Efficacy and safety of endoscopic submucosal dissection for superficial colorectal tumors more than 50 mm in diameter

Prevalence of Endoscopically Curable Low-Risk Cancer Among Large (≥20 mm) Nonpedunculated Polyps in the Right Colon

BACKGROUND AND AIMS

Endoscopic submucosal dissection is increasingly promoted for the treatment of all large nonpedunculated colorectal polyps (LNPCPs) to cure potential low-risk cancers (superficial submucosal invasion without additional high-risk histopathologic features). The effect of a universal en bloc strategy on oncologic outcomes for the treatment of LNPCPs in the right colon is unknown. We evaluated this in a large Western population.

METHODS

A prospective cohort of patients referred for endoscopic resection (ER) of LNPCPs was analyzed. Patients found to have cancer after ER and those referred directly to surgery were included. The primary outcome was to determine the proportion of right colon LNPCPs with low-risk cancer.

RESULTS

Over 180 months until June 2023, 3294 sporadic right colon LNPCPs in 2956 patients were referred for ER at 7 sites (median size 30 [interquartile range 22.5-37.5] mm). A total of 63 (2.1%) patients were referred directly to surgery, and cancer was proven in 56 (88.9%). A total of 2851 (96.4%) of 2956 LNPCPs underwent ER (median size 35 [interquartile range 25-45] mm), of which 75 (2.6%) were cancers. The overall prevalence of cancer in the right colon was 4.4% (n = 131 of 2956). Detailed histopathologic analysis was possible in 115 (88%) of 131 cancers (71 after ER, 44 direct to surgery). After excluding missing histopathologic data, 23 (0.78%) of 2940 sporadic right colon LNPCPs were low-risk cancers.

CONCLUSIONS

The proportion of right colon LNPCPs referred for ER containing low-risk cancer amenable to endoscopic cure was <1%, in a large, multicenter Western cohort. A universal endoscopic submucosal dissection strategy for the management of right colon LNPCPs is unlikely to yield improved patient outcomes given the minimal impact on oncologic outcomes.

CLINICALTRIALS

gov, Numbers: NCT01368289, NCT02000141.

Prospective single-arm trial on feasibility and safety of an endoscopic robotic system for colonic endoscopic submucosal dissection

BACKGROUND

The development of the EndoMaster "Endoluminal Access Surgical Efficacy" (EASE) system aims to enhance the safety and efficacy of colonic endoscopic submucosal dissection (ESD) through two flexible robotic arms. This is the first clinical trial to evaluate the performance of colorectal ESD using EndoMaster.

METHOD

Patients with early mucosal colorectal neoplasia that was not suitable for en bloc resection with snare-based techniques were recruited. The EndoMaster EASE robotic system consisted of an independently designed flexible robotic platform with two robotic arms. The primary outcome was the complete resection rate using EndoMaster. Secondary outcomes included operating time, hospital stay, procedure-related complications, and oncologic outcomes.

RESULTS

43 patients underwent robotic ESD, with a median robotic dissection time of 49 minutes. The technical success rate was 86.0%, while en bloc resection rate among cases with technical success was 94.6%. The complete resection rate was 83.8% and the median size of specimen was 35 mm (range 15-90 mm). The median hospital stay was 2 (range 1-7) days and there was one delayed bleed after 4 days, which was controlled endoscopically. One patient sustained perforation during the procedure, which was completely closed using clips without sequelae. Two patients were treated by salvage surgery.

CONCLUSION

This first clinical trial confirmed the safety and efficacy of performing colorectal ESD using the EndoMaster EASE robotic system.

Hybrid Versus Conventional Endoscopic Submucosal Dissection for Laterally Spreading Tumors (LSTs): A Retrospective Multicenter Study

Background and Aims

Endoscopic submucosal dissection (ESD) is an established treatment for laterally spreading tumors (LSTs). Hybrid ESD, a novel technique, is gaining popularity for colorectal neoplasms. This study aimed to compare hybrid ESD with conventional ESD for treating LSTs.

Methods

Data from patients with colorectal LSTs ≥ 10 mm who underwent ESD at six centers from May 2020 to April 2023 were analyzed retrospectively. The study assessed baseline characteristics, hospitalization costs, and outcomes (operative time, R0 resection rate, complications).

Results

890 patients were included: 490 underwent conventional ESD and 400 hybrid ESD. Hybrid ESD showed significantly shorter procedure times and lower hospitalization costs compared to conventional ESD. However, the R0 resection rate and lifting sign positivity were lower with hybrid ESD. Subgroup analysis indicated potential cost savings and shorter operative times for lesions 10-30 mm with hybrid ESD, without compromising R0 resection rates. For lesions ≥ 30 mm, hybrid ESD had lower R0 resection rates despite cost savings.

Conclusion

Hybrid ESD offers a viable alternative to conventional ESD for LSTs sized 10-30 mm, reducing procedure duration and costs while ensuring R0 resection.

Multicenter prospective randomized controlled clinical trial comparing the pocket-creation method with and without single-clip traction of colonic endoscopic submucosal dissection

BACKGROUND

The pocket-creation method (PCM) was developed to overcome the technical difficulties of endoscopic submucosal dissection (ESD), although opening the pocket remains challenging. We developed a novel technique of PCM with single-clip traction (PCM-CT), which uses a reopenable clip as a traction device to maintain stability during the procedure. No prospective study has compared the efficacy of PCM-CT and PCM. This study aimed to investigate the effectiveness of PCM-CT vs. PCM in a randomized controlled trial.

METHODS

This randomized controlled clinical trial was conducted at four Japanese institutions. Patients with superficial colorectal neoplastic lesions were included following Japanese guidelines for colorectal cancer. Seven moderately experienced endoscopists performed the ESD procedures using either PCM-CT or PCM.

