Endoscopic Submucosal Dissection in North America: A Large Prospective Multicenter Study

Third space endoscopy pulmonary complications and chylothorax post peroral endoscopic myotomy

Third-space endoscopy (TSE) has emerged as an effective treatment modality for various gastrointestinal motility diseases and gastrointestinal tumors. TSE is based on the concept of working in the submucosa using a mucosal flap valve technique, which is the underlying premise for all TSE procedures; thus, some complications are shared across the spectrum of TSE procedures. Despite the high safety profiles of most TSE procedures, studies have reported various adverse events, including insufflation-related complications, bleeding, perforation, and infection. Although the occurrence rate of those complications is not very high, they sometimes result in critical conditions. No reports of chylous effusion following TSE procedures, particularly per-oral endoscopic myotomy, have been documented previously. We are presenting the first reported case of chylous pleural effusion after per-oral endoscopic myotomy. Additionally, we aim to present a comprehensive overview, discuss the existing data, and provide insights into pulmonary post-endoscopic complications in light of recent advancements in endoscopic procedures, especially TSE.

Prophylactic clip closure in preventing delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulants: a multicenter retrospective cohort study in Japan

BACKGROUND

 The effectiveness of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) is uncertain among patients on anticoagulants. We therefore aimed to assess this effectiveness using data from a large multicenter study.

METHODS

 We used the ABCD-J study database to analyze delayed bleeding among 34 455 colorectal ESD cases from 47 Japanese institutions. Delayed bleeding rates among the no/partial and complete closure groups were compared in patients on direct oral anticoagulants (DOACs) or warfarin. Propensity score matching was used for baseline characteristics to reduce the effects of selection bias.

RESULTS

 Overall, data from 1478 patients on anticoagulants who underwent colorectal ESD were examined. After propensity score matching, the complete and no/partial closure groups were compared in 212 patients on DOACs and 82 on warfarin. The complete closure group showed a significantly lower delayed bleeding rate in patients receiving DOACs (10.8 % vs. 5.2 %, absolute risk reduction [ARR] 5.7 %, P = 0.048) and warfarin (17.1 % vs. 6.1 %, ARR 11.0 %, P = 0.049). Additionally, complete closure significantly reduced the risk of delayed bleeding among patients taking DOACs for right-sided lesions (ARR 6.7 %, P = 0.04), whereas no risk reduction was observed for left-sided (P > 0.99) or rectal (P = 0.50) lesions. A similar trend was observed among patients on warfarin.

CONCLUSIONS

 Prophylactic complete clip closure after colorectal ESD significantly reduced the delayed bleeding rate in patients receiving DOACs or warfarin. It should be performed after ESD, particularly for right-sided lesions.

A retrospective study on endoscopic submucosal dissection for the treatment of ileocecal valve lesions

BACKGROUND

Endoscopic submucosal dissection (ESD) for ileocecal valve (ICV) lesions poses unique technical challenges because of its anatomic complexity. This study aimed to evaluate the effectiveness and safety of ESD for ICV lesions.

METHODS

From December 2016 to June 2023, the clinic characteristics and outcomes of ESD on 51 ICV lesions and 84 cecal lesions were reviewed. Factors related to longer procedure time were analyzed for ESD of ICV lesions.

RESULTS

Baseline characteristics and clinical features of the lesions were not significantly different between the groups. The median procedure time of the ICV group was significantly longer than that of the cecal group (35 min vs. 24 min, respectively; P =.04). There were no significant differences in en bloc resection rates between the ICV and cecal groups (92.2% vs. 97.6%, respectively; P =.14). During the median follow-up of 32 months (IQR, 6-89), there was no case of recurrence in the ICV group. A specimen diameter of ≥25 mm and a circumferential spread of ≥1/2 were factors related to a longer procedure time (specimen diameter: OR=4.2 95%CI, 2.1-15.4, P =.02; circumferential spread: OR=3.7, 95%CI, 1.2-12.7, P =.03).

CONCLUSION

ESD for ICV lesions requires a longer procedure duration than ESD for cecal lesions, but it is safe and effective, making it a challenging and promising therapeutic approach.

Risk factors and predictive nomogram for non-curative resection in patients with early gastric cancer treated with endoscopic submucosal dissection: a retrospective cohort study

INTRODUCTION

The objective of this study was to determine independent clinicopathological factors that can predict submucosal invasion and non-curative resection (NCR) outcomes after endoscopic submucosal dissection (ESD) in patients with early gastric cancer (EGC).

