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

Non-Curative Endoscopic Submucosal Dissection: Current Concepts, Pitfalls and Future Perspectives

Endoscopic submucosal dissection (ESD) is very effective for the treatment of digestive tract neoplasia. However, it is very demanding, with a long learning curve, and, therefore, a significant rate of non-curative resections is expected, considering lesion characteristics, location, and endoscopist experience. The management of patients after a non-curative ESD is not definitely established. It must consider patients' comorbidities and expected survival, as well as the morbidity and mortality of complementary treatments such as surgery, chemotherapy, or radiotherapy. On the other hand, there is a window of opportunity to offer those additional treatments to complete neoplastic treatment and give patients an oncological cure. This decision is sometimes difficult, since the diverse histological criteria that define a non-curative ESD do not have the same weight regarding residual risk and oncological progression. The prediction of residual lesion would be paramount to decide whether to refer patients to surgery; nowadays, this prediction is far from perfect, since most of the patients that undergo surgery due to a non-curative ESD do not have residual neoplasia in the surgical specimen. In this review, ESD curativeness and the management of non-curative ESDs performed for esophageal, gastric, and colorectal lesions will be addressed.

A novel reopenable clip with sharp claw for complete closure of mucosal defects after colorectal endoscopic submucosal dissection

The MANTIS Closure Device (MCD; Boston Scientific, Marlborough, Massachusetts, USA) is a reopenable clip with a sharp claw used for closure after endoscopic submucosal dissection (ESD). We evaluated the effectiveness of the MCD for fast and complete closure after colorectal ESD.Cases involving closure with the MCD after ESD of 20-60-mm colorectal lesions between April 2023 and January 2024 were reviewed. The primary end point was complete closure of the ESD defect with the MCD. Secondary end points included closure time, delayed bleeding, delayed perforation, and post-ESD coagulation syndrome (PECS). MCD application involved: 1) grasping the mucosa on the anal-side of the defect; 2) pushing the clip toward the oral-side mucosa and deploying it; 3) adding other reopenable clips for complete closure.61 cases involving MCD were analyzed. Mean tumor size was 32.3 (SD 9.2) mm. Complete closure rate was 98.4% and mean closure time was 6.9 (SD 2.6) minutes. The mean number of MCDs and other clips used was 1.0 (SD 0.1) and 4.7 (SD 1.4), respectively. Rates of delayed bleeding, delayed perforation, and PECS were 0%, 0%, and 9.8%, respectively.Fast and complete closure after colorectal ESD was successfully achieved using the MCD.

Usefulness of the Bridge Formation Method for Colorectal Endoscopic Submucosal Dissection: A Propensity Score-Matched Study

Aims

Colorectal endoscopic submucosal dissection (ESD) has become a standard treatment for superficial colorectal neoplasms worldwide. However, challenges remain in achieving dissection at the precise layer. In this study, we evaluated the effectiveness of a novel ESD technique involving natural traction, referred to as the bridge formation method (BFM).

Methods and Results

The two main features of the BFM are creating a large mucosal flap and leaving normal mucosa on both sides of the lesion until the bridge is made at the end of the procedure. This retrospective study included consecutive patients with 2647 colorectal lesions resected by ESD from September 2003 to December 2023. We divided them into the BFM group and the non-BFM group and conducted propensity score matching.After propensity score matching, 1648 cases were enrolled (824 cases in each group). The en bloc resection rate was significantly higher in the BFM than non-BFM group (99.6% vs. 96.7%, p < 0.01). The R0 resection rate and the average dissection speed (㎟/min) were significantly higher in the BFM than non-BFM group (98.8% vs. 96.4%, p < 0.01, and 18.9 vs. 18.0, p = 0.03). The occurrence rates of perforation and delayed bleeding showed no significant difference between the non-BFM and BFM groups (2.8% vs. 3.6%, p = 0.40, and 1.1% vs. 1.0%, p = 1.00).

Conclusions

The BFM is a suitable method for colorectal ESD as it enables rapid dissection and improves both en bloc resection and R0 resection rates.

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.

Pitfalls during histological assessment in locally resected pT1 colorectal cancer

Colorectal cancer (CRC) is a common malignancy worldwide, and the stage of the tumour is closely related to clinical outcome. Bowel cancer screening programmes have resulted in the identification of colorectal cancer at earlier stages. Approximately 10% of patients with the earliest stage of CRC (i.e. pT1) will possess regional lymph node metastases (LNM). Therefore, if these patients have initially been treated by local resection (e.g. polypectomy), this subgroup will require surgical resection. Identification of pathological risk factors for LNM within locally resected pT1 CRC is a very important process during the histological assessment of these lesions. This paper describes the most commonly encountered and clinically significant difficulties in the histological assessment of these cases. These pitfalls are illustrated using four examples of locally resected pT1 CRC that were received by our department during routine diagnostic practice.

Impact of Annual Case Volume on Colorectal Endoscopic Submucosal Dissection Outcomes in a Large Prospective Cohort Study

INTRODUCTION

The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort.

METHODS

Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed.

RESULTS

Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers.

DISCUSSION

Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

Soft Coagulation Versus Argon Plasma Coagulation After Large Non-pedunculated Colorectal Polyp Resection: A Meta-analysis

INTRODUCTION

Thermal ablative methods (such as argon plasma coagulation (APC) and soft tip snare coagulation (STSC) are commonly used to treat polyp margins. We aim to appraise the current literature and compare clinical outcomes between patients with treated (with APC vs. STSC) and non-treated endoscopic mucosal resection (EMR) margins.

METHODS

We searched major databases from inception until November 2023 for randomly controlled trials (RCTs) comparing EMR of large non-pedunculated colorectal polyps with and without treated margins. Pooled data were analyzed for the primary outcome of recurrence at first screening colonoscopy, and adverse events. Analysis was performed using a random effects model and data were reported using 95% CIs.

RESULTS

A total of 5 RCT's were found, which included 1020 polyps (577 in treatment and 443 in control groups). Three studies included treatment with STSC and 3 studies used APC as the modality for margin ablation. Of the included patients, 53% were female and the average age was similar between treatment and control groups (65.9 vs. 66.1 y). Seventy-one percent of lesions were proximal to the splenic flexure. The mean follow-up to the first colonoscopy and average polyp size were comparable (6.3 vs. 6.2 mo; 28.2 vs. 28.0 mm, respectively). Pooled analysis showed that margin ablation was associated with significantly lower rates of recurrence [odds ratio (OR) 0.267, 95% CI 0.18-0.4, P<0.001] with low heterogeneity between studies (I2=0%, P=0.47). Pooled analysis showed no significant difference between STSC and APC in terms of recurrence (OR 0.6, 95% CI 0.27-1.7, I2=0%, P=0.3) or adverse events (OR 0.67, 95% CI 0.3-1.6, I2 13%, P=0.46).

CONCLUSION

Our study shows that ablation of EMR margins is very effective at preventing recurrence at first surveillance colonoscopy. We found no difference between STSC or APC in terms of polyp recurrence or adverse outcomes.

Survey of the Actual Practices Used for Endoscopic Removal of Colon Polyps in Korea: A Comparison with the Current Guidelines

Background/Aims

We investigated the clinical practice patterns of Korean endoscopists for the endoscopic resection of colorectal polyps.

Methods

From September to November 2021, an online survey was conducted regarding the preferred resection methods for colorectal polyps, and responses were compared with the international guidelines.

Results

Among 246 respondents, those with <4 years, 4-9 years, and ≥10 years of experience in colonoscopy practices accounted for 25.6%, 34.1%, and 40.2% of endoscopists, respectively. The most preferred resection methods for non-pedunculated lesions were cold forceps polypectomy for ≤3 mm lesions (81.7%), cold snare polypectomy for 4-5 mm (61.0%) and 6-9 mm (43.5%) lesions, hot endoscopic mucosal resection (EMR) for 10-19 mm lesions (72.0%), precut EMR for 20-25 mm lesions (22.0%), and endoscopic submucosal dissection (ESD) for ≥26 mm lesions (29.3%). Hot EMR was favored for pedunculated lesions with a head size <20 mm and stalk size <10 mm (75.6%) and for those with a head size ≥20 mm or stalk size ≥10 mm (58.5%). For suspected superficial and deep submucosal lesions measuring 10-19 mm and ≥20 mm, ESD (26.0% and 38.6%) and surgery (36.6% and 46.3%) were preferred, respectively. The adherence rate to the guidelines ranged from 11.2% to 96.9%, depending on the size, shape, and histology of the lesions.