RESULTS

100 patients were enrolled in the study. Compared with PCM, PCM-CT achieved significantly faster mean (SD) dissection speed (21.4 [10.8] vs. 27.0 [14.5] mm2/min [95%CI 0.5 to 10.7], P = 0.03), and reduced the mean procedure time (81.8 [57.9] vs. 64.8 [47.6] minutes [95%CI -38.2 to 4.3], P = 0.12) and pocket-opening time (37.8 [33.0] vs. 30.0 [28.9] minutes [95%CI -20.2 to 4.6], P = 0.22). En bloc and R0 resection rates were not significantly different between the two groups (100% vs. 100%, P >0.99; 100% vs. 96%, P = 0.50, respectively). No significant differences were observed in adverse events between the two groups.

CONCLUSION

ESD facilitated by the novel PCM-CT method appeared to be significantly faster than PCM. Both methods achieved high R0 resection rates.

Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of rectal lesions involving the dentate line

BACKGROUND

The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line.

METHODS

We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed.

RESULTS

We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions.

CONCLUSION

ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

Diagnostic and therapeutic strategies for colorectal tumor with positive muscle-retracting sign

Objectives

Endoscopic submucosal dissection (ESD) for colorectal tumors with positive muscle-retracting (MR) sign often results in incomplete resection or discontinuation owing to the difficulty of submucosal dissection. The present study aimed to evaluate the usefulness of endoscopic ultrasonography (EUS) in diagnosing the MR sign and performing ESD using the pocket-creation method (PCM).

Methods

Thirty-six cases of colorectal tumors with positive MR sign during ESD between January 2015 and December 2021 were retrospectively reviewed. Cases were divided into two groups: 1) the conventional method (CM) group, comprising 29 cases, and 2) the PCM group with seven cases, in which preoperative EUS and ESD using PCM were performed. Treatment outcomes were compared between the groups. The diagnostic yield of EUS for the MR sign was evaluated among large sessile tumors >20 mm in which preoperative EUS was performed.

Results

Histologic diagnosis was adenoma or Tis carcinoma in 12 cases (33%), T1 carcinoma in 18 cases (50%), T2 carcinoma in four cases (11%), and unevaluable in two cases (6%). The sensitivity and specificity of the EUS-MR sign for large sessile tumors were 87.5% and 83.3%, respectively. ESD was achieved in all cases in the PCM group, although it was discontinued in eight cases (28%) in the CM group. There were significant differences between the PCM and CM groups in en bloc resection (100% vs. 48%, p = 0.013) and R0 resection rates (71% vs. 31%, p = 0.049).

Conclusion

The MR sign can be predicted by preoperative EUS, and ESD using PCM allows en bloc resection.

Characteristics of positive horizontal margins in patients who underwent colorectal endoscopic submucosal dissection

Objectives

Endoscopic submucosal dissection (ESD) enables en bloc resection of colorectal neoplasms, but occasionally results in positive horizontal margins (HMs). However, the site of the resected specimen that tends to be positive for HM has not been investigated. We aimed to clarify the characteristics associated with HMs in lesions resected en bloc with ESD.

Methods

Patients with colorectal neoplasms who underwent en bloc resection with ESD were included in this study. The patients were divided into negative HMs (HM0) and positive or indeterminate HMs (HM1) groups. The characteristics associated with HM1 resection were investigated. In addition, the local recurrence rate during endoscopic follow-up for >6 months after ESD was observed.

Results

In total, 201 lesions were analyzed in 189 patients (HM0, 189 lesions; HM1, 12 lesions). The HM1 group had a significantly larger median lesion diameter (25 vs. 55 mm; p < 0.001) and more lesions with >50% circumference than did the HM0 group (p < 0.001). Furthermore, the prevalence of severe fibrosis was significantly higher in the HM1 group than in the HM0 group (p < 0.001). Positive horizontal sites of the resected specimens were more frequent at the oral and anal sites than at the lateral sites. No local recurrences were observed in either group.

Conclusions

The characteristics associated with HM1 depended on lesion size, particularly lesions with >50% circumference, and submucosal fibrosis.

Hybrid endoscopic submucosal dissection as a salvage option for difficult colorectal conventional endoscopic submucosal dissection

BACKGROUND

When total submucosal dissection is difficult to achieve during conventional colorectal endoscopic submucosal dissection (C-ESD), the lesion can be resected by final snaring through salvage hybrid ESD (SH-ESD). This study aimed to examine the outcomes of SH-ESD and identify its indications that could achieve en bloc resection.

METHODS

We recruited 1039 consecutive patients with colorectal lesions that underwent ESD at Hiroshima University Hospital between January 2015 and December 2020. C-ESD was attempted thoroughly in 924 lesions (C-ESD group, including 9 lesions in which ESD was discontinued), and SH-ESD was performed owing to some difficulties in 115 lesions (SH-ESD group). Risk factors for incomplete resection by SH-ESD and ESD discontinuation were evaluated using multivariate analysis. The outcomes were compared between cases with remaining undissected submucosa of < 20 mm in diameter in the SH-ESD and C-ESD groups, using propensity score matching.

RESULTS

Multivariate analysis revealed that a procedure time > 80 min and remaining undissected submucosa ≥ 20 mm in diameter were significant risk factors for incomplete resection after SH-ESD and ESD discontinuation. By propensity score matching analysis, procedure time was significantly shorter in the SH-ESD group with remaining undissected submucosa < 20 mm in diameter than in the C-ESD group (71 min vs. 90 min, p = 0.0053), although no significant difference was found in the en bloc resection rate (94% vs. 87%, p = 0.0914).

CONCLUSION

SH-ESD can be an alternative surgical method when conventional ESD is difficult to continue in cases in which the remaining undissected submucosa is < 20 mm in diameter.

