid amount, degree of device satisfaction, and adverse events were evaluated and compared between groups. RESULTS Fifty-one patients were analyzed (OSK: 25 patients and CK: 26 patients). No baseline differences were observed between groups, with the exception of a higher portion of males in the OSK group. The mean injection time was significantly reduced in the OSK group (39.0 seconds) compared to that in the CK group (87.5 seconds, p<0.001). A decrease of more than 10 minutes in the total procedure time (18.0 minutes vs 28.1 minutes, p=0.055) in the OSK group compared to the CK group was observed. Second-look esophagogastroduodenoscopy revealed two delayed bleeding cases in the OSK group that were easily controlled by endoscopic hemostasis. CONCLUSIONS OSK reduced the injection time and showed a decrease in total procedure time compared with the CK approach. OSK can be a feasible tool for ESD, especially in difficult cases.
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Affiliation(s)
- Hyunil Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jin Woo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea
| | - Su Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung Chul Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sang Jin Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea
| | - Tae-Hwa Go
- Department of Biostatistics Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
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Kemper G, Turan AS, Schoon EJ, Schrauwen RWM, Epping LSM, Gerges C, Beyna T, Neuhaus H, Gündug U, Siersema PD, van Geenen EJM. Endoscopic techniques to reduce recurrence rates after colorectal EMR: systematic review and meta-analysis. Surg Endosc 2021; 35:5422-5429. [PMID: 34076765 PMCID: PMC8437853 DOI: 10.1007/s00464-021-08574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/18/2021] [Indexed: 11/21/2022]
Abstract
Background Colorectal endoscopic mucosal resection (EMR) is an effective, safe, and minimally invasive treatment for large lateral spreading and sessile polyps. The reported high recurrence rate of approximately 20% is however one of the major drawbacks. Several endoscopic interventions have been suggested to reduce recurrence rates. We conducted a systematic review and meta-analysis to assess the efficacy of endoscopic interventions targeting the EMR margin to reduce recurrence rates. Methods We searched in PubMed and Ovid for studies comparing recurrence rates after interventions targeting the EMR margin with standard EMR. The primary outcome was the recurrence rate at the first surveillance colonoscopy (SC1) assessed histologically or macroscopically. For the meta-analysis, risk ratios (RRs) were calculated and pooled using a random effects model. The secondary outcome was post-procedural complication rates. Results Six studies with a total of 1335 lesions were included in the meta-analysis. The techniques performed in the intervention group targeting the resection margin were argon plasma coagulation, snare tip soft coagulation, extended EMR, and precutting EMR. The interventions reduced the adenoma recurrence rate with more than 50%, resulting in a pooled RR of 0.37 (95% CI 0.18, 0.76) comparing the intervention group with the control groups. Overall post-procedural complication rates did not increase significantly in the intervention arm (RR 1.30; 95% CI 0.65, 2.58). Conclusion Interventions targeting the EMR margin decrease recurrence rates and may not result in more complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08574-z.
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Affiliation(s)
- Gijs Kemper
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands.
| | - Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, The Netherlands
| | - Ludger S M Epping
- Department of Gastroenterology and Hepatology, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - Christian Gerges
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Horst Neuhaus
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Ufuk Gündug
- Department of Internal Medicine and Gastroenterology, Katholisches Karl Leisner Klinikum - St.-Antonius-Hospital Kleve, Kleve, Germany
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, 6500 HB, Nijmegen, The Netherlands
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Suresh S, Zhang J, Ahmed A, Abu Ghanimeh M, Elbanna A, Kaur R, Isseh M, Watson A, Dang DT, Chathadi KV, Pompa R, Singla S, Piraka C, Zuchelli T. Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review. Endosc Int Open 2021; 9:E867-E873. [PMID: 34079869 PMCID: PMC8159587 DOI: 10.1055/a-1399-8398] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Cold snare endoscopic mucosal resection (EMR) is being increasingly utilized for non-pedunculated polyps ≥ 20 mm due to adverse events associated with use of cautery. Larger studies evaluating adenoma recurrence rate (ARR) and risk factors for recurrence following cold snare EMR of large polyps are lacking. The aim of this study was to define ARR for polyps ≥ 20 mm removed by cold snare EMR and to identify risk factors for recurrence. Patients and methods A retrospective chart review of colon cold snare EMR procedures performed between January 2015 and July 2019 at a tertiary care medical center was performed. During this period, 310 non-pedunculated polyps ≥ 20 mm were excised using cold snare EMR with follow-up surveillance colonoscopy. Patient demographic data as well as polyp characteristics at the time of index and surveillance colonoscopy were collected and analyzed. Results A total of 108 of 310 polyps (34.8 %) demonstrated adenoma recurrence at follow-up colonoscopy. Patients with a higher ARR were older ( P = 0.008), had endoscopic clips placed at index procedure ( P = 0.017), and were more likely to be Asian and African American ( P = 0.02). ARR was higher in larger polyps ( P < 0.001), tubulovillous adenomas ( P < 0.001), and polyps with high-grade dysplasia ( P = 0.003). Conclusions Although cold snare EMR remains a feasible alternative to hot snare polypectomy for resection of non-pedunculated polyps ≥ 20 mm, endoscopists must also carefully consider factors associated with increased ARR when utilizing this technique.