Conclusions

Adherence to the guidelines for endoscopic resection techniques varied depending on the characteristics of colorectal polyps. Thus, an individualized approach is required to increase adherence to the guidelines.

Long‐term prognostic outcomes in high‐risk T1 colorectal cancer: A multicentre retrospective comparison of surgery versus observation postendoscopic treatment

Aim

The risk of lymph node metastasis after endoscopic resection of high‐risk T1 colorectal cancer prompts additional resection. However, age and comorbidities are considered in decision‐making and some surgeons opt for observation. We compared the long‐term outcomes of these approaches with the aim of clarifying the need for additional resection.

Method

This multicentre retrospective study included high‐risk T1 colorectal cancer patients treated with endoscopic submucosal dissection (ESD) between January 2013 and April 2021. Patients who met one or more of the following criteria were eligible for inclusion: submucosal invasion depth ≥1000 μm, vessel invasion, poor differentiation, budding grade 2/3 or a positive vertical margin. Patients were divided into resection (R) and observation (O) groups. Outcomes were evaluated based on overall survival (OS) and 5‐year cancer‐specific survival (CSS), with an additional stratified analysis using the age‐adjusted Charlson comorbidity index (ACCI).

Results

The study included 178 patients (group R, n = 131; group O, n = 47). Patients in group O were significantly older and had more comorbidities. Group R showed better 5‐year OS and CSS (OS 87.0% vs. 58.9%, p = 0.001; CSS 98.8% vs. 78.4%, p = 0.002). Stratification by ACCI revealed that benefits of additional resection remained for patients with ACCI ≤ 6 (OS 91.2% vs. 58.3%, p = 0.013; CSS 98.4% vs. 61.7%, p < 0.001) but not for those with ACCI ≥7 (OS 75.9% vs. 59.8%, p = 0.289; CSS 100% vs. 100%, p = 0.617).

Conclusions

Significant survival benefits were demonstrated in group R patients with high‐risk T1 cancer. However, the survival benefit of additional surgical resection was unconfirmed in patients with ACCI ≥ 7.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spinal anesthesia for endoscopic submucosal dissection of large rectosigmoid lesions: Feasibility study

Background and study aims Colorectal endoscopic submucosal dissection (ESD) is often challenging and time-consuming. Prolonged sedation and general anesthesia are associated with a relevant risk of anesthesia-related adverse events (ARAEs), especially in elderly and frail patients. Spinal anesthesia (SA), a simple technique providing analgesia and motor block without systemic drug administration, has never been described in gastrointestinal endoscopy. We assessed the feasibility of SA in colorectal lesion ESD. Patients and methods We retrospectively collected data on all consecutive patients who underwent ESD for colorectal laterally spreading tumors (LSTs) under SA in our center during the last 3 years. We evaluated the rates of technical success, i.e. ESD completion under SA without need of conversion to deep sedation or general anesthesia, and ARAEs after SA. Results ESD under SA was performed on 20 rectosigmoid LSTs ≥ 35 mm. Technical success was achieved in 95.0% of cases (19/20), while one patient (5.0%) required conversion to deep sedation. Two patients (10.0%) experienced acute urinary retention that was successfully treated with temporary catheterization. Conclusions Our initial experience suggests that SA for ESD of large rectosigmoid LSTs is feasible, and it may prove to be a valuable option, especially for elderly and frail patients.

Comparing underwater endoscopic submucosal dissection and conventional endoscopic submucosal dissection for large laterally spreading tumor: a randomized controlled trial (with video)

BACKGROUND AND AIMS

Colorectal endoscopic submucosal dissection (ESD) is challenging despite its usefulness. Underwater ESD (UESD) provides better traction and a clearer view of the submucosal layer than conventional ESD (CESD). This study compared the efficiency of UESD and CESD for large (20-50 mm) laterally spreading tumors (LSTs).

METHODS

Preplanned sample size was calculated from our previous experience. As a result, 28 patients were required for the UESD group and CESD group each. The primary outcome was total procedure time; the secondary outcome was dissection speed.

RESULTS

Fifty-six patients were enrolled, and a total of 28 patients were assigned to each group. The mean LST size was 31.6 mm and 31.3 mm in the UESD and CESD groups, respectively. Fibrosis was observed in 67.9% and 60.7% of patients in the UESD and CESD groups. Total procedure time (mean ± standard deviation) for the UESD group was significantly shorter than that for the CESD group (49.5 ± 20.3 minutes vs 75.7 ± 36.1 minutes; mean difference, -26.2 minutes; 95% confidence interval, -42.0 to -10.5 minutes). Dissection speed of the UESD group was significantly faster than that of the CESD group (21.9 ± 6.9 mm2/min vs 15.2 ± 7.3 mm2/min; mean difference, 6.7 mm2/min; 95% confidence interval, 2.8 to 10.4 mm2/min). There was no difference between groups in the R0 resection rate or en bloc resection rate. No perforations were observed in either group.

CONCLUSIONS

UESD was superior to CESD in total procedure time and dissection speed. UESD can be recommended as the preferred method for the resection of large LSTs.

A multicenter, retrospective study of a through-the-needle injection-capable electrosurgical knife for endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a technically challenging resection technique for en bloc removal of dysplastic and early cancerous GI lesions. We conducted a single-arm retrospective study evaluating the safety and efficacy of a new through-the-needle injection-capable electrosurgical knife used in upper and lower ESD procedures performed at 6 U.S. academic centers.

METHODS

Data were retrospectively collected on consecutive cases in which the new ESD knife was used. The primary efficacy endpoint was successful ESD (en bloc resection with negative margins). Secondary efficacy endpoints included en bloc resection rate, curative resection rate, median ESD time, and median dissection speed. The safety endpoint was device- or procedure-related serious adverse events.

RESULTS

ESD procedures of 581 lesions in 579 patients were reviewed, including 187 (32.2%) upper GI and 394 (67.8%) lower GI lesions. Prior treatment was reported in 283 (48.9%) patients. Successful ESD was achieved in 477 (82.1% of 581) lesions-lower for patients with versus without submucosal fibrosis (73.6% vs 87.0%, respectively; P < .001) but similar for those with versus without previous treatment (81.7% vs 82.3%, respectively; P = .848). A total of 443 (76.2% of 581) lesions met criteria for curative resection. Median ESD time was 1.0 (range, 0.1-4.5) hour. Median dissection speed was 17.1 (interquartile range, 5.3-29.8) cm2/h. Related serious adverse events were reported in 15 (2.6%) patients, including delayed hemorrhage (1.9%), perforation (0.5%), or postpolypectomy syndrome (0.2%).

CONCLUSION

A newly developed through-the-needle injection-capable ESD knife showed a good success rate and excellent safety at U.S.

CENTERS

(Clinical trial registration number: NCT04580940.).

Endoscopic submucosal dissection of colorectal pedunculated polyps

Background and study aims For pedunculated colon polyps, en bloc resection with inclusion of the polyp stalk is necessary to yield an accurate histologic staging. This can be challenging in cases of a large polyp and/or broad stalk using conventional snare resection. We evaluated the feasibility of endoscopic submucosal dissection (ESD) for large pedunculated polyps with broad stalks. Patients and methods Between February 2019 and November 2021 all patients with large pedunculated polyps defined as polyp diameter ≥ 20 mm and or a broad stalk > 5 mm were enrolled in the study. All polyps were resected in ESD technique with dissection of the polyp stalk at the base after injection. Results Twenty-five patients (male = 18, age mean: 67 years) were included. En bloc resection was achieved in 100% of the patients (25/25 polyps). Polyps were mainly located in the sigmoid (n = 19) and rectum (n = 3). Median polyp size was 30×25×17 mm. Histologic examination revealed the following results: adenoma low-grade intraepithelial neoplasia (LG-IEN): nine; high-grade intraepithelial neoplasia (HG-IEN): seven; pTis: three; adenoarcinoma: five (G1, pT1, L0, V0, Haggitt 3: 2/G2, pT1, L0, V0, Haggitt 3:2/G3, pT1, Bd3, V1, Haggitt 4: 1); other: 1. R0 resection rate was 100% and the curative resection rate yielded 96% (24/25) without severe adverse events. Conclusions ESD achieved high en bloc and R0 resection rates for large pedunculated polyps. In our collective, up to 32% of polyps already had adenocarcinoma, resulting in a high curative resection rate due to complete resection and subsequently accurate risk classification.