The feasibility of endoscopic resection for colorectal laterally spreading tumors

The present study aimed to investigate the feasibility and safety of endoscopic resection for colorectal laterally spreading tumors (LSTs) in different size groups. This retrospective study included 2699 patients with LSTs who underwent endoscopic treatment at the Second Xiangya Hospital of Central South University from May 2012 to February 2022. The patient baseline and procedure outcomes were compared between the < 5 cm group, 5-10 cm group, and ≥ 10 cm group. Meanwhile, lesions larger than 5 cm in diameter were longitudinally compared for endoscopic safety using ESD with surgical operation outcomes. There were 2105 patients in the < 5 cm group, 547 patients in the 5-10 cm group, and 47 patients in the ≥ 10 cm group. En bloc resection and R0 resection rates, the incidence of adverse events, length of stay (LOS), and medical costs significantly differed between the groups (P < 0.01). Comorbidity of diabetes or hypertension, history of antithrombotic drug use, lesion size, location, gross type, endoscopic procedures selection, and circumferential extent of the mucosal defect were independent risk factors for delayed bleeding (P < 0.05). En bloc resection, R0 resection, and lesion canceration were associated with local recurrence. For lesions larger than 5 cm in diameter, ESD had similar R0 resection and local recurrence rates compared with a surgical operation but a lower en bloc rate, LOS, and medical costs. Expert endoscopists can significantly increase en bloc and R0 resection rates and reduce the incidence of adverse events. Endoscopic resection results distinguish in different size groups of colorectal LSTs, yet its safety and feasibility are not inferior to a surgical operation.

Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience

BACKGROUND AND AIMS

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

METHODS

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

RESULTS

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

CONCLUSIONS

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

Endoscopic submucosal dissection training: evaluation of an ex vivo training model with continuous perfusion (ETM-CP) for hands-on teaching and training in China

BACKGROUND

The existing ex vivo models of endoscopic submucosal dissection (ESD) cannot simulate intraoperative hemorrhage well. We aimed to establish an ESD training method by applying an ex vivo training model with continuous perfusion (ETM-CP).

METHODS

Four training sessions were conducted for 25 novices under the guidance of 2 experts. Eventually, 10 novices completed ESD operations on a total of 89 patients after the training. The resection effectiveness, resection speed, complication rate, and novice performance before and after the training were compared. The data regarding the effects of the training and the model were gathered through a questionnaire survey.

RESULTS

In terms of the simulation effect of the model, ETM-CP was evaluated as similar to the live pig in all aspects (P > 0.05). The questionnaire analysis revealed that the ESD theoretical knowledge, skill operation, and self-confidence of novices were improved after the training (P < 0.05). The resection time per unit area had a correlation with the number of training periods (rs = - 0.232). For novice performance, the resection time per unit area was shortened (P < 0.05). There was no difference in patient performance between the novice group and the expert group after the training in terms of en bloc resection, R0 resection, complication rate, endoscopic resection bleeding (ERB) score, muscularis propria injury (MPI) score, and resection time per unit area (P > 0.05).

CONCLUSION

The ETM-CP is effective for ESD training.

Reopenable clip-over-the-line method for closing large mucosal defects following gastric endoscopic submucosal dissection: Prospective feasibility study

OBJECTIVES

Large mucosal defects following gastric endoscopic submucosal dissection (ESD) cause postoperative bleeding. To address this limitation and ensure closure of large mucosal defects, we developed the reopenable clip-over-the-line method (ROLM) using a reopenable clip and nylon line. The purpose of this study was to evaluate the feasibility of the ROLM for closure of large mucosal defects following gastric ESD in a prospective, consecutive series of cases.

METHODS

We performed the ROLM on 50 consecutive patients with gastric mucosal defects at the Ise Red Cross Hospital and Mie Prefectural Shima Hospital. The time to complete the ROLM, numbers of clips and lines required, size of defect, and closure success rate were measured, and postoperative adverse events were recorded.

RESULTS

In all, 50 lesions were included in this study period between July 2021 and March 2022. The success rates of defect closure and defect closure without submucosal dead space of the ROLM were both 100% (50/50), with a median ROLM time of 30 (range, 14-35) min and a median resected specimen major axis of 45 (range, 31-73) mm. The median number of reopenable clips used was 31 (range, 10-93). Following gastric ESD, two cases of post-ESD bleeding were observed during the follow-up periods.

CONCLUSION

Our results suggest that ROLM is a feasible strategy for complete closure of mucosal defects post-ESD without submucosal dead space. Future comparative studies with post-ESD bleeding rate as the main outcome are desirable to evaluate the efficacy of ROLM.

The usefulness of a double-balloon endolumenal interventional platform for colorectal endoscopic submucosal dissection by non-expert endoscopists in a porcine model (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is an optimal treatment for colorectal tumors; however, it is technically difficult, especially for non-experts. Therefore, a device that helps non-experts perform colorectal ESD would be beneficial. A double-balloon endolumenal interventional platform (DEIP) was recently developed to assist colorectal ESD through endoscope stabilization and traction. This study assessed the usefulness of colorectal ESD using the DEIP (DEIP-ESD) by endoscopists, including non-experts, in a living porcine model.

METHODS

Two pigs were used to perform eight DEIP-ESD and eight conventional cap-assisted ESD (C-ESD) procedures. Three experts and five non-experts each resected one lesion using DEIP-ESD and one using C-ESD. We evaluated the treatment outcomes and performed stratified analyses between the experts and non-experts.

RESULTS

Dissection speed was significantly faster in DEIP-ESD than in C-ESD (13.3 mm²/min vs 28.5 mm²/min, P = 0.002). However, the total procedure time did not differ significantly between DEIP-ESD and C-ESD. In the stratified analyses, the dissection speed of non-experts was significantly faster in DEIP-ESD than in C-ESD (10.9 mm²/min vs 25.1 mm²/min, P = 0.016), while that of experts increased in DEIP-ESD but to a lesser extent (19.1 mm²/min vs 28.8 mm²/min, P = 0.1). The total procedure time did not differ between DEIP-ESD and C-ESD for both experts and non-experts. The self-completion rate of non-experts also increased in DEIP-ESD. Moreover, the number of muscularis propria injuries induced by non-experts was fewer in DEIP-ESD than in C-ESD.