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Affiliation(s)
- Suraj Suresh
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Jinyu Zhang
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Abdelwahab Ahmed
- Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Mouhanna Abu Ghanimeh
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Ahmed Elbanna
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Randeep Kaur
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, United States
| | - Mahmoud Isseh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Andrew Watson
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Duyen T. Dang
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Krishnavel V. Chathadi
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Robert Pompa
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Sumit Singla
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Cyrus Piraka
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
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Li DF, Lai MG, Yang MF, Zou ZY, Xu J, Peng RM, Xiong F, Wei C, Zhang DG, Xu ZL, Wang LS, Yao J. The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: systematic review and meta-analysis. Endoscopy 2021; 53:636-646. [PMID: 32767283 DOI: 10.1055/a-1234-8918] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) is a promising strategy for nonpedunculated colorectal polyp removal. However, the efficacy and safety of the technique for the treatment of ≥ 10-mm colorectal polyps remain unclear. We aimed to comprehensively assess the efficacy and safety of UEMR for polyps sized 10-19 mm and ≥ 20 mm. METHODS PubMed, EMBASE, and the Cochrane Library databases were searched for relevant articles from January 2012 to November 2019. Primary outcomes were the rates of adverse events and residual polyps. Secondary outcomes were the complete resection, en bloc resection, and R0 resection rates. RESULTS 18 articles including 1142 polyps from 1093 patients met our inclusion criteria. The overall adverse event and residual polyp rates were slightly lower for UEMR when removing colorectal polyps of 10-19 mm vs. ≥ 20 mm (3.5 % vs. 4.3 % and 1.2 % vs. 2.6 %, respectively). The UEMR-related complete resection rate was slightly higher for colorectal polyps of 10-19 mm vs. ≥ 20 mm (97.9 % vs. 92.0 %). However, the en bloc and R0 resection rates were dramatically higher for UEMR removal of polyps of 10-19 mm vs. ≥ 20 mm (83.4 % vs. 36.1 % and 73.0 % vs. 40.0 %, respectively). In addition, univariate meta-regression revealed that polyp size was an independent predictor for complete resection rate (P = 0.03) and en bloc resection (P = 0.01). CONCLUSIONS UEMR was an effective and safe technique for the removal of ≥ 10-mm nonpedunculated colorectal polyps. However, UEMR exhibited low en bloc and R0 resection rates for the treatment of ≥ 20-mm polyps.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ming-Guang Lai
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Mei-Feng Yang
- Department of Hematology, Yantian District People's Hospital, Shenzhen, Guangdong, China
| | - Zhi-Yuan Zou
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jing Xu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Ru-Mei Peng
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, Hunan, China
| | - Feng Xiong
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Cheng Wei
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
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Chandrasekhara V, Kumta NA, Abu Dayyeh BK, Bhutani MS, Jirapinyo P, Krishnan K, Maple JT, Melson J, Pannala R, Parsi MA, Sethi A, Trikudanathan G, Trindade AJ, Lichtenstein DR. Endoscopic polypectomy devices. VideoGIE 2021; 6:283-293. [PMID: 34278088 PMCID: PMC8267590 DOI: 10.1016/j.vgie.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.