Resection of Early Colorectal Neoplasms Using Endoscopic Submucosal Dissection: A Retrospective Multicenter Cohort Study

Background: Endoscopic submucosal dissection (ESD) is a reliable method that can replace surgery in the treatment of early colorectal cancer under certain conditions. Aim: The aim of the study was to analyze factors influencing the ESD procedure in early colorectal cancer, with the intention of improving its effectiveness. Patients and Methods: We conducted a multicenter, retrospective cohort study on 214 patients who underwent ESD procedures for early colorectal cancer from January 2016 to October 2023. Results:En bloc resection was achieved in 197 (92.1%) of ESD procedures, R0 resection in 149 (69.6%), and curative resection in 54 (40.9%). The submucosal invasion was classified as level 1 (SM1) in 96 cases (45.3%), level 2 (SM2) in 61 cases (28.8%), and level 3 (SM3) in 36 cases (17%). R0 resection was achieved more often in the rectum-92 (81.4%), compared to the right-24 (64.9%) and left colon-33 (61.1%), p = 0.009. In rectal tumors, R0 resection was achieved in 51 (98.1%) SM1 invasion, 27 (73%) SM2 invasion, and 13 (65%) SM3 invasion (p < 0.001). Lateral and vertical resection margins were positive in 12 (7.7%) and 52 (25.2%) cases, respectively. Vertical resection margins were statistically more often positive in lesions located in the right colon-11 cases (28.9%) and left colon-21 cases (38.9%), than in rectum-20 cases (17.5%); p = 0.010. Complications were found in 32 (15%) cases of ESD procedure-perforation in 12 cases (5.6%) and delayed bleeding in four cases (1.9%). Procedures performed in the right colon were associated with a significantly higher risk of any complications (30%) and perforations (15%) than those performed in the rectum (10.3% and 2.6%) or the left colon (13.8% and 5.2%; p = 0.016; p = 0.015), respectively. Conclusions: ESD for early colon cancer is a viable strategy due to its effectiveness and low complication rate. The ESD technique performed in the rectum yields the best results; however, in the right colon, it still requires careful attention.

Conventional versus rubber band traction-assisted endoscopic submucosal dissection for rectal neuroendocrine tumors: a single-center retrospective study (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is a safe and effective technique for the treatment of gastrointestinal tumors, including rectal neuroendocrine tumors (r-NETs). However, the relative advantages of traction-assisted ESD for the treatment of small rectal lesions are still debated.

AIMS

We conducted a study to compare the efficacy and safety of rubber band traction-assisted ESD (RBT-ESD) to conventional ESD (C-ESD).

METHODS

This study retrospectively analyzed consecutive patients with r-NET treated with ESD between October 2021 and October 2023. Our study assessed differences between the groups in the complete resection rate of lesions, muscular layer injury, surgical complications, operation time, resection speed, time to liquid diet, postoperative hospital stay, hospital cost, and recurrence rate.

RESULTS

A total of 119 patients with r-NETs participated in this study (RBT-ESD group, n = 27; C-ESD group, n = 92). The operation time in RBT-ESD group was shorter than in C-ESD group, but the difference was not statistically significant (16.0 min [9.0-22.0 min] vs. 18.0 min [13.3-27.0 min], P = 0.056). However, the resection speed was significantly faster in the RBT-ESD group (6.7 vs. 4.1 mm2/min, P = 0.005). Furthermore, the RBT-ESD group showed significantly less muscular layer injury (P = 0.047) and faster diet recovery (P = 0.035). No significant differences were observed in the complete resection rate, surgical complications, postoperative hospital stay, hospital cost, or recurrence rate between the two groups.

CONCLUSION

For r-NETs of < 2 cm in size, the RBT method did not significantly shorten the operation time but resulted in faster resection speed, less muscular layer injury, and earlier postoperative recovery to a liquid diet.

Safety and Efficacy of Endoscopic Submucosal Dissection for Rectal Neoplasms Extending to the Dentate Line: A Systematic Review and Meta-analysis

OBJECTIVE

Endoscopic submucosal dissection (ESD) is a superior, minimally invasive technique compared with other snare-based endoscopic resection techniques for rectal neoplasms extending to the dentate line (RNDLs). However, performing a successful ESD in the anal canal can be challenging due to vascularity and limited scope stability. In this meta-analysis, we aim to evaluate the safety and efficacy of ESD for RNDLs.

METHODS

We performed a comprehensive electronic database search from January 2005 through January 2024 for studies evaluating outcomes of ESD performed for managing RNDLs. Pooled proportions were calculated using random-effect models. Heterogeneity was evaluated using I2 and Q statistics.

RESULTS

Data were extracted from 11 studies comprising 496 patients. The pooled en bloc resection rates were 93.60% (95% CI = 90.70-95.70). The pooled R0 resection rate was 80.60% (95% CI = 70.50-87.80). The pooled recurrence rate was 4.00% (95% CI = 2.40-6.50). There was no evidence of significant heterogeneity calculated using the Q test and I2 statistic. The main adverse events were anal pain, postprocedural bleeding, and anal stricture with pooled rates of 20.20% (95% CI = 14.80-26.90), 8.20% (95% CI = 4.70-14.0), and 3.50% (95% CI = 2.10-5.70), respectively.

CONCLUSIONS

ESD is a safe and effective option for managing RNDLs with a low recurrence rate. Adverse events such as postprocedural perianal pain, postprocedural bleeding, and anal stenosis seem to be more common compared with colorectal ESD done for more proximal lesions. However, these can typically be managed conservatively or with minimally invasive endoscopic techniques.

Comparative Study on the Effectiveness, Safety, and Economic Costs of Endoscopic Submucosal Dissection for Colorectal Tumors Under Conscious Sedation and General Anesthesia

BACKGROUND

Endoscopic submucosal dissection (ESD) is a minimally invasive surgical procedure used for en bloc removal of colorectal tumors. Although colorectal ESD is ideally conducted under conscious sedation, it is often performed under general anesthesia because of its complexity and lengthy duration. Currently, there is limited research on colorectal ESD performed under conscious sedation. The purpose of this study was to evaluate the effectiveness, safety, and economic cost of colorectal ESD under conscious sedation compared to general anesthesia.

MATERIALS AND METHODS

Retrospective analysis of 301 patients who underwent ESD treatment for colorectal tumors at the Endoscopy Center of Peking University Cancer Hospital from January 2018 to November 2020. Patients were divided into the sedation group (group S, n=88) and the general anesthesia group (group A, n=213) based on the anesthetic method. To balance the confounding factors between the 2 groups, 75 matched pairs were obtained after using propensity score matching (PSM). Intraoperative and postoperative parameters were then compared between the matched groups.

RESULTS

After PSM, there was no statistically significant difference between group S and group A in terms of the surgical time, en bloc resection rate, and complete resection rate. There was also no statistically significant difference in the occurrence rates of bleeding, perforation, and post-ESD electrocoagulation syndrome (PEECS) between the 2 groups. However, the length of hospital stay was significantly shorter in group S (1.23±0.89d) than in group A (5.92±3.05d) ( P <0.05). The hospitalization costs were also significantly lower in group S (16482.34±13154.32 yuan) compared with group A (34743.74±13779.40 yuan) (P < 0.05 ).

CONCLUSIONS

Compared to general anesthesia, performing ESD for colorectal tumors under conscious sedation has equivalent effectiveness and safety while shortening the hospital stay and reducing the economic costs.

Clinical utility of a novel anchor pronged clip for mucosal defect closure after colorectal endoscopic submucosal dissection (with video)

Background and study aims The MANTIS Clip (Boston Scientific) is a novel anchor pronged clip designed to enhance tissue grasping and facilitate the closure of defects in the gastrointestinal tract. This study evaluates the feasibility and effectiveness of the MANTIS Clip for closing mucosal defects following colorectal endoscopic submucosal dissection (C-ESD). Patients and methods A retrospective single-center study was conducted on patients who underwent C-ESD with MANTIS Clip closure from May 2023 to April 2024. The primary outcome measured was the complete closure success rate. Secondary outcomes included defect size, sustained closure rate, closure time, number of clips used, adverse events (AEs), and hospital stay duration. Results The MANTIS Clip was used in 52 cases. The complete closure rate was 98.1% (51/52), with a sustained closure rate of 96.1% (49/51). The median closed defect size was 32 mm, with the largest being 62 mm. The median closure time was 8 minutes. Typically, one MANTIS Clip per defect was used, with only one lesion requiring two clips. The median number of additional clips used was seven. AEs included one case of bleeding (1.9%) and one case of post-ESD coagulation syndrome (1.9%), both managed without extending hospital stays. The median C-reactive protein level on the first day post-ESD was 0.35 mg/dL and the median hospital stay was 5 days. Conclusions The MANTIS Clip is effective and practical for mucosal defect closure post-C-ESD, demonstrating high success and sustained closure rates with minimal complications. Future multicenter randomized trials are needed to further assess its efficacy and safety.