METHODS

Data were collected from consecutive patients who underwent gastric ESD at the First Affiliated Hospital of Ningbo University between 2016 and 2023. A retrospective analysis was conducted using the chi-squared test and logistic regression analysis. Multiple logistic regression analysis was applied to investigate factors independently predicting both submucosal invasion and NCR. These factors were used to construct predictive nomograms.

RESULTS

A total of 511 patients (535 EGC lesions) underwent ESD. Of these, 452 were curative (84.7%), and 83 (15.5%) were non-curative. Multivariate analysis revealed that location in the body and fundus or cardia of the stomach, larger tumor size (≥ 30 mm), and histological undifferentiated type were independent risk factors for submucosal invasion and deep submucosal invasion in patients with EGC (all P < 0.05). Multivariate analysis showed that tumor size of 20 ~ 29 mm, tumor size ≥ 30 mm, elevated lesions, depressed lesions, undifferentiated tumors and submucosal invasion were all independent predictors of NCR for EGCs (all P < 0.05). The area under the ROC curve (AUC) of the nomogram model for predicting submucosal invasion and non-curative resection was 0.821 (95% CI, 0.758 ~ 0.884) and 0.937 (95%CI, 0.889 ~ 0.985), respectively.

CONCLUSIONS

We developed nomograms to predict the risk of submucosal invasion and NCR prior to ESD. These predictive factors in addition to the existing ESD criteria can help provide the best treatment option for patients with EGC.

Feasibility and predictors of same-day discharge following endoscopic submucosal dissection for early esophageal cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is a common treatment for early esophageal cancer. Although ESD is considered safe, same-day discharge (SDD) is only feasible in selected patients. Therefore, identifying factors associated with the likelihood of SDD is crucial for optimizing patient selection and clinical management.

METHODS

We conducted a retrospective analysis of patients with early esophageal cancer treated with ESD between August 2020 and July 2024. Patients were divided into SDD and non-SDD groups. Preoperative clinical features were compared between the groups. Univariate and multivariate logistic regression analyses were performed to identify independent predictors associated with the feasibility of SDD.

RESULTS

Among 146 patients, 42 (28.8%) were discharged on the same day. Multivariate analysis identified larger lesion size (OR = 2.152, 95% CI: 2.037-2.280, p = 0.008), history of alcohol abuse (OR = 6.507, 95% CI: 3.169-11.211, p = 0.032), and tumor location in the upper esophagus (OR = 7.827, 95% CI: 5.481-14.547, p = 0.023) as significant factors negatively associated with SDD feasibility. Notably, larger lesions were associated with a lower likelihood of SDD.

CONCLUSION

Tumor size, upper esophageal location, and a history of alcohol abuse were identified as independent predictors associated with reduced feasibility of same-day discharge following ESD.

Treatment outcomes of non-curative endoscopic submucosal dissection for superficial gastric neoplasia: A retrospective study at a tertiary care center in the United States

Objectives

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer; additional treatment may be recommended for patients in whom resection is not curative per the American Society for Gastrointestinal Endoscopy guidelines. The aim of this study was to assess treatment outcomes of ESD for gastric neoplasia, with a focus on cases of non-curative resection.

Methods

This was a retrospective study of all individuals undergoing ESD for the treatment of gastric adenocarcinoma or dysplasia in a high-volume tertiary care center in the United States. Data on patient demographic characteristics, clinical history, lesion characteristics, and procedural and clinical outcomes were collected from the electronic medical record.

Results

Among 82 cases undergoing ESD for the management of gastric neoplasia, 32 cases resulted in non-curative resection. 20 of these non-curative cases did not get additional treatment, among which recurrence occurred in two cases with positive horizontal margins only. These patients did not show lymph node metastasis and underwent further endoscopic or surgical resection. There was no recurrence in 11 cases with undifferentiated carcinomas of ≤2 cm in size.

Conclusions

Although this study was limited by its retrospective design, small sample size, and follow-up duration, our findings suggest that a risk-adapted strategy could be employed for certain patients undergoing non-curative ESD per American Society for Gastrointestinal Endoscopy guidelines, with close follow-up instead of routine surgery in select cases with favorable features. Further studies are needed to refine the criteria for additional treatment after non-curative ESD in Western populations.