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Affiliation(s)
- Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Amrita Sethi
- Department of Digestive and Liver Diseases, Columbia University Medical Center/New York-Presbyterian, New York, New York
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Chen B, Du L, Luo L, Cen M, Kim JJ. Prophylactic clips to reduce delayed polypectomy bleeding after resection of large colorectal polyps: a systematic review and meta-analysis of randomized trials. Gastrointest Endosc 2021; 93:807-815. [PMID: 33049265 DOI: 10.1016/j.gie.2020.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Prophylactic clips to prevent delayed polypectomy bleeding (DPB) after endoscopic resection of large colorectal polyps remains controversial. We performed a systematic review and meta-analysis to evaluate the efficacy of prophylactic clips for preventing DPB by synthesizing the results of randomized trials. METHODS PubMed, Cochrane Library, and EMBASE were searched to October 2019 to identify randomized controlled trials evaluating the efficacy of placing prophylactic clips to reduce DPB after resection of large (≥10 mm) colorectal polyps. The primary outcome was DPB defined by GI bleeding after the conclusion of the colonoscopy. RESULTS Eight studies (n = 3415) met the study criteria, all with a low risk of bias. The overall pooled incidence of DPB was 3.9% (95% confidence interval [CI], 2.4%-5.4%) in patients receiving endoscopic resection of colorectal polyps ≥10 mm. Placing prophylactic clips reduced DPB in patients receiving prophylactic clips (relative risk [RR], 0.61; 95% CI, 0.43-0.85; I2 = 37.8%) compared with no clips with a number needed to treat (NNT) of 52 (95% CI, 31-163). In stratified analyses, placing clips was associated with reduced risks of DPB in patients with polyps ≥20 mm (RR, 0.54; 95% CI, 0.35-0.84; I2 = 0.0%; NNT, 30), nonpedunculated morphology (RR, 0.54; 95% CI, 0.36-0.81; I2 = 0.0%; NNT, 39), and located proximal to the hepatic flexure (RR, 0.49; 95% CI, 0.31-0.78; I2 = 54.8%; NNT, 25) compared with no clips. CONCLUSIONS Prophylactic clips after endoscopic resection of colorectal polyps ≥10 mm demonstrated a modest reduction in the risk of DPB. Larger reductions were observed in patients with polyps ≥20 mm, nonpedunculated morphology, or located proximal to the hepatic flexure.
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Affiliation(s)
- Binrui Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Lijun Du
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Liang Luo
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Mengsha Cen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - John J Kim
- Division of Gastroenterology & Hepatology, Loma Linda University Health, Loma Linda, California, USA
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Tang SJ. Clip band ligation ablation. VideoGIE 2021; 6:136-138. [PMID: 33738365 PMCID: PMC7947634 DOI: 10.1016/j.vgie.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shou-Jiang Tang
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Guo Y, Li HM, Zhu WQ. Cold or Hot Snare with Endoscopic Mucosal Resection for 6-9 mm Colorectal Polyps: A Propensity Score Matching Analysis. J Laparoendosc Adv Surg Tech A 2021; 32:158-164. [PMID: 33651638 DOI: 10.1089/lap.2020.0983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To investigate the efficacy and safety of cold snare endoscopic mucosal resection (CS-EMR) and hot snare endoscopic mucosal resection (HS-EMR) for colorectal polyps with diameters of 6-9 mm. Methods: Retrospective analysis was performed on the clinical data of 485 patients with colorectal polyps (6-9 mm in size) who were treated with CS-EMR or HS-EMR in the endoscopy center of Hangzhou Third People's Hospital from January 2017 to December 2019. Colorectal polyps were lifted by submucosal injection of normal saline. The CS-EMR group used a cold snare to remove the lifting polyps, while the HS-EMR group used a hot snare. Propensity score matching analysis with 1:1 matching and the nearest neighbor matching method were performed to ensure well-balanced characteristics of the CS-EMR and HS-EMR groups. Matching factors included age, gender, body mass index, blood routine, coagulation indicators, polyp site, size, number, and morphology. This resulted in a balanced cohort of 128 patients per group. Polyp recovery, complications, clipping for disclosure, and length of hospital stay were compared after matching. t-Tests, χ2 tests, McNemar's tests, and Fisher's exact test were used for comparison between the two groups before and after matching. Results: There were no differences between the two groups of intraoperative and postoperative bleeding (P > .05), but the CS-EMR clipping rate was lower than the HS-EMR group (P < .01). There was a higher incidence of post-polypectomy syndrome (PPS) (P = .03) and longer hospital stays (P < .01) in the HS-EMR group than the CS-EMR group. Conclusions: Compared with HS-EMR, CS-EMR is more convenient to operate, with a low incidence of PPS, clipping rates, and short hospital stays. It is a safe and effective removal method for 6-9 mm colorectal polyps.