Traction-assisted endoscopic submucosal dissection for resection of ileocecal valve neoplasia: a French retrospective multicenter case series

BACKGROUND

The ileocecal valve (ICV) is considered to be one of the most difficult locations for endoscopic submucosal dissection (ESD). The objective of this study was to evaluate the efficacy and safety of traction-assisted ESD in this situation.

METHODS

All patients who underwent traction-assisted ESD for an ICV lesion at three centers were identified from a prospective ESD database. En bloc and R0 rates were evaluated. Factors associated with non-R0 resection were explored.

RESULTS

106 patients with an ICV lesion were included. The median lesion size was 50 mm (interquartile range 38-60) and 58.5% (62/106) invaded the terminal ileum. The en bloc and R0 resection rates were 94.3% and 76.4%, respectively. Factors associated with non-R0 resection were lesions covering ≥75% of the ICV (odds ratio [OR] 0.21. 95%CI 0.06-0.76; P=0.02), and involving the anal lip (OR 0.36, 95%CI 0.13-0.99; P=0.04) or more than two sites on the ICV (OR 0.27, 95%CI 0.07-0.99; P=0.03).

CONCLUSION

Traction-assisted ESD for treatment of ICV lesions was a safe and feasible option. Large lesions and anal lip involvement appeared to be factors predictive of difficulty.

Predictors of En Bloc, R0 Resection, and Postprocedural Complications After Advanced Endoscopic Resections for Colorectal Neoplasms: Results of 1213 Procedures

BACKGROUND

Advanced endoscopic resection techniques are used to treat colorectal neoplasms that are not amenable to conventional colonoscopic resection. Literature regarding the predictors of the outcomes of advanced endoscopic resections, especially from a colorectal surgical unit, is limited.

OBJECTIVE

To determine the predictors of short-term and long-term outcomes after advanced endoscopic resections.

DESIGN

Retrospective case series.

SETTINGS

Tertiary care center.

PATIENTS

Patients who underwent advanced endoscopic resections for colorectal neoplasms from November 2011 to August 2022.

INTERVENTIONS

Endoscopic mucosal resection, endoscopic submucosal dissection, hybrid endoscopic submucosal dissection, and combined endoscopic laparoscopic surgery.

MAIN OUTCOME MEASURES

Predictors of en bloc and R0 resection, bleeding, and perforation were determined using univariable and multivariable logistic regression models. Cox regression models were used to determine the predictors of tumor recurrence.

RESULTS

A total of 1213 colorectal lesions from 1047 patients were resected (median age 66 [interquartile range, 58-72] years, 484 women [46.2%], median BMI 28.6 [interquartile range, 24.8-32.6]). Most neoplasms were in the proximal colon (898; 74%). The median lesion size was 30 (interquartile range, 20-40; range, 0-120) mm. Nine hundred eleven lesions (75.1%) underwent previous interventions. The most common Paris and Kudo classifications were 0 to IIa flat elevation (444; 36.6%) and IIIs (301; 24.8%), respectively. En bloc and R0 resection rates were 56.6% and 54.3%, respectively. Smaller lesions, rectal location, and procedure type (endoscopic submucosal dissection) were associated with significantly higher en bloc and R0 resection rates. Bleeding and perforation rates were 5% and 6.6%, respectively. Increased age was a predictor for bleeding (OR 1.06; 95% CI, 1.03-1.09; p < 0.0001). Lesion size was a predictor for perforation (OR 1.02; 95% CI, 1.00-1.03; p = 0.03). The tumor recurrence rate was 6.6%. En bloc (HR 1.41; 95% CI, 1.05-1.93; p = 0.02) and R0 resection (HR 1.49; 95% CI, 1.11-2.06; p = 0.008) were associated with decreased recurrence risk.

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

Outcomes of advanced endoscopic resections can be predicted by patient-related and lesion-related characteristics. See Video Abstract .

PREDICTORES DE LA RESECCION R, EN BLOQUE Y LAS COMPLICACIONES POR RESECCIONES ENDOSCPICAS AVANZADAS EN CASOS DE NEOPLASIA COLORRECTAL RESULTADOS DE PROCEDIMIENTOS

ANTECEDENTES:Las técnicas avanzadas de resección endoscópica se utilizan para el tratamiento de neoplasias colorrectales que no son susceptibles de resección colonoscópica convencional. La literatura sobre los predictores de los resultados de las resecciones endoscópicas avanzadas, especialmente en una unidad de cirugía colorrectal, es limitada.OBJETIVO:Determinar los predictores de resultados a corto y largo plazo después de resecciones endoscópicas avanzadas.DISEÑO:Serie de casos retrospectivos.LUGAR:Centro de tercer nivel de atención.PACIENTES:Pacientes sometidos a resecciones endoscópicas avanzadas por neoplasias colorrectales desde noviembre de 2011 hasta agosto de 2022.INTERVENCIÓNES:Resección endoscópica de la mucosa, disección endoscópica submucosa (ESD), ESD híbrida, cirugía laparoscópica endoscópica combinada.PRINCIPALES MEDIDAS DE RESULTADO:Los predictores de resección en bloque y R0, sangrado y perforación se determinaron mediante modelos de regresión logística univariables y multivariables. Se utilizaron modelos de regresión de Cox para determinar los predictores de recurrencia del tumor.RESULTADOS:Se resecaron 1.213 lesiones colorrectales en 1.047 pacientes [edad media 66 (58-72) años, 484 (46,2%) mujeres, índice de masa corporal medio 28,6 (24,8-32,6) kg/m 2 ]. La mayoría de las neoplasias se encontraban en el colon proximal (898, 74%). El tamaño medio de la lesión fue de 30mm (RIC: 20-40, rango: 0-120). 911 (75,1%) lesiones tenían intervenciones previas. Las clasificaciones de París y Kudo más comunes fueron 0-IIa elevación plana (444, 36,6%) y III (301, 24,8%), respectivamente. Las tasas de resección en bloque y R0 fueron del 56,6% y 54,3%, respectivamente. Las lesiones más pequeñas, la ubicación rectal y el tipo de procedimiento (ESD) se asociaron con tasas de resección en bloque y R0 significativamente más altas. Las tasas de sangrado y perforación fueron del 5% y 6,6%, respectivamente. La edad avanzada [1,06 (1,03-1,09), p < 0,0001] fue un predictor de sangrado. El tamaño de la lesión [1,02 (1,00-1,03), p = 0,03] fue un predictor de perforación. La tasa de recurrencia del tumor fue del 6,6%. En bloque [HR 1,41 (IC 95% 1,05-1,93), p = 0,02] y la resección R0 [HR 1,49 (IC 95% 1,11-2,06), p = 0,008] se asociaron con un menor riesgo de recurrencia.LIMITACIONES:Estudio unicéntrico, retrospectivo.CONCLUSIONES:Los resultados de las resecciones endoscópicas avanzadas pueden predecirse según las características del paciente y de la lesión. (Traducción-Dr. Xavier Delgadillo ).

The Derivation and External Validation of a Fibrosis Risk Model for Colorectal Tumours Undergoing Endoscopic Submucosal Dissection

Background: Endoscopic submucosal dissection (ESD) is an advanced technique that can become more challenging in the presence of submucosal fibrosis. Predicting the grade of fibrosis is important in order to identify technically difficult ESD. Aims and Methods: Our study aimed to derive and validate a prediction model to determine the preoperative degree of submucosal fibrosis in colorectal tumours undergoing ESD. A predictive model was developed to derive the probability of an increasing submucosal fibrosis in the derivation cohort and then externally validated. Results: 309 patients (age: 68 ± 10.9 years) underwent colorectal ESD between January 2016 and June 2020. F0, F1, and F2 fibroses were reported in 196 (63.4%), 70 (22.6%), and 43 (13.9%) cases, respectively. R0 resection was found in 266 (87%) lesions. At multivariable analysis in the derivation cohort, lesion morphology (OR = 0.37 and CI = 0.14-0.97 for LST-NG vs. 0-Is; OR = 0.29 and CI = 0.1-0.87 for the LST mixed type vs. 0-Is; and OR = 0.32 and CI = 0.1-1.03 for LST-G vs. 0-Is) and increasing size (OR = 1.02 and CI = 1.01-1.04 for a 1 mm increase) were significantly associated with an increasing degree of fibrosis. The model had fair discriminating ability in the derivation group (AUROC = 0.61 and CI = 0.52-0.69 for F1-F2 vs. F0 fibroses; AUROC = 0.61 and CI = 0.45-0.77 for F2 vs. F0-F1 fibroses) and in the validation group (AUROC = 0.71 and CI = 0.59-0.83 for F1-F2 vs. F0 fibroses; AUROC = 0.65 and CI = 0.52-0.77 for F2 vs. F0-F1 fibroses). Conclusions: Our findings introduce a new tool for the stratification of ESD technical difficulty based on lesion size and morphological characteristics which could become crucial during the procedure's planning process.