CONCLUSIONS

DEIP could facilitate colorectal ESD by improving dissection efficiency without increasing adverse events, especially when performed by non-experts.

Gauze extension method for specimens resected by endoscopic submucosal dissection

Video 1The gauze extension method for resected specimens.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

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.

Volume of surgical interventions for benign colorectal tumors – an analysis of 3510 surgical and endoscopic resections in the single colorectal center in Poland

Introduction: Colorectal cancer is the most frequent neoplasm of the whole gastrointestinal track. Due to screening colonoscopy program, colorectal lesions are often diagnosed at early stage. The vast majority of them are possible to remove endoscopically. However, a substantial percentage of benign lesion in Western centers are still operated. The aim of this article was to determine the percentage of surgical resections due to benign adenomas in the reference center of endoscopic submucosal dissection (ESD) and colorectal surgery in Poland. Materials and Methods: Retrospective analysis of 3 510 patients operated from 2015 to 2019 in Center of Bowel Treatment in Brzeziny. Results: We have analyzed 3 510 endoscopic and surgical procedures performed in the colon: 601 ESDs; 1 002 endoscopic mucosal resections (EMRs); and 1,907 surgical resections. Out of 601 ESDs, 57 invaded the submucosa, of which 29 (4.8%) were non-therapeutic ESDs. In 5 patients, due to occurrence of post-ESD perforation, an additional surgical intervention was necessary. Out of the 1,002 EMRs, 22 cases (2.2%) were diagnosed with deeply infiltrating cancers, which required a surgery. The overall percentage of the need for surgery in the endoscopically treated patients (ESD + mucosectomy) was 3.5% (56/1 603). Among resection surgeries, 15 of them (0.8%) ended with the diagnosis of a benign lesion in the postoperative histopathological examination. Conclusions: Inclusion advanced endoscopic techniques such as ESD to routine clinical practice in colorectal centers gives clear benefits for the patients. Well defined and standardized process of qualifying for appropriate treatment allows to significantly reduce the percentage of abdominal approach surgery due to benign colorectal lesions.  

Colorectal Endoscopic Submucosal Dissection in a Western Center: Analysis of Outcomes and Safety Profile

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a well-established endoscopic technique for the treatment of gastrointestinal lesions. Colorectal ESD outcomes are less reported in the Western literature, and Portuguese data are still very scarce. Our aim was to describe our experience on colorectal ESD regarding its outcomes and safety profile.

METHODS

We conducted a retrospective evaluation of recorded data on ESDs performed between 2015 and 2020. Only ESDs performed on epithelial neoplastic lesions were selected for further analysis.

RESULTS

Of a total of 167 colorectal ESDs, 153 were included. Technical success was achieved in 147 procedures (96%). The lesions were located in the colon (n = 24) and rectum (n = 123). The en bloc resection rate was 92% and 97%, the R0 resection rate was 83% and 82%, and the curative resection rate was 79% and 78% for the colon and the rectum, respectively. The need for a hybrid technique was the only risk factor for piecemeal or R1 resection. We report a perforation rate of 3.4% and a 4.1% rate of delayed bleeding; all the adverse events were manageable endoscopically, without the need of blood transfusions or surgery. Most of the lesions were laterally spreading tumours of the granular mixed type (70%), and 20% of the lesions were malignant (12% submucosal and 8% intramucosal cancer).

CONCLUSION

Our series on colorectal ESD reports a very good efficacy and safety profile. This technique can be applied by endoscopists experienced in ESD.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The pocket-creation method facilitates endoscopic submucosal dissection of gastric neoplasms involving the pyloric ring

Background and study aims  Endoscopic submucosal dissection (ESD) of superficial gastric lesions involving the pyloric ring is difficult. The pocket-creation method (PCM) with a small-caliber-tip transparent hood can overcome this difficulty by compressing the pyloric sphincter applying both traction and counter-traction. The aim of this study is to clarify the usefulness of the PCM for ESD of superficial gastric neoplasms involving the pyloric ring compared to the conventional method (CM). Patients and methods  From October 2006 to August 2019, 66 gastric lesions requiring duodenal submucosal dissection beyond the pyloric ring in 66 patients were resected. The CM was mainly performed in the first period (CM group, n = 46) and the PCM in the second period (PCM group, n = 20). We retrospectively reviewed their medical records. Results  Although no significant differences were observed in en bloc resection rates between the two groups, the PCM group had a significantly higher R0 resection rate than the CM group ( P  = 0.047). There were no holes in resected specimens in the PCM group while three specimens in the CM group had a hole. The dissection speed in the PCM group tended to be higher than in the CM group, although it did not reach statistical significance ( P  = 0.148). No significant differences were observed for the incidence of adverse events. Conclusions  This is the first study reporting the advantages of the PCM over the CM for ESD of gastric lesions involving the pyloric ring. We believe that the PCM is an effective strategy to compress the pyloric sphincter and facilitates R0 resection.

A Template for Curriculum Development to Teach Complex Surgical or Endoscopic Techniques With Logistical Challenges

OBJECTIVE

The current, unprecedented pace of change in medicine challenges healthcare professionals to stay up-to-date. To more effectively disseminate new surgical or endoscopic techniques a modern paradigm of training is required. Our aim was to develop a curricular framework for complex techniques that provide logistical challenges to training in order to increase safe, effective use. We use colonic endoscopic submucosal dissection (cESD) as an example.

DESIGN

Curriculum development followed a multistep process representing best practice in training and education. First, a Clinical Needs Assessment established the demand for/sustainability of training. A Training Needs Analysis then identified the knowledge, skills, and attitudes required to perform cESD. A modified Delphi process defined desired learner characteristics, identified indications/contraindications to cESD, and developed a procedural task list. A pilot simulation program gathered feedback from cESD faculty experts and learners. Finally, a Behavioral Observation Scale was developed as a clinical assessment tool to assess procedural performance.

SETTING

The Houston Methodist Institute for Technology, Innovation and Education.