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Affiliation(s)
- Yan Guo
- Department of Gastroenterology, Hangzhou Third People's Hospital, Hangzhou, China
| | - Hua-Ming Li
- Department of Gastroenterology, Hangzhou Third People's Hospital, Hangzhou, China
| | - Wei-Qin Zhu
- Department of Gastroenterology, Hangzhou Third People's Hospital, Hangzhou, China
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43
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Aihara H, Kushnir V, Anand GS, Cassani L, Chahal P, Dacha S, Duloy A, Ghassemi S, Huang C, Kowalski TE, Qayed E, Sheth SG, Simons-Linares CR, Taylor JR, Umar SB, Vela SAF, Walsh CM, Williams RL, Wagh MS. Core curriculum for endoscopic mucosal resection. Gastrointest Endosc 2021; 93:293-296. [PMID: 32843191 DOI: 10.1016/j.gie.2020.06.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 12/11/2022]
Affiliation(s)
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gobind S Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Lisa Cassani
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, and Atlanta VA Medical Center, Atlanta, Georgia, USA
| | - Prabhleen Chahal
- Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Sunil Dacha
- Division of Gastroenterology, Department of Internal Medicine, Houston Methodist Hospital and Texas A&M University, Houston, Texas, USA
| | - Anna Duloy
- Division of Gastroenterology, University of Colorado-Denver, Aurora, Colorado, USA
| | - Sahar Ghassemi
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina
| | - Christopher Huang
- Section of Gastroenterology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jason R Taylor
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University, St Louis, Missouri, USA
| | - Sarah B Umar
- Division of Gastroenterology Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Stacie A F Vela
- Gastroenterology Section, Phoenix VA Health Care System, University of Arizona-Phoenix, Phoenix, Arizona
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Canada
| | - Renee L Williams
- Department of Medicine, Division of Gastroenterology, NYU Grossman School of Medicine, New York, New York, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver, Aurora, Colorado, USA
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44
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Olivas AD, Setia N, Weber CR, Xiao SY, Villa E, Chapman CG, Siddiqui UD, Waxman I, Hart J, Alpert L. Histologic changes caused by injection of a novel submucosal lifting agent for endoscopic resection in GI lesions. Gastrointest Endosc 2021; 93:470-476. [PMID: 32593688 DOI: 10.1016/j.gie.2020.06.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/11/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ORISE Gel is a recently introduced, U.S. Food and Drug Administration-approved submucosal lifting agent used in endoscopic resection of GI lesions. Histologically evident gel deposits in resected specimens may pose a potential diagnostic pitfall. To aid in recognition of this procedure-related artifact, we report the largest histologic series of ORISE Gel in endoscopic and surgical resection specimens to date. METHODS Fifty-eight EMR/endoscopic submucosal dissection (ESD) specimens with ORISE Gel injection and 5 interval surgical resection specimens with previous ORISE Gel injection were included. Patient demographics and endoscopy reports were obtained. Histologic slides from all cases were reviewed. Histochemical stains were performed on select cases. RESULTS Fifty-one EMR and 7 ESD specimens were identified. In 51 of 58 (88%) endoscopic resection specimens, amorphous, pale blue-gray, finely granular material was evident in the submucosa, as well as focally within the mucosa in 4 cases. Most cases showed homogeneous near-complete filling of the submucosa with this material, whereas a few demonstrated areas of condensation and retraction. Mucicarmine and periodic acid-Schiff stains were negative for mucin. Interval surgical resection specimens revealed extensive deposition of dense, eosinophilic material with associated multinucleated giant cells in the submucosa in all cases, with transmural extension in 3 cases. CONCLUSION ORISE Gel injection during endoscopic resection of GI lesions results in deposition of amorphous, blue-gray material seen in histologic sections, whereas interval surgical resection specimens demonstrate dense, eosinophilic material with an associated giant cell reaction. Awareness of these artifacts will help avoid misinterpretation of their presence as pathologic findings.