Risk factors for unsuccessful colorectal endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND AND AIMS

Despite its growing popularity, endoscopic submucosal dissection (ESD) for colorectal neoplasms is still technically challenging. The factors contributing to the failure of ESD are not yet comprehensively elucidated. Therefore, this systematic review was conducted to explore the potential risk factors associated with unsuccessful colorectal ESD.

METHODS

A comprehensive search of Medline and Embase databases was conducted to identify relevant publications from inception until March 14, 2023. Unsuccessful ESD was defined as cases involving incomplete resection or the occurrence of adverse events, such as perforation and delayed bleeding.

RESULTS

Among the 2067 citations initially identified, a total of 23 cohort studies and 16 case-control studies met the inclusion criteria. Following meta-analyses, several significant risk factors for incomplete resection were identified, including lesion diameter ≥40 or 50 mm, right-side colonic location, deeper submucosal invasion, and severe fibrosis. Similarly, lesion diameter ≥40 or 50 mm and severe fibrosis emerged as risk factors for perforation. However, no individual factor was found to be statistically associated with delayed bleeding.

CONCLUSIONS

This meta-analysis identified risk factors correlated with incomplete resection and adverse events following ESD. The findings provide valuable insights that can guide clinical decision-making, aiding gastroenterologists in accurately identifying high-risk individuals.

Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm

Background

Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors.

Summary

A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection.

Key Messages

Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.

Risk Factors for Post-Endoscopic Submucosal Dissection Electrocoagulation Syndrome in Patients with Colorectal Neoplasms: A Multicenter, Large-Scale, Retrospective Cohort Study by the Honam Association for the Study of Intestinal Disease (HASID)

Background and Objectives: Colorectal endoscopic submucosal dissection (ESD) is an effective technique for removing colorectal neoplasms with large or cancerous lesions. However, there are few studies on post-ESD electrocoagulation syndrome (PECS), a complication of colorectal ESD. Therefore, this study aimed to investigate the various risk factors for PECS after colorectal ESD. Materials and Methods: We retrospectively analyzed the medical records of 1413 lesions from 1408 patients who underwent colorectal ESD at five tertiary hospitals between January 2015 and December 2020. We investigated the incidence and risk factors associated with PECS. Based on the data, we developed a risk-scoring model to predict the risk of PECS after colorectal ESD. Results: The incidence rate of PECS was 2.6% (37 patients). In multivariate analysis, the use of anti-platelet agents (odds ratio (OR), 2.474; 95% confidence interval (CI), 1.088-5.626; p < 0.031), a lesion larger than 6 cm (OR 3.755; 95% CI, 1.237-11.395; p = 0.028), a deep submucosal invasion (OR 2.579; 95% CI, 1.022-6.507; p = 0.045), and an ESD procedure time ≥ 60 min (OR 2.691; 95% CI, 1.302-5.560; p = 0.008) were independent risk factors of PECS after colorectal ESD. We developed a scoring model for predicting PECS using these four factors. As the score increased, the incidence of PECS also increased, from 1.3% to 16.6%. PECS occurred more frequently in the high-risk group (≥2) (1.8% vs. 12.4%, p < 0.001). Conclusions: In this study, the risk factors for PECS after colorectal ESD were the use of anti-platelet agents, a lesion larger than 6 cm, a deep submucosal invasion, and an ESD procedure time ≥ 60 min. The risk-scoring model developed in this study using these factors could be effective in predicting and preventing PECS.

Application of Endoscopic Submucosal Dissection (ESD) in Treatment of Gastrointestinal Lesions-Single Center Experience

Background and Objectives: Endoscopic resection of gastrointestinal (GI) tract lesions, originating from Japan, is becoming more frequently used in European countries. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) ensure minimally invasive removal of benign, premalignant, and early neoplastic tumors of esophagus, stomach, and intestine in selected group of patients. Aim of this study was to determine the outcomes, radical resection rate (R0), and complication rate of ESD procedures performed in our department. Methods: The data from 100 ESD procedures of esophageal, gastric, duodenal, and colorectal lesions performed in out unit between 02.01.2020 and 30.06.2023 were collected and analyzed retrospectively. Results: A total of 42 male and 58 female patients in the median age of 64 years (range, 31-89 years) underwent ESD. Mean duration of the procedure was 66 minutes (ranging 25-185 minutes). Tumors were located in the esophagus in 8 cases (8%), stomach in 25 cases (25%), duodenum in 1 case (1%), and colon in 66 cases (66%). Radical resection was achieved in 98 cases (98%); 2 patients were qualified for surgical treatment. Average size of dissection lesions was 26 × 19 mm. The biggest one was 60 × 60 mm (sigmoid adenoma), and the smallest one was 5 × 5 mm (gastrointestinal neuroectodermal tumors). Complication occurred in 10 patients (10%)-9 perforations of the wall of intestine (9%) and 1 hemorrhage, which required endoscopic intervention (1%). Conclusions: Implementation of ESD to clinical practice gives the opportunity for minimally invasive, radical treatment of benign, premalignant, and early neoplastic lesions of gastrointestinal tract in selected group of patients. Experienced endoscopists, following current guidelines and standardized process of qualification, are crucial to minimize the risk of severe complications.

Approaches and considerations in the endoscopic treatment of T1 colorectal cancer

The detection of early colorectal cancer (CRC) is increasing through the implementation of screening programs. This increased detection enhances the likelihood of minimally invasive surgery and significantly lowers the risk of recurrence, thereby improving patient survival and reducing mortality rates. T1 CRC, the earliest stage, is treated endoscopically in cases with a low risk of lymph node metastasis (LNM). The advantages of endoscopic treatment compared with surgery include minimal invasiveness and limited tissue disruption, which reduce morbidity and mortality, preserve bowel function to avoid colectomy, accelerate recovery, and improve cost-effectiveness. However, T1 CRC has a risk of LNM. Thus, selection of the appropriate treatment between endoscopic treatment and surgery, while avoiding overtreatment, is challenging considering the potential for complete resection, LNM, and recurrence risk.

Combined endoscopic mucosal resection and full-thickness resection for large colorectal polyps: a systematic review and meta-analysis

BACKGROUND AND AIMS

Combined endoscopic mucosal resection (EMR) with endoscopic Full thickness resection (EFTR) is an emerging technique that has been developed to target colorectal polyps larger than 2 cm. We performed a systematic review and meta-analysis to evaluate this technique for the resection of large colorectal lesions.

METHODS

We conducted a comprehensive search of multiple electronic databases from inception through August 2023, to identify studies that reported on hybrid FTR. A random-effects model was employed to calculate the overall pooled technical success, macroscopic complete resection, free vertical margins resection rate, adverse events, and recurrence on follow up.

RESULTS

A total of 8 Study arms with 244 patients (30% women) were included in the analysis. The pooled technical success rate was 97% (95% CI 88%-100%, I2 = 79.93%). The pooled rate of macroscopic complete resection was achieved in 95% (95% CI 90%-99%, I2 = 49.98) with a free vertical margins resection rate 88% (95% CI, 78%-96%, I2 = 63.32). The overall adverse events rate was 2% (95% CI 0%-5%, I2 = 11.64) and recurrence rate of 6% (95% CI 2%-12%, I2=20.32).

CONCLUSION

Combined EMR with EFTR is effective and safe for resecting large, and complex colorectal adenomas, offering a good alternative for high surgical risk patients. Regional heterogeneity was observed, indicating that outcomes may be impacted by differences in operator expertise and industry training certification across regions. Comparative studies that directly compare combined EMR with EFTR against alternative methods such as ESD and surgical resection are needed.

Is there a best choice of equipment for colorectal endoscopic submucosal dissection?