PARTICIPANTS

The first Curriculum Design Summit engaged 11 clinical SMEs, 4 education and training SMEs, 3 market development SMEs, and 1 medical device research and design engineer. The second Curriculum Design Summit engaged 10 clinical SMEs, 4 education and training SMEs, and 4 market development SMEs. We also engaged 12 Learner SMEs at both hands-on pilot courses who currently are training to perform cESD.

RESULTS

Desired learner criteria were defined (e.g., in practice >2 years, available case volume ≥25/year) to ensure ability and motivation of learners. Lesions were classified by (1) suitability for cESD (Clinical T1N0M0, Paris 0-IIa +1s  > 2 cm, 0-IIc + IIa, 0-IIc), and (2) suitability for trainee experience level. A comprehensive cESD task list was constructed and an assessment tool created based on SME review of key characteristics (e.g., comprehensiveness and usability).

CONCLUSION

We describe a comprehensive framework to develop educational curricula for complex surgical/endoscopic techniques with logistical challenges. To illustrate the sustainability of this training model and impact on patient outcomes, we plan to further develop and implement this program nationally.

Prospective randomized trial comparing the pocket-creation method and conventional method of colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Colorectal endoscopic submucosal dissection (ESD) is recognized as a challenging procedure. Previously, we reported that a new ESD strategy using the pocket-creation method (PCM) is useful for colorectal ESD, but no prospective randomized study has evaluated the efficacy of the PCM. The aim of this study was to evaluate the efficacy and safety of PCM for colorectal ESD compared with the conventional method (CM).

METHODS

This was a prospective randomized controlled trial at 3 institutions in Japan. Patients with superficial colorectal neoplastic lesions >20 mm predicted to be intramucosal were randomly assigned to undergo ESD using the PCM or CM. Primary outcome was the ESD completion rate defined as completion of colorectal ESD with an en bloc resection using the assigned ESD method without changing to other methods or assisted by other devices.

RESULTS

We analyzed 59 patients with 59 colorectal tumors in the PCM group and 55 in the CM group. The ESD completion rate was significantly higher in the PCM group compared with the CM group (93% [55/59] vs 73% [40/55]; P  = .01). En bloc resection rates, R0 resection rates, procedure time, and dissection speed were not significantly different between the 2 groups. The incidence of adverse events was similar in the 2 groups.

CONCLUSIONS

Use of the PCM allows the endoscopist to complete the procedure with the intended method more often than the CM with similar clinical outcomes. (Clinical trial registration number: UMIN 000024394.).

The pocket-creation method may facilitate endoscopic submucosal dissection of large colorectal sessile tumors

Background and study aims  Resecting large colorectal sessile tumors using endoscopic submucosal dissection (ESD) is challenging because of severe submucosal fibrosis. Previously, we reported that ESD strategy using the pocket-creation method (PCM) is useful for large colorectal sessile tumors, but there are no large studies reporting the effectiveness and safety of the PCM for resection of large colorectal sessile tumors. Patients and methods  This was a retrospective review of 90 large colorectal sessile tumors in 89 patients who underwent ESD in our institution. Large colorectal sessile tumors were defined as polypoid lesions 20 mm or more in diameter. We divided them into PCM (n = 40) and conventional method (CM) groups (n = 50). The primary outcome measure was en bloc resection. The inverse-probability-treatment weighting (IPTW) approach was used to adjust for selection bias. Results  Both PCM and CM achieved high en bloc resection (100 % vs. 94 %, non-adjusted P  = 0.25, IPTW-adjusted P  = 0.19) and R0 resection rates (88 % vs. 78 %, non-adjusted P  = 0.28, IPTW-adjusted P  = 0.27). When PCM was used, the rate of pathologically negative vertical margins was significantly greater than with the CM (IPTW-adjusted P  = 0.045). The dissection time was significantly shorter (IPTW-adjusted P  = 0.025) and dissection speed faster (IPTW-adjusted P  = 0.013) using the PCM than when the CM was used. There was no significant difference in the incidence of adverse events (intraprocedural perforation and delayed bleeding, IPTW-adjusted P  = 0.68). Conclusion  Although en bloc resection and R0 resection rates were similar, PCM significantly increased the rate of negative vertical margins with rapid dissection for treatment of large colorectal sessile tumors.

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

INTRODUCTION

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

AREA COVERED

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

EXPERT OPINION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term outcomes of endoscopic treatment for colorectal laterally spreading tumor: a large-scale multicenter retrospective study from China

BACKGROUND

Laterally spreading tumor (LST) is a type of precancerous lesion of colorectal cancer with high malignant potential. The present study aimed to evaluate long-term outcomes of endoscopic treatment for LST in Chinese patients.

METHODS

This study was a retrospective review of data collected from 653 included patients with LST from six regional representative hospitals in China between January 2007 and January 2017. Demographic characteristics, endoscopic features of LST, operation-related data, and follow-up results were collected and analyzed.

RESULTS

LST-granular type (LST-G, 80.3%) was much more common than LST-non-grandular type (LST-NG, 19.7%). The overall submucosal invasion rate of all LSTs was 6.1% and the submucosal invasion rate of LST-NG was significantly higher than that of LST-G (6.79% vs. 3.87%, p = 0.000). The en bloc resection rate of ESD and EMR treatment was 96% and 93.7%, respectively, with pathologic R0 resection rate of 90.1% and 82.8%. After an average duration of follow-up about 34.52 ± 11.76 months, the recurrence rate of ESD was 3.47%, and the recurrence rate of EMR was 8.8% after an average follow-up of about 38.44 ± 4.42 months. However, the recurrence rate of ESD was much lower than piecemeal EMR for LST (3.47% vs. 8.62%, p = 0.017). Retroflexion-assisted technique applied for resection of rectal LST was associated with a significantly shortened operating time (85.40 min vs. 174.18 min, p = 0.002).

CONCLUSION

Endoscopic resection is a safe and efficient modality for the treatment of colorectal LST with a relatively low recurrence rate and shortened operating time with the use of retroflexion.