Analysis of lens cloudiness during endoscopic submucosal dissection procedures: Effects of a novel lens cleaner

Objectives

We aimed to identify independent factors for intraoperative endoscopic lens cloudiness during gastric and colorectal endoscopic submucosal dissections, investigate the effectiveness of Cleastay, an endoscope anti-fog solution, and examine factors associated with severe submucosal fat deposition.

Methods

A total of 220 patients who underwent gastric or colorectal endoscopic submucosal dissections in two institutions between January 2022 and October 2023 were included. Significant factors related to cloudiness were determined using univariate and multivariate analyses. Patient background and tumor characteristics related to severe submucosal fat deposition were investigated, and the degree of intraoperative endoscopic lens cloudiness and outcomes were compared between the Cleash and Cleastay groups.

Results

In the multivariate analysis, factors increasing lens cloudiness included long procedure time (odds ratio [OR], 17.51; 95% confidence interval [CI], 1.52-202.08), stomach (vs. colon; OR, 5.08; 95% CI, 1.99-12.96), and severe submucosal fat deposition (OR, 12.19; 95% CI, 5.02-29.60). Conversely, the use of Cleastay (vs. Cleash; OR, 0.066; 95% CI, 0.021-0.21) was identified as a factor reducing cloudiness. Location analysis revealed that severe submucosal fat deposition was more common in the upper stomach and right colon.

Conclusions

It was suggested that Cleastay is more useful for endoscopic submucosal dissection of the upper stomach and right colon, where severe submucosal fat deposition is expected.

Colorectal endoscopic submucosal dissection in the USA: The current state and future perspectives

Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.

Efficacy-cost analysis of endoscopic mucosal resection and cold snare polypectomy: A propensity score matching analysis

BACKGROUND

Although substantial evidence supports the advantages of cold snare polypectomy (CSP) in terms of polypectomy efficacy and reduced postoperative adverse events, few studies have examined the cost differences between CSP and traditional endoscopic mucosal resection (EMR) for the treatment of intestinal polyps.

AIM

To compare the efficacy-cost of EMR and CSP in the treatment of intestinal polyps.

METHODS

A total of 100 patients with intestinal polyps were included in the retrospective data of our hospital from April 2022 to May 2023. According to the treatment methods, they were divided into EMR (n = 46) group and CSP (n = 54) group. The baseline data of the two groups were balanced by 1:1 propensity score matching (PSM), and the cost-effectiveness analysis was performed on the two groups after matching. The recurrence rate of the two groups of patients was followed up for 1 year, and they were divided into recurrence group and non-recurrence group according to whether they recurred. Multivariate logistic regression analysis was used to screen out the influencing factors affecting the recurrence of intestinal polyps after endoscopic resection.

RESULTS

Significant disparities were observed in the number of polyps and smoking background between the two groups before PSM (P < 0.05). Following PSM, the number of polyps and smoking history were well balanced between the EMR and CSP groups. The direct cost incurred by the CSP group was markedly higher than that incurred by the EMR group. Concurrently, the cost-effectiveness ratio in the CSP group was substantially reduced when juxtaposed with that in the EMR group (P < 0.05). Upon completion of the 1-year follow-up, the rate of recurrence after endoscopic intestinal polypectomy was 38.00%. Multivariate methods revealed that age ≥ 60 years, male sex, number of polyps ≥ 3, and pathological type of adenoma were risk factors for recurrence after endoscopic intestinal polypectomy (all P < 0.05).

CONCLUSION

CSP was more cost-effective for the treatment of intestinal polyps. An age ≥ 60 years, male sex, having a number of polyps ≥ 3, and pathological type of adenoma are independent influencing factors for recurrence.

Endoscopic diagnosis of gastric carcinoma of fundic gland type: A case report

RATIONALE

Gastric carcinoma of fundic gland type is a new type of gastric cancer with a low incidence rate. The mechanism of gastric carcinoma of the fundic gland differs significantly from that of common adenocarcinoma. While it typically presents as a benign growth, there are cases where it can progress to malignancy. If early endoscopy fails to provide an accurate diagnosis and the treatment is inappropriate, the tumor may metastasize and spread.

PATIENT CONCERNS

A 61-year-old male, abdominal discomfort, was performed gastroscopy.