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a widely used technique to remove early neoplastic lesions. It was primarily used in the initial days to treat gastric lesions, but recently, the horizon of this endoscopic procedure has expanded, which has allowed us to manage other technically more complex locations, such as the colorectum.

AREAS COVERED

There has been an exponential growth regarding the wide range of devices available in the market for performing colorectal ESD. As a result, the aim of this review is to highlight the indication of this endoscopic technique, which device is best suited for which indication, as well as future trajectories in this field.

EXPERT OPINION

Although some devices have proven to be more advantageous than others in this area, very often the choice is still subjective, which is commonly attributed to individual preferences and experience. However, an accurate knowledge of the available tools and their functioning, with their pros and cons, is fundamental for any endoscopist venturing into the field of third space endoscopy. In this way, one can choose which device best suits a particular situation, along with simultaneously having the wealth of knowledge related to therapeutic armamentarium at our disposal in the endoscopy suite.

Efficacy and safety of salvage endoscopy in the treatment of residual or recurrent colorectal neoplasia after endoscopic resection: a systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the efficacy and safety of salvage endoscopy for residual or recurrence of colorectal tumors after endoscopic resection.

METHODS

Multiple databases including PubMed, EMBASE and the Cochrane Library were searched to screen for eligible studies and perform data extraction and pooled analysis.

RESULTS

Sixteen studies on salvage endoscopy for residual or recurrent colorectal cancer after endoscopic resection were included, covering approximately 994 patients. The results of the meta-analysis demonstrated that salvage endoscopic therapy for residual or recurrent colorectal tumors following endoscopic resection achieved an en bloc resection rate of 92% (95% CI 0.85-0.97; I2 = 91%) and an R0 resection rate of 82% (95% CI 0.75-0.87; I2 = 78%). The rates of intraoperative or postoperative bleeding and perforation were 10%/1% and 5%/2%, and the recurrence rate was 2%.

CONCLUSIONS

Salvage endoscopic resection is an effective and safe treatment strategy for residual or recurrent colorectal tumors after endoscopic resection.

Clinical outcomes of colorectal neoplasm with positive resection margin after endoscopic submucosal dissection

A positive resection margin after colorectal endoscopic submucosal dissection (ESD) is associated with an increased risk of recurrence. We aimed to identify the clinical significance of positive resection margins in colorectal neoplasms after ESD. We reviewed 632 patients who had en bloc colorectal ESD at two hospitals between 2015 and 2020. The recurrence rates and presence of residual tumor after surgery were evaluated. The rate of additional surgery after ESD and recurrence rate were significantly higher in patients with incomplete resection (n = 75) compared to patients with complete resection (n = 557). When focusing solely on non-invasive lesions, no significant differences in recurrence rates were observed between the groups with complete and incomplete resection (0.2% vs. 1.9%, p = 0.057). Among 84 patients with submucosal invasive carcinoma, 39 patients underwent additional surgery due to non-curative resection. Positive vertical margin and lymphovascular invasion were associated with residual tumor. Lymphovascular invasion was associated with lymph node metastasis. However, no residual tumor nor lymph node metastases were found in patients with only one unfavorable histological factor. In conclusion, a positive resection margin in non-invasive colorectal lesions, did not significantly impact the recurrence rate. Also, in T1 colorectal cancer with a positive vertical resection margin, salvage surgery can be considered in selected patients with additional risk factors.

Endoscopic submucosal dissection and JNET classification for colorectal neoplasia: A North American academic center experience

Objectives

Endoscopic submucosal dissection (ESD) enables minimally invasive resection of superficial gastrointestinal neoplasms en bloc regardless of size. The Japan narrow band imaging expert team (JNET) classification utilizes optical magnification and narrow band imaging (NBI) to predict pathology. In North America, ESD is far from ubiquitous, and regional outcomes are not widely described. To date there are no North American studies describing the application and yield of the JNET classification as applied in the practice of ESD.

Methods

A retrospective, single-center, cohort analysis was performed on a prospectively maintained database of ESD procedures. Between July 2016 and February 2023, all consecutive patients treated with ESD for colorectal lesions were identified and stratified by lesion location, JNET, NBI International Colorectal Endoscopic, lateral spreading tumors, and Paris classifications. Univariate analysis was used for clinicopathological data. p < 0.05 was considered statistically significant.

Results

A total of 112 patients were identified. One lesion, a lipoma, was excluded. Overall, 49.5% (55/111) of lesions were colonic and 50.5% (56/111) rectal. Most lesions were lateral spreading tumors (60.4%, 67/111). Overall, 96.4% (107/111) ESDs were successfully completed, 98.1% (105/107) en bloc, and 87.9% (94/107) R0. Adverse events occurred in 1.8% (2/111) of procedures. The median diameter was 4.0 cm and resected in a median time of 62.0 min. Overall, 70.1% (47/67) lesions were upstaged from pre-ESD biopsy. JNET 2B showed 80.2% (95% CI 71.5-87.1) accuracy for high-grade dysplasia or sm1. All JNET type 3 were ≥sm2 (p < 0.001).

Conclusions

ESD permits safe and effective resection of superficial colorectal neoplasms. JNET classification was more accurate than pre-resection biopsy at predicting histology in this series.

Planned Hybrid Endoscopic Submucosal Dissection as Alternative for Colorectal Neoplasms: A Propensity Score-Matched Study

BACKGROUND AND AIMS

Hybrid endoscopic submucosal dissection (H-ESD), a modified ESD with a snare, has become increasingly utilized to overcome the limitations of conventional ESD (C-ESD). This study aimed to compare the efficacy and safety of Planned H-ESD and C-ESD for colorectal lesions.

METHODS

Propensity score matching was performed to control for confounding variables in this retrospective study. Outcomes included en bloc resection and complete resection (R0) rates, procedure time, adverse event rates, and local recurrence rate.

RESULTS

1286 lesions were enrolled in the study. After matching, 263 lesions were assigned to each group. The Planned H-ESD group has lower en bloc rate but similar R0 resection rate compared to the C-ESD group (90.9% vs 98.1%, P = 0.001; 77.2% vs 77.9%, P = 0.917). The median procedure time was shorter in the Planned H-ESD group (27.0 min vs 35.0 min, P = 0.001). There were no significant differences in adverse events rates or local recurrence rate. Subgroup analysis based on lesion size revealed that a significantly lower en bloc resection rate in the Planned H-ESD group compared to the C-ESD group for lesions ≥ 40 mm (71.0% vs 94.3%, P = 0.027), but there was no significant difference for lesions < 40 mm.

CONCLUSION

The Planned H-ESD has a lower en bloc resection rate but a similar R0 resection rate, adverse event rates, local recurrence rate, and shorter procedure duration. Compared to C-ESD, Planned H-ESD presents advantages for managing colorectal neoplasms below 40 mm.

An Analysis of Delayed Bleeding in Cases of Colorectal Endoscopic Submucosal Dissection Due to Types of Direct Oral Anticoagulants in Japan

BACKGROUND & AIMS

Reported rates of delayed bleeding (DB) after endoscopic resection using direct oral anticoagulants (DOACs) are high and heterogeneous. This large-scale multicenter study analyzed cases of DB after colorectal endoscopic submucosal dissection related to various types of DOACs in Japan (the ABCD-J study) with those associated with warfarin.

METHODS

We retrospectively reviewed 1019 lesions in patients treated with DOACs and 459 lesions in patients treated with warfarin among 34,455 endoscopic submucosal dissection cases from 47 Japanese institutions between 2012 and 2021. The DB rate (DBR) with each DOAC was compared with that with warfarin. Risk factors for DB in patients treated with DOACs or warfarin were also investigated.

RESULTS

The mean tumor sizes in the DOAC and warfarin groups were 29.6 ± 14.0 and 30.3 ± 16.4 mm, respectively. In the DOAC group, the DBR with dabigatran (18.26%) was significantly higher than that with apixaban (10.08%, P = .029), edoxaban (7.73%, P = .001), and rivaroxaban (7.21%, P < .001). Only rivaroxaban showed a significantly lower DBR than warfarin (11.76%, P = .033). In the multivariate analysis, heparin bridging therapy (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.27-3.73, P = .005), rectal location (2.01, 1.28-3.16, P = .002), and procedure time ≥55 minutes (2.43, 1.49-3.95, P < .001) were significant risk factors for DB in the DOAC group. The DB risk in the DOAC group (OR, (95% CI)) was 2.13 (1.30-3.50) and 4.53 (2.52-8.15) for 1 and 2 significant risk factors, respectively.