The pocket-creation method facilitates colonic endoscopic submucosal dissection (with video)

BACKGROUND AND AIMS

Colonic endoscopic submucosal dissection (ESD) is more difficult than rectal ESD because of poor maneuverability of the endoscope due to physiologic flexion, peristalsis, and respiratory movements. The aim of this study was to assess the usefulness of the pocket-creation method (PCM) for colonic ESD compared with the conventional method (CM) regardless of lesion shape or location.

METHODS

A total of 887 colorectal lesions were treated by ESD. Of 887 lesions, 271 rectal lesions, 72 lesions smaller than 20 mm in diameter, and 1 non-neoplastic lesion were excluded. This is a retrospective chart review of the remaining 543 colon lesions in 512 patients. We divided them into the PCM group (n = 280) and the CM group (n = 263). The primary outcome was the en bloc resection rate. Secondary outcomes were R0 resection (en bloc resection with negative margin), adverse events, dissection time (in minutes), and dissection speed (in mm²/min).

RESULTS

The PCM group achieved a significantly higher en bloc resection rate (PCM, 100% [280/280], vs CM, 96% [253/263]; P < .001) and R0 resection rate (91% [255/280] vs 85% [224/263], respectively; P = .033) than the CM group. Dissection time was similar (69.5 ± 44.4 vs 78.7 ± 62.6 minutes, P = .676). Dissection speed was significantly faster with the PCM than with the CM (23.5 ± 11.6 vs 20.9 ± 13.6 mm²/min, P < .001). The incidence of adverse events was similar (perforation, 2% vs 4% [P = .152], and delayed bleeding, 2% vs 1% [P = .361]).

CONCLUSIONS

Colonic ESD using the PCM significantly improves the rates of en bloc resection and R0 resection and facilitates rapid dissection.

Preoperative endoscopic predictors of severe submucosal fibrosis in colorectal tumors undergoing endoscopic submucosal dissection

Background and study aims  Endoscopic submucosal dissection (ESD) enables en bloc removal of colorectal neoplasms regardless of size. Submucosal fibrosis is a significant factor for technical difficulty and poor outcomes. We assessed the predictive factors for severe submucosal fibrosis and the ESD outcomes. Patients and methods  Patients undergoing ESD from January 2006 to September 2017 were retrospectively reviewed. The degree of submucosal fibrosis was classified into three types: no fibrosis (F0), mild fibrosis (F1), and severe fibrosis (F2). F0 and F1 cases were grouped as non-severe fibrosis for comparison with the severe fibrosis group. Predictors of severe submucosal fibrosis and ESD outcomes were evaluated. Results  ESD was performed in 524 lesions (60 % male; mean age, 67.8 years). Eighty lesions with severe fibrosis (15.3 %) were observed. The overall en bloc resection rate and curative resection rate were 94.3 % and 77.7 %, respectively. Rates of en bloc resection (91.2 % vs. 94.8 %, P  = 0.2) and perforation (7.5 % vs. 5.6 %, P  = 0.45) were no different between severe fibrosis and non-severe fibrosis groups. However, incidences of non-curative resection and low resection speed were significantly higher in the severe fibrosis group. Among protruding lesions, tumor height and volume were significantly greater in the severe counterparts. A diameter ≥ 40 mm, endoscopic finding of the tumor beyond fold, and fold convergence were independent risk factors for severe fibrosis. Conclusions  Severe submucosal fibrosis is a significant risk factor for non-curative resection and a long procedural time. Tumor size and morphology might help to predict the severity of fibrosis.

Clinical outcomes of endoscopic submucosal dissection for laterally spreading tumors involving the dentate line

OBJECTIVE

Endoscopic submucosal dissection (ESD) for laterally spreading tumors (LST) involving the dentate line (LST-DL) is challenging because of the specific anatomical features of the anorectum. This study aimed to evaluate the efficacy and safety of ESD for LST-DL.

METHODS

Consecutive patients with LST-DL who had undergone ESD at our hospital between January 2010 and December 2015 were retrospectively enrolled in this study. Rates of en bloc resection, R0 resection, and complications, pathological characteristics, and tumor recurrence were analyzed and compared with those of LST in the rectum not involving the dentate line (LST-NDL).

RESULTS

Altogether 49 patients with LST-DL (median age 63 years; 39 women; median lesion size 57 mm; median follow-up period of 24 months) and 96 patients with LST-NDL (median age 67 years; 31 women; median lesion size 47 mm; median follow-up period of 31 months) were enrolled. En bloc resection (93.9% [46/49] vs 94.8% [91/96]) and en bloc R0 resection rates (83.7% [41/49] vs 88.5% [85/96]), respectively, for LST-DL and LST-NDL, with no significant differences. However, ESD for LST-DL had a longer procedure time (77 min vs 54 min, P = 0.02), a greater postprocedural perianal pain rate (28.6% vs 0%, P < 0.001), and more anal strictures (4.1% vs 0%, P = 0.04). The complication rates of perforation, bleeding and fever, recurrence rate, and pathological characteristics did not differ between the two groups.

CONCLUSIONS

ESD is a safe and effective therapeutic modality for LST-DL. However, this procedure should be performed by experienced endoscopists and the difficulty needs to be fully considered.

Comparison of Endoscopic Submucosal Dissection for Primary and Recurrent Colorectal Lesions: A Single-Center European Study

INTRODUCTION

Endoscopic submucosal dissection (ESD) is an acknowledged endoscopic technique for the management of early gastrointestinal neoplasia. The clinical experience and the research from the Eastern ESD centers show that experienced endoscopists can successfully treat even the most demanding recurrent colorectal lesions.

AIM

The aim of this study was to analyze the clinical outcomes of the management of recurrent colorectal lesions in comparison with those of primary lesions in the setting of high-volume European center.

METHODS

A retrospective analysis of 298 cases (228 primary lesions and 70 recurrent lesions) performed by a single endoscopist was carried out. Evaluating learning curves for both primary and recurrent lesions, cumulative sum analysis was performed.