DIAGNOSES

Gastroscopy revealed a raised lesion approximately 1.8 cm × 1.5 cm in size in the middle of the gastric body, with surface flushing.

INTERVENTIONS

The patient was performed endoscopic submucosal dissection.

OUTCOMES

The pathology showed gastric carcinoma of fundic gland type SM2, and the cure grade was eCura B. Follow-up review was conducted after communicating with the patient. After 6 months of follow-up, the patient shows no signs of recurrence or metastasis; future observations will require ongoing monitoring. This case emphasizes the difficulties of endoscopic diagnosis, and postoperative pathology confirmed the diagnosis of gastric carcinoma of the fundic gland type.

LESSONS

Gastric carcinoma of the fundic gland type is characterized by low atypia and easy SM invasion. This case highlights the importance of using endoscopy to identify this type, and select appropriate treatment methods. Because the infiltrative characteristics differ from those of conventional early gastric cancer, selecting endoscopic submucosal dissection treatment for lesions smaller than 2 cm can reduce postoperative tumor recurrence and metastasis.

The Contemporary Diagnostic Approaches to Esophageal Symptomatology

Esophageal symptoms, including dysphagia, heartburn, and non-cardiac chest pain, are prevalent concerns in gastroenterology. This review examines the roles of advanced diagnostic modalities such as high-resolution manometry (HRM), pH-impedance monitoring, and EndoFLIP in understanding esophageal physiology and pathology. Here, we discuss the clinical presentations of common esophageal symptoms and explore how structural abnormalities like strictures and motility disorders, including achalasia and esophageal spasms, are assessed using these tools. The diagnostic utility of endoscopy in visualizing mucosal and structural changes is highlighted alongside emerging technologies like artificial intelligence in enhancing detection capabilities. Complementary techniques, such as barium esophagrams and reflux monitoring, provide additional functional and anatomical insights, crucial for comprehensive patient evaluation. The integration of these diagnostic approaches fosters a deeper understanding of esophageal disorders, guiding effective management strategies and improving patient outcomes. This review aimed to highlight the importance of adopting a multimodal diagnostic approach in modern gastroenterological practice.

Transrectal Drainage Tube Use for Preventing Postendoscopic Submucosal Dissection Coagulation Syndrome in Patients With Colorectal Lesions: A Multicenter Randomized Controlled Clinical Trial

INTRODUCTION

Postendoscopic submucosal dissection (ESD) coagulation syndrome (PECS) prevention is one of the common postoperative complications of colorectal ESD. Considering the increasing incidence of PECS, it is critical to investigate various prevention methods. The objective of this study was to evaluate the efficacy of transrectal drainage tubes (TDTs) in PECS prevention in patients following colorectal ESD.

METHODS

From July 2022 to July 2023, a multicenter, randomized controlled clinical trial was conducted in 3 hospitals in China. Patients with superficial colorectal lesions ≥20 mm who had undergone ESD for a single lesion were enrolled. Initially, 229 patients were included in the study and 5 were excluded. Two hundred twenty-four were randomly assigned to the TDT and non-TDT group in the end. This open-label study utilized a parallel design with a 1:1 allocation ratio, and endoscopists and patients were not blind to the randomization, and a 24 Fr drainage tube was inserted approximately 10-15 cm above the anus after the ESD under the endoscopy and tightly attached to a drainage bag. The TDTs were removed in 1-3 days following the ESD.

RESULTS

A total of 229 eligible patients were enrolled in this study, and 5 patients were excluded. Ultimately, 224 patients were assigned to the TDT group (n = 112) and non-TDT group (n = 112). The median age for the patients was 63.45 years (IQR 57-71; 59 men [52.68%]) in the TDT group and 60.95 years (IQR 54-68; 60 men [53.57%]) in the non-TDT group. Intention-to-treat analysis showed patients in the TDT group had a lower incidence of PECS than patients in the non-TDT group (7 [6.25%] vs 20 [17.86%]; relative risk, 0.350; 95% confidence interval [CI], 0.154-0.795; P = 0.008). In the subgroup analysis, TDTs were found to prevent PECS in patients of the female gender (odd ratio, 0.097; 95% CI, 0.021-0.449; P = 0.001), tumor size <4 cm (odd ratio, 0.203; 95% CI, 0.056-0.728; P = 0.011), tumor located in the left-sided colorectum (odd ratio, 0. 339 95% CI, 0.120-0.957; P = 0.035), and shorter procedure time (<45 minutes) (odd ratio, 0.316; 95% CI, 0.113-0.879; P = 0.023). The tube fell off in 1 case (0.89%) accidentally ahead of time. No TDT-related complication was observed.