CONCLUSIONS

Dabigatran was associated with a higher DBR than other DOACs, and only rivaroxaban was associated with a significantly lower DBR than warfarin.

Does Prophylactic Closure Improve Outcomes After Colorectal Endoscopic Submucosal Dissection? A Systematic Review and Meta-analysis

BACKGROUND

Several studies have described prophylactic closure after endoscopic submucosal dissection (ESD) of colorectal lesions for improving postoperative outcomes. We reviewed the evidence on the impact of prophylactic closure after ESD.

METHODS

A literature search was conducted on PubMed, Embase, CENTRAL, and Web of Science by 2 reviewers independently for studies published up to July 9, 2023. All types of comparative studies were eligible.

RESULTS

Ten studies compared 939 patients undergoing prophylactic closure with 1074 controls. Three were randomized controlled trials (RCTs) while the rest were observational. Pooled data from all included studies showed that prophylactic closure resulted in reduced incidence of delayed bleeding after ESD [odds ratio (OR): 0.30; 95% CI: 0.15, 0.72; I2 =0%]. These results were significant only for observational studies but not for RCTs. Meta-analysis showed no significant difference in the risk of delayed perforation (OR: 0.55; 95% CI: 0.18, 1.70; I2 =0%) or post-ESD coagulation syndrome (PECS) (OR: 1.15; 95% CI: 0.41, 3.19; I2 =63%) between closure and nonclosure groups.

CONCLUSIONS

Observational data suggest that prophylactic closure of colorectal mucosal defects after ESD may reduce the risk of delayed bleeding. However, the results are not concurred by RCTs. Furthermore, there seems to be no impact of prophylactic closure on the risk of delayed perforation and PECS.

Endoscopic full-thickness resection vs. endoscopic submucosal dissection of residual/recurrent colonic lesions on scars: a retrospective Italian and Japanese comparative study

BACKGROUND AND AIMS

Endoscopic treatment of recurrent/residual colonic lesions on scars is a challenging procedure. In this setting, endoscopic submucosal dissection (ESD) is considered the first choice, despite a significant rate of complications. Endoscopic full-thickness resection (eFTR) has been shown to be well-tolerated and effective for these lesions. The aim of this study is to conduct a comparison of outcomes for resection of such lesions between ESD and eFTR in an Italian and a Japanese referral center.

METHODS

From January 2018 to July 2020, we retrospectively enrolled patients with residual/recurrent colonic lesions, 20 treated by eFTR in Italy and 43 treated by ESD in Japan. The primary outcome was to compare the two techniques in terms of en-bloc and R0-resection rates, whereas complications, time of procedure, and outcomes at 3-month follow-up were evaluated as secondary outcomes.

RESULTS

R0 resection rate was not significantly different between the two groups [18/20 (90%) and 41/43 (95%); P= 0.66]. En-bloc resection was 100% in both groups. No significant difference was found in the procedure time (54 min vs. 61 min; P= 0.9). There was a higher perforation rate in the ESD group [11/43 (26%) vs. 0/20 (0%); P= 0.01]. At the 3-month follow-up, two lesions relapsed in the eFTR cohort and none in the ESD cohort (P= 0.1).

CONCLUSION

eFTR is a safer, as effective and equally time-consuming technique compared with ESD for the treatment of residual/recurrent colonic lesions on scars and could become an alternative therapeutic option for such lesions.

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.

Comparison of two pathological processing methods for large endoscopic submucosal dissection (ESD) specimens

AIMS

Accurate histopathological evaluation of the endoscopic submucosal dissection (ESD) specimens is essential for clinicians to guide further triage and management. This study aimed to report a novel processing technique for large ESD (≥4 cm) specimens.

METHODS

92 patients with colorectal neoplasms who had undergone ESD were included. 46 ESD specimens were treated with conventional handling process, while the rest 46 cases were given the optimised method. Macrobiocassettes and L-shaped embedding moulds were applied in the optimised method. We evaluated the efficacy of this improved procedure in terms of the number of paraffin blocks, storage space and time consumption of pathological assessment.

RESULTS

The average diameter of ESD specimens was 4.5±0.4 cm and 4.7±0.5 cm in the control and test group (p=0.023), respectively. In control group, 398 paraffin blocks of 46 cases were obtained. With the same cases number and larger lesion size, only 276 blocks were achieved in test group (p<0.001). As for the storage space, the total volume of paraffin blocks and slides (4554.0 cm3 and 1207.5 cm3) of optimised method was significantly reduced compared with the control group (6208.8 cm3 and 1741.3 cm3) (p=0.001, p<0.001). In addition, the optimised method was superior to the conventional one in shortening time consumption of pathological assessment (164.5 min and 269.0 min, p<0.001).

CONCLUSIONS

The optimised technique not only reduced the workload and storage space, but also facilitated accurate pathological assessment.

Colorectal endoscopic submucosal dissection in the West: A systematic review and meta-analysis

Background and study aims The advantages of endoscopic submucosal dissection (ESD) over endoscopic mucosal resection for large colorectal neoplasms are well established; however, the technical challenges and lack of adequate training in ESD limit its widespread adoption in Western countries. Methods A literature search was performed in Medline, Embase, Web of Science, and the Cochrane Library for studies conducted in non-Asian countries evaluating the effectiveness of colorectal ESD. A random effects model was used to obtain pooled en bloc, R0 resection rates, and adverse events (AEs). Results Thirty-three studies comprising 3,958 ESD procedures met the inclusion criteria. Of the polyps, 96.7% (2,817 of 2913) were ≥ 2 cm. Pooled en bloc resection (31 studies), R0 resection (29 studies), and curative resection rates were 84.6% (95% confidence interval [CI] [83.3%-85.9%]), 75.6% (95% CI [74.1%-77.0%]), and 81.9% (95% CI [78.6%-84.9%]), respectively. Surgery for invasive cancer was performed in 4.8% (23 studies). ESD-related perforation (25 studies) was observed in 5.5% and bleeding in 4.1% (delayed bleeding 3.4%). 1.8% of patients underwent surgery for procedure-related complications. A high degree of heterogeneity was observed for en bloc resection, R0 resection, and curative resection. Heterogeneity for AEs (perforation [I 2 13%], delayed bleeding [I 2 30%], and overall bleeding [I 2 49%]) was low to moderate. Conclusions The effectiveness of colorectal ESD for large colorectal polyps and early colorectal cancers is improving in Western countries, and recent resection rates are comparable to that seen in Asia. Colorectal perforation is still observed in about 5% of ESD; however, < 2% of patients need emergency surgery for AEs.

Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases

BACKGROUND/AIMS

Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD).

METHODS

We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes.

RESULTS

Resection time was significantly shorter in the following order: RH-ESD (149 [90-197] minutes) >C-ESD (90 [60-140] minutes) >SH-ESD (52 [29-80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%-30%]) than in the en bloc resection group (40% [20%-60%]).

CONCLUSION

RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

Use of endoscopic submucosal dissection or full-thickness resection device to treat residual colorectal neoplasia after endoscopic resection: a multicenter historical cohort study

INTRODUCTION : Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different management techniques are feasible including endoscopic full-thickness resection using the full-thickness resection device (FTRD) system and endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of these two techniques for the treatment of such lesions. METHODS : All consecutive patients with RCN treated either using the FTRD or by ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate, defined as an en bloc resection with histologically tumor-free lateral and deep margins. RESULTS : 275 patients (median age 70 years; 160 men) who underwent 177 ESD and 98 FTRD procedures for RCN were included. R0 resection was achieved in 83.3 % and 77.6 % for ESD and FTRD, respectively (P = 0.25). Lesions treated by ESD were however larger than those treated by FTRD (P < 0.001). The R0 rates for lesions of 20-30 mm were 83.9 % and 57.1 % in the ESD and FTRD groups, respectively, and for lesions of 30-40 mm were 93.6 % and 33.3 %, respectively. On multivariable analysis, ESD procedures were associated with statistically higher en bloc and R0 resection rates after adjustment for lesion size (P = 0.02 and P < 0.001, respectively). The adverse event rate was higher in the ESD group (16.3 % vs. 5.1 %), mostly owing to intraoperative perforations. CONCLUSION:  ESD is effective in achieving R0 resection for RCN whatever the size and location of the lesions. When residual lesions are smaller than 20 mm, the FTRD is an effective alternative.

Using of endoscopic polypectomy in patients with diagnosed malignant colorectal polyp - The cross-sectional clinical study

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.