RESULTS

Primary lesions had ∼9% higher R0 resection rate (86.84% versus 78.51%). Yet, this difference did not reach statistical significance (P = .091). The presence of recurrent lesion and lengthy procedure (≥150 min) are risks factors of R1 resection, whereas rectal localization of the lesion was associated with lower risk of R1 resection. The cumulative R0 of 80% was achieved at 36th procedure in the primary lesions group, whereas for the recurrent lesions it was reached at 50th procedure (overall 229 procedures).

CONCLUSIONS

Our study underlines the importance of proper experience in ESD before the management of recurrent lesions. Even after the completion of high volume of primary lesions, first recurrent lesions can pose a challenge. Nevertheless, the final outcomes are promising, as the complications do not pose a serious risk to the patients and high R0 resection rate can be achieved in a reasonable timeframe.

Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center

BACKGROUND

Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm.

OBJECTIVE

We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted in a tertiary referral unit for interventional endoscopy.

PATIENTS

A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm.

MAIN OUTCOME MEASURES

Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission.

RESULTS

Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%).

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.

Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection

OBJECTIVE

Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 µm or less than one-third of the submucosa) on colorectal lesions removed by ESD.

DESIGN

A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions.

RESULTS

51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2%; 95% CI 78.8% to 85.3%) were adenomas (low- and high-grade dysplasia, 26.8% and 55.4%, respectively). Overall, 15.7% were submucosal cancers, but only slightly more than half (8.0%; 95% CI 6.1% to 10.3%) had an infiltration depth of ≤1000 µm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3% (95% CI 52.2% to 89.4%) for malignant lesions, the prevalence of curative resection lowered to 6% (95% CI 4.2% to 7.2%) with an NNT of 16.7.

CONCLUSION

The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.

Real-life evaluation of the safety, efficacy and therapeutic outcomes of endoscopic submucosal dissection in a Western tertiary centre

BACKGROUND

Endoscopic submucosal dissection (ESD) enables accurate pathological evaluation and low recurrence rates. Large series describing ESD outcomes in Western countries are scarce.

OBJECTIVE

To evaluate the real-life experience of ESD in a single Western centre.

METHODS

Data of all the patients submitted to ESD in our centre were prospectively recorded in a database, from the first procedure in 2011 until May 2017. Feasibility, en bloc and R0 resection rates and safety were assessed.

RESULTS

Three hundred and one ESDs were performed (37 in submucosal lesions) on 283 patients (54% male). Lesions were located in the oesophagus (n = 13), stomach (n = 169), duodenum (n = 4), colon (n = 35) and rectum (n = 80). ESD was technically successful in 292 lesions (97%); among malignant or premalignant epithelial lesions (n = 232), the en bloc resection rate was 91% and, of those, the R0 resection rate was 87% (between 69% in the colon and 93% in the stomach). Two patients needed surgery due to adverse events. Surgery for non-curative ESD was performed in 12 cases (58% without residual lesion). There were 10 perforations, 9 of them closed endoscopically. Mortality was 0%.

CONCLUSION

Our real-life experience shows that ESD is feasible, safe and effective in Western settings.

Endoscopic Submucosal Tunnel Dissection: A Feasible Solution for Large Superficial Rectal Neoplastic Lesions

BACKGROUND

Although endoscopic submucosal tunnel dissection has been used for the resection of esophageal and stomach neoplastic lesions, there are still no reports about large superficial rectal neoplastic lesions. Compared with esophageal and stomach endoscopic submucosal dissection, the dissection of large superficial rectal neoplastic lesions is more difficult because of the flimsy bowel wall with abundant vasculature in the submucosal region, which results in poor endoscopic maneuverability and serious complications, such as bleeding and perforation.

OBJECTIVE

The study aimed to assess the efficacy and safety of endoscopic submucosal tunnel dissection for large superficial rectal neoplastic lesions over 5 to 24 months in selected patients.

DESIGN

This was a prospective, single-center evaluation.

SETTINGS

The study was conducted at a digestive endoscopic center.

PATIENTS

Patients with large superficial rectal neoplastic lesions were included.

INTERVENTIONS

Endoscopic submucosal tunnel dissection was performed in all of the patients with large, superficial rectal neoplastic lesions. The submucosal tunnel was created via a submucosal incision from the anal incision to the oral incision. Next, tunnel wall resection was performed to completely remove the lesion.

MAIN OUTCOME MEASURES

Dissection speed, complications, and recurrence rate were measured.

RESULTS

A total of 19 patients, including 13 men and 6 women, with an average age of 60.1 ± 12.2 years (range, 34.0-75.0 y) underwent endoscopic submucosal tunnel dissection. The average size of lesions was 17.54 ± 13.47 cm. The mean operative time was 84.84 ± 53.49 minutes, and the operating speed was 21.01 ± 9.00 mm/min. En bloc resections with negative basal margins were achieved in all cases without serious intraoperative complications. No recurrence was observed in any patient within 5 to 24 months after the operations.

LIMITATIONS

This was a single-center study.

CONCLUSIONS

Endoscopic submucosal tunnel dissection is feasible, safe, and effective for the treatment of large, superficial rectal neoplastic lesions in selected patients. See Video Abstract at http://links.lww.com/DCR/A321.

Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an endoscopic resection technique for lesions suspicious of superficial malignancy. It is performed using an ESD knife on its own (standard technique) or by the sequential use of a knife and a snare (hybrid technique). The experience with these techniques is different in Asian and non-Asian countries. We performed a systematic review and meta-analysis of available evidence on colorectal ESD.

METHODS

Electronic databases were searched up to August 2016 for studies evaluating R0, en bloc resection, and adverse event rates of both techniques for the treatment of colorectal lesions. Proportions were pooled by a random effects model.