DISCUSSION

The results from this randomized clinical study indicate that the application of TDTs effectively reduced the incidence of PECS in patients after colorectal ESD ( chictr.org.cn Identifier: ChiCTR2200062164).

AGA Clinical Practice Update on Screening and Surveillance in Individuals at Increased Risk for Gastric Cancer in the United States: Expert Review

DESCRIPTION

Gastric cancer (GC) is a leading cause of preventable cancer and mortality in certain US populations. The most impactful way to reduce GC mortality is via primary prevention, namely Helicobacter pylori eradication, and secondary prevention, namely endoscopic screening and surveillance of precancerous conditions, such as gastric intestinal metaplasia (GIM). An emerging body of evidence supports the possible impact of these strategies on GC incidence and mortality in identifiable high-risk populations in the United States. Accordingly, the primary objective of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) Expert Review is to provide best practice advice for primary and secondary prevention of GC in the context of current clinical practice and evidence in the United States.

METHODS

This CPU Expert Review was commissioned and approved by the AGA Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature and expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: There are identifiable high-risk groups in the United States who should be considered for GC screening. These include first-generation immigrants from high-incidence GC regions and possibly other non-White racial and ethnic groups, those with a family history of GC in a first-degree relative, and individuals with certain hereditary gastrointestinal polyposis or hereditary cancer syndromes. BEST PRACTICE ADVICE 2: Endoscopy is the best test for screening or surveillance in individuals at increased risk for GC. Endoscopy enables direct visualization to endoscopically stage the mucosa and identify areas concerning for neoplasia, as well as enables biopsies for further histologic examination and mucosal staging. Both endoscopic and histologic staging are key for risk stratification and determining whether ongoing surveillance is indicated and at what interval. BEST PRACTICE ADVICE 3: High-quality upper endoscopy for the detection of premalignant and malignant gastric lesions should include the use of a high-definition white-light endoscopy system with image enhancement, gastric mucosal cleansing, and insufflation to achieve optimal mucosal visualization, in addition to adequate visual inspection time, photodocumentation, and use of a systematic biopsy protocol for mucosal staging when appropriate. BEST PRACTICE ADVICE 4: H pylori eradication is essential and serves as an adjunct to endoscopic screening and surveillance for primary and secondary prevention of GC. Opportunistic screening for H pylori infection should be considered in individuals deemed to be at increased risk for GC (refer to Best Practice Advice 1). Screening for H pylori infection in adult household members of individuals who test positive for H pylori (so-called "familial-based testing") should also be considered. BEST PRACTICE ADVICE 5: In individuals with suspected gastric atrophy with or without intestinal metaplasia, gastric biopsies should be obtained according to a systematic protocol (eg, updated Sydney System) to enable histologic confirmation and staging. A minimum of 5 total biopsies should be obtained, with samples from the antrum/incisura and corpus placed in separately labeled jars (eg, jar 1, "antrum/incisura" and jar 2, "corpus"). Any suspicious areas should be described and biopsied separately. BEST PRACTICE ADVICE 6: GIM and dysplasia are endoscopically detectable. However, these findings often go undiagnosed when endoscopists are unfamiliar with the characteristic visual features; accordingly, there is an unmet need for improved training, especially in the United States. Artificial intelligence tools appear promising for the detection of early gastric neoplasia in the adequately visualized stomach, but data are too preliminary to recommend routine use. BEST PRACTICE ADVICE 7: Endoscopists should work with their local pathologists to achieve consensus for consistent documentation of histologic risk-stratification parameters when atrophic gastritis with or without metaplasia is diagnosed. At a minimum, the presence or absence of H pylori infection, severity of atrophy and/or metaplasia, and histologic subtyping of GIM, if applicable, should be documented to inform clinical decision making. BEST PRACTICE ADVICE 8: If the index screening endoscopy performed in an individual at increased risk for GC (refer to Best Practice Advice 1) does not identify atrophy, GIM, or neoplasia, then the decision to continue screening should be based on that individual's risk factors and preferences. If the individual has a family history of GC or multiple risk factors for GC, then ongoing screening should be considered. The optimal screening intervals in such scenarios are not well defined. BEST PRACTICE ADVICE 9: Endoscopists should ensure that all individuals with confirmed gastric atrophy with or without GIM undergo risk stratification. Individuals with severe atrophic gastritis and/or multifocal or incomplete GIM are likely to benefit from endoscopic surveillance, particularly if they have other risk factors for GC (eg, family history). Endoscopic surveillance should be considered every 3 years; however, intervals are not well defined and shorter intervals may be advisable in those with multiple risk factors, such as severe GIM that is anatomically extensive. BEST PRACTICE ADVICE 10: Indefinite and low-grade dysplasia can be difficult to reproducibly identify by endoscopy and accurately diagnose on histopathology. Accordingly, all dysplasia should be confirmed by an experienced gastrointestinal pathologist, and clinicians should refer patients with visible or nonvisible dysplasia to an endoscopist or center with expertise in the diagnosis and management of gastric neoplasia. Individuals with indefinite or low-grade dysplasia who are infected with H pylori should be treated and have eradication confirmed, followed by repeat endoscopy and biopsies by an experienced endoscopist, as visual and histologic discernment may improve once inflammation subsides. BEST PRACTICE ADVICE 11: Individuals with suspected high-grade dysplasia or early GC should undergo endoscopic submucosal dissection with the goal of en bloc, R0 resection to enable accurate pathologic staging with curative intent. Eradication of active H pylori infection is essential, but should not delay endoscopic intervention. Endoscopic submucosal dissection should be performed at a center with endoscopic and pathologic expertise. BEST PRACTICE ADVICE 12: Individuals with a history of successfully resected gastric dysplasia or cancer require ongoing endoscopic surveillance. Suggested surveillance intervals exist, but additional data are required to refine surveillance recommendations, particularly in the United States. BEST PRACTICE ADVICE 13: Type I gastric carcinoids in individuals with atrophic gastritis are typically indolent, especially if <1 cm. Endoscopists may consider resecting gastric carcinoids <1 cm and should endoscopically resect lesions measuring 1-2 cm. Individuals with type I gastric carcinoids >2 cm should undergo cross-sectional imaging and be referred for surgical resection, given the risk of metastasis. Individuals with type I gastric carcinoids should undergo surveillance, but the intervals are not well defined. BEST PRACTICE ADVICE 14: In general, only individuals who are fit for endoscopic or potentially surgical treatment should be screened for GC and continued surveillance of premalignant gastric conditions. If a person is no longer fit for endoscopic or surgical treatment, then screening and surveillance should be stopped. BEST PRACTICE ADVICE 15: To achieve health equity, a personalized approach should be taken to assess an individual's risk for GC to determine whether screening and surveillance should be pursued. In conjunction, modifiable risk factors for GC should be distinctly addressed, as most of these risk factors disproportionately impact people at high risk for GC and represent health care disparities.

