Rectal reconstruction after endoscopic submucosal dissection for removal of a giant rectal lesion

Prospective, randomized controlled study evaluating a double-balloon interventional endoscopic platform for colorectal endoscopic submucosal dissection (with video)

BACKGROUNDS AND AIMS

Endoscopic submucosal dissection (ESD) can be challenging and time-consuming. A double-balloon interventional platform (DBIP) was designed to assist with navigation, stabilization, traction, and device delivery during complex colorectal polypectomy. We compared traditional ESD (T-ESD) with DBIP-assisted ESD (DBIP-ESD) in a prospective, randomized trial.

METHODS

Patients with colorectal polyps ≥2 cm were randomly assigned (1:1) to DBIP-ESD or T-ESD. The primary study endpoint was the mean total procedure time difference between groups. Secondary endpoints were intraprocedural time points, en bloc resection rate, procedure cost, adverse events, and 3-month assessment. A sample size of 200 subjects for ≥80% power was calculated. Interim analysis for early study termination was planned at 70% enrollment if the primary endpoint was met (P ≤ .05).

RESULTS

One hundred forty-seven patients were enrolled between February 2019 and February 2020. Seven patients dropped out, and the interim analysis was performed on 140 patients (71 DBIP-ESD, 69 T-ESD). Demographics, comorbidities, and lesion size, location, and classification were similar between groups. The mean procedure time decreased with DBIP-ESD (88.6 ± 42.7 minutes) versus T-ESD (139.5 ± 83.2 minutes; difference of ∼51 minutes [36.5%]; P < .001], with procedural savings of $610.16 (11.4%) per patient after DBIP cost. The DBIP increased dissection speed by 49.0% (15.1 ± 8.0 vs 7.7 ± 6.6 cm2/h, P < .001). En bloc resection was superior with the addition of DBIP (97.2% vs 87.0%, P = .030). The mean navigation time with DBIP-ESD for sutured defect closure decreased by 7.7 minutes (P < .001). There were no adverse events in the DBIP-ESD group.

CONCLUSIONS

DBIP-ESD decreased the total procedure time, improved the en bloc resection rate, and facilitated sutured defect closure, making DBIP a promising and cost-effective tool to improve colorectal ESD adoption. (Clinical trial registration number: NCT03846609.).

Colonic endoscopic submucosal dissection using a novel robotic system (with video)

BACKGROUND AND AIMS

One of the difficulties in performing endoscopic submucosal dissection (ESD) is the lack of retraction during submucosal dissection. The development of the EndoMaster EASE System (EndoMaster Pte Ltd, Singapore) aims to enhance the safety and efficacy of ESD through 2 flexible robotic arms for tissue retraction and dissection. This is a preclinical animal study to evaluate the performance of colorectal ESD using the latest version of the EndoMaster EASE System.

METHODS

The latest version of the EndoMaster EASE System consists of an independently designed, flexible platform with a built-in endoscopic imaging system and 3 working channels, 2 for the passage of robotic arms and 1 for accessories. In this animal study, the outcome measures were operating time (from starting incision to finishing dissection), completeness of resection, procedure-related adverse events, and limitations of arm manipulation in a narrow working space as assessed by counting the frequency of blind cutting.

RESULTS

Five ESD procedures were performed in a 66.7-kg porcine model with the animal under general anesthesia. The mean operative time was 73.8 minutes, and the mean size of the specimen resected was 1340 mm². There was no perforation, although profuse bleeding was encountered during 1 robotic ESD procedure.

CONCLUSIONS

The current preclinical study confirmed the feasibility of performing colorectal ESD using the latest version of the EndoMaster EASE System. The system was also tested for the ability to manage adverse events including bleeding and perforation. This study provided important preclinical experience for clinical trial.

EMR/ESD: Techniques, Complications, and Evidence

PURPOSE OF REVIEW

To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

RECENT FINDINGS

EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.

The Development of the Overstitch System and Its Potentials

Endoscopic suturing device for flexible endoscopy was conceptualized by Apollo Group in collaboration with Olympus Optical Ltd. The first modification of suturing device for flexible endoscopy (Eagle Claw) was manufactured by Olympus engineers and extensively used by members of Apollo Group in numerous bench-top experiments on isolated pig stomachs and in live porcine model. The suturing system for flexible endoscopy in humans (Overstitch) was cleared for general clinical use in the United States in 2008. The latest model is compatible with more than 20 single-channel flexible endoscopes with diameters ranging from 8.8 mm to 9.8 mm made by major endoscope manufacturers.