RESULTS

Ninety-seven studies (71 performed in Asia) evaluated the standard technique and 12 studies (7 in Asia) the hybrid technique. The R0 resection rate of the standard technique was 82.9%, and it was significantly lower in non-Asian versus Asian countries: 71.3% versus 85.6%. The en bloc resection rate was 91% and was significantly lower in non-Asian versus Asian countries (81.2% vs 93%, respectively). Surgery was needed in 1.1% of the ESD-related adverse events, with a significant difference between non-Asian and Asian countries (3.1% vs 0.8%). The R0 and en bloc resection rates with the hybrid technique were significantly lower than those achieved with the standard technique: 60.6% and 68.4%, respectively, with similar adverse event rates.

CONCLUSIONS

In non-Asian countries the standard ESD technique is still failing to achieve acceptable levels of performance. The hybrid technique showed low R0 resection rates and should not be considered as an adequate alternative to the standard technique.

Endoscopic submucosal dissection for large colorectal neoplasms

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) for colorectal neoplasms (CRN) of >50 mm is considered technically difficult. The ITknife nano™ was developed specifically for ESD of CRN and esophageal superficial neoplasms; however, only limited data are available regarding its use in this procedure. Here we assessed the safety and efficacy of ESD using the ITknife nano™ for large CRN (>50 mm).

METHODS

We carried out a retrospective study, including consecutive patients with CRN larger than 50 mm that were treated by ESD between September 2002 and August 2016 at our institution. To clarify features of the ITknife nano™ and to assess its safety and efficacy, we compared en bloc/curative resection rates, complications, and resection speed between ESD done using the Dual knife™ with and without the ITknife nano™.

RESULTS

We analyzed a total of 177 ESD-treated large CRN (median tumor size, 61 mm). Among the 133 CRN treated by ESD using the ITknife nano™, en bloc and curative resection rates were 96.2% and 80.5%, respectively. Perforation occurred in eight cases (6.0%) and delayed bleeding in four cases (3.0%). All complications were endoscopically managed. Resection speed was significantly faster for ESD using the ITknife nano™ (25.3 mm² /min) compared to using the Dual knife™ only (19.9 mm² /min; P = 0.02).

CONCLUSIONS

Use of the ITknife nano™ for ESD treatment of large CRN (>50 mm) is feasible and may contribute to reduced procedure times. Further controlled studies are needed to confirm these findings.

Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type

Background and study aims The pocket-creation method (PCM) is a novel strategy for endoscopic submucosal dissection (ESD). The aim of this study is to determine the efficacy of the PCM for colorectal laterally spreading tumors, non-granular type (LST-NG). Patients and methods The records of 126 consecutive patients with colorectal LST-NG who underwent ESD between April 2012 and July 2015 were retrospectively reviewed. Patients were divided into PCM (n = 73) and conventional method (CM) (n = 53) groups. Results The en bloc resection rate in the PCM group was significantly higher than in the CM group (100 % [73/73] vs. 92 % [49/53], P = 0.03). The en bloc resection rate with severe fibrosis was higher in the PCM group than in the CM group (100 % [3/3] vs. 60 % [3/5]). The R0 resection rate for the two groups was not statistically significantly different (93 % [68/73] vs. 91 % [48/53], P = 0.74). The perforation rate in the PCM group was lower than in the CM group although not statistically significantly less (0 % 0/73 vs. 4 % 2/53, P = 0.18). For lesions resected en bloc, dissection speed for the PCM group was significantly faster than for the CM group (median [IQR], 19 [13 -24] vs. 14 [10 - 22] mm²/min, P = 0.03). Conclusion ESD using PCM achieves a reliable and safe resection of colorectal LST-NG.

Endoscopic submucosal dissection for flat or sessile colorectal neoplasia > 20 mm: A European single-center series of 182 cases

BACKGROUND AND STUDY AIMS

Colorectal endoscopic submucosal dissection (ESD) is an attractive method for en bloc resection of larger flat neoplastic lesions. Experience with this method is limited in the Western World.

PATIENTS AND METHODS

A total of 182 consecutive flat or sessile colorectal lesions (cecum n = 43; right-sided colon n = 65; left-sided colon n = 11, rectum: n = 63) with a size > 20 mm (mean 41.0 ± 17.4 mm) were resected in 178 patients. The data were recorded prospectively.

RESULTS

ESD was technically feasible in 85.2 % of patients with a mean procedure time of 127.5 min (± 99.8) min and a complication rate of 11.5 % (microperforation 9.3 %, delayed bleeding 2.7 %, no case of emergency surgery, 30-day mortality rate 0 %). For 155 successfully completed procedures the en bloc and R0 resection rates were 88.4 and 62.6 %. Efficacy was better for smaller lesions (20 mm to 49 mm; n = 131) than for larger lesions (50 mm to 140 mm; n = 51) with R0 rates of 70.8 vs. 40.5 % (P < 0.001) and procedure times of 92.7 ± 62.4 minutes vs. 217.0 ± 120.9 minutes (P < 0,001).

CONCLUSIONS

This series confirms the efficacy of ESD for en bloc resection of colorectal lesions > 20 mm. RESULTS are satisfactory for lesions up to 50 mm. ESD for larger lesions was associated with low R0 resection rates and very long procedure times. The clinical consequences of microperforations were minor and do not argue against the spread of ESD in the West. Meeting presentations: The data were presented in part at DDW 2014, Chicago IL, USA (Gastrointest Endosc 2014; 79: AB536).

Training for advanced endoscopic procedures

Advanced endoscopy has evolved from diagnostic ERCP to an ever-increasing array of therapeutic procedures including EUS with FNA, ablative therapies, deep enteroscopy, luminal stenting, endoscopic suturing and endoscopic mucosal resection among others. As these procedures have become increasingly more complex, the risk of potential complications has also risen. Training in advanced endoscopy involves more than obtaining a minimum number of therapeutic procedures. The means of assessing a trainee's competence level and ability to practice independently continues to be a matter of debate. The use of quality indicators to measure performance levels may be beneficial as more advanced techniques and procedures become available.