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Affiliation(s)
- Andrea D Olivas
- Department of Pathology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Namrata Setia
- Department of Pathology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christopher R Weber
- Department of Pathology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Shu-Yuan Xiao
- Department of Pathology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Edward Villa
- Center for Endoscopic Research and Therapeutics, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christopher G Chapman
- Center for Endoscopic Research and Therapeutics, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics, University of Chicago Medical Center, Chicago, Illinois, USA
| | - John Hart
- Department of Pathology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Lindsay Alpert
- Department of Pathology, University of Chicago Medical Center, Chicago, Illinois, USA
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45
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Takashiro H, Saito H, Tawada K, Oyama Y, Tazawa S, Usui M, Nomoto H, Kita K. Efficacy of early clip-with-line method for colorectal endoscopic submucosal dissection. Surg Endosc 2021; 36:321-327. [PMID: 33481110 DOI: 10.1007/s00464-020-08280-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Colorectal endoscopic submucosal dissection (ESD) remains demanding due to technical difficulties and high risk of perforation. Most of the reported traction methods are initiated after creating a mucosal flap, which is time consuming. To obtain a good visualization at the mucosal incision stage, we developed the early clip-with-line (ECL) method. This method was started immediately after injection of sodium hyaluronate solution into the submucosal layer. In this study, we evaluated the efficacy and the safety of the ECL method for colorectal ESD. METHODS We retrospectively analyzed all cases of colorectal ESDs (41 cases in total) performed from January 2017 to February 2019 in our institution. From January 2017 to August 2018, 27 of these cases were performed using conventional (non-ECL) ESDs, while from September 2018 onwards, the remaining 14 cases were performed using the ECL method. Retrospective comparison between the ECL group and the non-ECL group was conducted in terms of clinical characteristics, treatment outcomes, and adverse events. RESULTS There were no significant differences in clinical characteristics between two groups. Procedure time (median [range]) was significantly shorter in the ECL group than in the non-ECL group (66 [29-131] min vs 90 [30-410] min; P = 0.03). As for adverse events, no case of perforation occurred in the ECL group, whereas perforation was observed in 7.4% (2/27) cases in the non-ECL group (no significant difference). CONCLUSION Early clip-with-line method for colorectal endoscopic submucosal dissection reduced procedure time.
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Affiliation(s)
- Hideyuki Takashiro
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan.
| | - Hirofumi Saito
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
| | - Katsunobu Tawada
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
| | - Yuhei Oyama
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
| | - Shinichi Tazawa
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
| | - Masatoshi Usui
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
| | - Hiromasa Nomoto
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
| | - Kazuhiko Kita
- Department of Gastroenterology, Chiba Kaihin Municipal Hospital, 3-31-1 Isobe, Mihama-ku, Chiba, Japan
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46
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Kang DU, Park JC, Hwang SW, Park SH, Yang DH, Kim KJ, Ye BD, Myung SJ, Yang SK, Byeon JS. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasia with or without the hybrid technique. Colorectal Dis 2020; 22:2008-2017. [PMID: 32866340 DOI: 10.1111/codi.15339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/04/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
AIM The main aim of this study was to compare the long-term outcome of a conventional colorectal endoscopic submucosal dissection (ESD) in which submucosal dissection was continued throughout until the completion of resection (ESD-T) to hybrid endoscopic submucosal dissection (ESD-H) in the colorectum. METHOD Medical records of 836 colorectal neoplasia patients treated by ESD-T or ESD-H were reviewed. ESD-H was defined as colorectal ESD with additional snaring in the final stage of the procedure. Primary outcomes were the overall and metastatic recurrence rates. Secondary outcomes were short-term outcomes such as the en bloc resection rate, procedure time and adverse events. RESULTS The overall recurrence rate was higher in the ESD-H than in the ESD-T group (5.7% vs 0.7%, P = 0.001). The metastatic recurrence rate showed no significant difference between these groups (1.4% vs 1.4%, P = 1.000). Multivariate analysis revealed that a failed en bloc resection (hazard ratio 24.097; 95% CI 5.446-106.237; P < 0.001) and larger tumour size (hazard ratio 1.042; 95% CI 1.014-1.070; P = 0.003) were independently associated with overall recurrence. The ESD-H group showed a lower en bloc resection rate (56.8% vs 96.5%, P < 0.001), shorter procedure time (45.6 vs 54.3 min, P < 0.001) and higher perforation rate (10.3% vs 6.0%, P = 0.029). CONCLUSION Although long-term outcomes in terms of overall recurrence are inferior following ESD-H, a failed en bloc resection and large tumour size are the only independent risk factors for recurrence. Further investigations are warranted to improve the long-term outcomes of ESD-H.