Treatment for T1 colorectal cancers substratified by site and size: "horses for courses"

Background

Owing to advances in diagnostic technology, the diagnosis of T1 colorectal cancers (CRCs) continues to increase. However, the optimal management of T1 CRCs in the Western Hemisphere remains unclear due to limited population-based data directly comparing the efficacy of endoscopic therapy (ET) and surgical resection (SR). The purpose of this study was to report outcome data from a large Western cohort of patients who underwent ET or SR for early CRCs.

Methods

The SEER-18 database was used to identify patients with T1 CRCs diagnosed from 2004 to 2018 treated with ET or SR. Multivariable logistic regression models were employed to identify variables related to lymph node metastasis (LNM). Rates of ET and 1-year relative survival were calculated for each year. Effect of ET or SR on overall survival and cancer-specific survival was compared using Kaplan-Meier method stratified by tumor size and site.

Results

A total of 28,430 T1 CRCs patients were identified from 2004 to 2018 in US, with 22.7% undergoing ET and 77.3% undergoing SR. The incidence of T1 CRCs was 6.15 per 100,000 person-years, with male patients having a higher incidence. Left-sided colon was the most frequent location of tumors. The utilization of ET increased significantly from 2004 to 2018, with no significant change in 1-year relative survival rate. Predictors of LNM were age at diagnosis, sex, race, tumor size, histology, grade, and location. The 5-year relative survival rates were 91.4 and 95.4% for ET and SR, respectively. Subgroup analysis showed that OS and CSS were similar between ET and SR in T1N0M0 left-sided colon cancers with tumors 2 cm or less and in rectal cancers with tumors 1 cm or less.

Conclusion

Our study showed that ET was feasible and safe for patients with left-sided T1N0M0 colon cancers and tumors of 2 cm or less, as well as T1N0M0 rectal cancers and tumors of 1 cm or less. Therefore, the over- and under-use of ET should be avoided by carefully selecting patients based on tumor size and site.

Prophylactic clipping using the over-the-scope clip (OTSC) system after complex ESD and EMR of large colon polyps

BACKGROUND

Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps.

METHODS

This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding.

RESULTS

A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%.

CONCLUSIONS

The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.

Outcomes for Underwater Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection of 21-30-mm Colorectal Polyps: A Feasible Study

BACKGROUND AND AIMS

This randomized controlled trial (RCT) was designed to evaluate the short-term outcomes of underwater endoscopic mucosal resection (UEMR) and endoscopic submucosal dissection (ESD) of 21-30 mm colonic polyps.

METHOD

We conducted a single-center RCT. Patients diagnosed with suspected colorectal intramucosal carcinoma (21-30 mm and adaptable for both UEMR and ESD) were randomly assigned to the UEMR and ESD groups at a 1:1 ratio. The primary endpoint was the R0 resection rate. We independently performed one-sample tests against the set threshold for each treatment. The significance level was set at p = 0.224.

RESULT

Eleven polyps each in the UEMR and ESD groups, respectively, were analyzed. The R0 resection rate (%) was 36 (95% confidence interval 11-69) and 100 (72-100) for UEMR and ESD, respectively, with a significant difference between the two groups (p = 0.002). The p-value against the set threshold for UEMR was 0.743, whereas that for ESD was < 0.001 (one-sample binomial test). The en bloc resection rates (%) were 82 (48-97) and 100 (72-100) for UEMR and ESD, respectively; however, no significant difference was observed (p = 0.167). The mean treatment time (min) was significantly shorter in the UEMR group (8 ± 6) than in the ESD group (48 ± 29) (p = 0.001).

CONCLUSION

ESD could achieve a high R0 resection rate, while the en bloc resection rate was comparable between the two treatment techniques with less burden on patients undergoing UEMR for 21-30-mm colorectal polyps.

CLINICAL TRIAL REGISTRATION

The study was registered at the Japan Registry of Clinical Trial as jRCT1030210015 and jRCT1030210177.

Factors associated with increased duration of endoscopic submucosal dissection for rectal tumors: a 22-year retrospective analysis

BACKGROUND AND AIMS

Colorectal endoscopic submucosal dissection (ESD) is widely used in several countries. However, it is associated with technical difficulties. Rectal ESD is considered an intermediate step in colorectal ESD training. Nevertheless, some rectal lesions require a longer procedure time than usual, and the reason for the prolonged time taken for these specific lesions remains unclear. Therefore, this study aimed to clarify the factors associated with prolonged rectal ESD.

METHODS

In total, 483 rectal lesions resected using ESD from February 1998 to June 2021 were investigated. Prolonged ESD procedure time was defined as the time from the first submucosal injection to lesion removal exceeding 120 minutes, whereas other procedures were defined as average ESD procedure time. Clinicopathologic and endoscopic findings were compared between the 2 groups using univariate and multivariate analyses.

RESULTS

One hundred forty-four lesions were resected using a prolonged ESD procedure time of 202.9 ± 92.3 minutes, whereas 339 lesions were resected using an average ESD procedure time of 77.8 ± 29.4 minutes. Multivariate analysis revealed that tumors involving the dentate line (P = .026), resection size ≥50 mm (P < .001), invasion depth ≥T1b (P = .006), and circumferential range ≥2/3 (P = .001) were independent risk factors for prolonged-duration ESDs, regardless of whether the procedure was performed by an expert or not.

CONCLUSIONS

The results of the present study suggest that the location of a lesion involving the dentate line, resection size ≥50 mm, circumferential range ≥2/3, and invasion depth ≥T1b are the independent risk factors for prolonged ESD procedure time.

Efficacy and safety of combined EMR and endoscopic full-thickness resection (hybrid EFTR) for large nonlifting colorectal adenomas

BACKGROUND AND AIMS

Endoscopic full-thickness resection (EFTR) with a full-thickness resection device (FTRD) has become the standard technique for selected nonlifting colorectal adenomas, but tumor size is the major limitation. However, large lesions might be approached in combination with EMR. Herein, we report the largest single-center experience to date of combined EMR and EFTR (hybrid EFTR) in patients with large (≥25 mm) nonlifting colorectal adenomas not amenable to EMR or EFTR alone.

METHODS

This is a single-center retrospective analysis of consecutive patients who underwent hybrid EFTR of large (≥25 mm) nonlifting colorectal adenomas. Outcomes of technical success (successful advancement of the FTRD with consecutive successful clip deployment and snare resection), macroscopic complete resection, adverse events, and endoscopic follow-up were evaluated.

RESULTS

Seventy-five patients with nonlifting colorectal adenomas were included. Mean lesion size was 36.5 mm (range, 25-60 mm), and 66.6% were located in the right side of the colon. Technical success was 100% with macroscopic complete resection in 97.3%. Mean procedure time was 83.6 minutes. Adverse events occurred in 6.7%, leading to surgical therapy in 1.3%. Histology revealed T1 carcinoma in 16%. Endoscopic follow-up was available in 93.3% (mean follow-up time, 8.1 months; range, 3-36) and showed no signs of residual or recurrent adenoma in 88.6%. Recurrence (11.4%) was treated endoscopically.

CONCLUSIONS

Hybrid EFTR is safe and effective for advanced colorectal adenoma that cannot be approached by EMR or EFTR alone. Hybrid EFTR expands the indication of EFTR substantially in selected patients.

Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study

Endoscopic submucosal dissection (ESD) in colorectal lesions is demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a piecemeal ESD resection, or after an en bloc resection but with positive horizontal margins (local-risk resection-LocRR), for colorectal benign neoplasia. A retrospective multicenter analysis of consecutive colorectal ESDs was performed. Patients with LocRR ESDs for the treatment of benign colorectal lesions with at least one follow-up endoscopy were included. A cohort of en bloc resected lesions, with negative margins, was used as the control. A total of 2255 colorectal ESDs were reviewed; 352 of the ESDs were "non-curative". Among them, 209 were LocRR: 133 high-grade dysplasia and 76 low-grade dysplasia. Ten cases were excluded due to missing data. A total of 146 consecutive curative resections were retrieved for comparison. Compared to the "curative group", LocRRs were observed in lengthier procedures, with larger lesions, and in non-granular LSTs. Recurrence was higher in the LocRR group (16/199, 8% vs. 1/146, 0.7%; p = 0.002). However, statistical significance was lost when considering only en bloc resections with positive horizontal margins (p = 0.068). In conclusion, a higher rate of residual lesion was found after a piecemeal ESD resection, but not after an en bloc resection with positive horizontal margins.