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Affiliation(s)
- D U Kang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J C Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S W Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S H Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D H Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - K J Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - B D Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S J Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S K Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J S Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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47
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Naughton AP, Ryan ÉJ, Bardon CT, Boland MR, Aherne TM, Kelly ME, Whelan M, Neary PC, McNamara D, O'Riordan JM, Kavanagh DO. Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:2347-2359. [PMID: 32860082 DOI: 10.1007/s00384-020-03715-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective. AIM To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms. METHODS A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed. RESULTS This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01). CONCLUSION Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.
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Affiliation(s)
- Ailish P Naughton
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
| | | | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Thomas M Aherne
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Michael E Kelly
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - James M O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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48
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Yoon JH, Kim YJ, Lee KN, Jun DW, Koh DH, Lee HL. Effect on Bleeding Prevention of an Intravenous Proton Pump Inhibitor During the Fasting Period After Endoscopic Submucosal Dissection: a Prospective, Randomized, Double-Blind, Placebo-Controlled Trial. J Gastrointest Surg 2020; 24:2596-2601. [PMID: 31845139 DOI: 10.1007/s11605-019-04466-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 11/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND No consensus has been achieved on optimal perioperative strategies for patients undergoing endoscopic submucosal dissection (ESD). The aim of this study was to investigate the effects of an intravenous (IV) proton pump inhibitor (PPI) given during the fasting period after ESD on delayed bleeding following ESD. METHODS This study was designed as a prospective, randomized, double-blind, placebo-controlled trial in a single center. A total of 235 patients who underwent ESD for adenoma and early gastric cancer between March 2016 and September 2018 were randomized into a PPI group and placebo group. Patients were administrated intravenous pantoprazole 40 mg daily (PPI group) or placebo (placebo group) during the fasting period 48 h after ESD (from the day of ESD to the following day, 48 h). After oral feeding (48 h after ESD), oral PPI was given to both groups for 8 weeks. RESULTS Among 235 patients in the intention-to-treat (ITT) and 195 in the per-protocol (PP) analysis, there was no significant difference between the PPI and control groups in major bleeding (PPI vs. placebo; 3.3% vs. 1.7%, p = 0.27) or minor bleeding (PPI vs. placebo; 7.6% vs. 4.3%, p = 0.41) after ESD. There was no significant difference in age (p = 0.28), histology (p = 0.75), tumor size (p = 0.48), or procedure time (p = 0.49) between the two groups. The only independent risk factor for major delayed bleeding was the combined use of aspirin and antiplatelet agent (OR; 12.25, 95% CI; 1.06-141.19, p = 0.04). CONCLUSIONS Administration of routine IV PPI during the fasting period 48 h after ESD does not reduce delayed post-ESD bleeding.
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Affiliation(s)
- Jai Hoon Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Youn Jeong Kim
- Division of Infectious disease, Department of Internal medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kang Nyeong Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Dong Hee Koh
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
| | - Hang Lak Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea.
- Department of Gastroenterology, Hanyang University Hospital, Sungdonggu Hangdangdong 17, Seoul, 133-070, South Korea.
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49
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Landin MD, Guerrón AD. Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Surg Clin North Am 2020; 100:1069-1078. [PMID: 33128880 DOI: 10.1016/j.suc.2020.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Therapeutic endoscopy is an emerging field within general surgery. This article explores the evidence for and usage of endoscopic mucosal resection and endoscopic submucosal dissection throughout the gastrointestinal tract. We aim to educate surgeons and provide an understanding of these techniques. With education and appropriate training, the surgeon will gain confidence and hopefully adopt these tools into their daily practice.
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Affiliation(s)
- MacKenzie D Landin
- Division of Metabolic and Bariatric Surgery, Duke University, 407 Crutchfield Street, Durham, NC 27704, USA
| | - A Daniel Guerrón
- Division of Metabolic and Bariatric Surgery, Duke University, 407 Crutchfield Street, Durham, NC 27704, USA.
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50
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Abstract
Surgeons have been involved, since the beginning, in the development and evolution of endoscopy. They have been instrumental in developing new methods and have been actively involved in most of the therapeutic applications. The continued evolution of endoscopic technique is inevitable and will involve the integration of new technology with innovative thinking.
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Affiliation(s)
- Jeffrey L Ponsky
- Department of General Surgery, Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Andrew T Strong
- Department of General Surgery, Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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