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.

Use of Snare Tip Endoscopic Submucosal Dissection in the Endoluminal Management of Complex Colon Lesions

BACKGROUND

Endoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions.

OBJECTIVE

This study aimed to assess patient outcomes after endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip.

DESIGN

A retrospective review of a prospectively maintained database at a single tertiary care center was conducted.

SETTINGS

This study was conducted at a single tertiary care center.

PATIENTS

Adult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that were lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded.

MAIN OUTCOME MEASURES

En bloc resection rates, operative time, perioperative complications, and short-term outcomes, such as length of stay and lesion recurrence on follow-up colonoscopy, were evaluated.

RESULTS

A total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8%, with an average procedure time of 37.1 ± 29.8 minutes. There were 2 perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy.

LIMITATIONS

This study was retrospective, conducted by 2 skilled endoscopists with experience in endoscopic resection, and had short-term follow-up.

CONCLUSIONS

Snare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing the adoption of endoscopic resection and improving patient accessibility. See Video Abstract .

USO DE LA DISECCIN SUBMUCOSA ENDOSCPICA CON PUNTA DE ASA EN EL TRATAMIENTO ENDOLUMINAL DE LESIONES COMPLEJAS DEL COLON

ANTECEDENTES:La disección submucosa endoscópica para lesiones avanzadas del colon generalmente se realiza con bisturíes endoscópicos especializados y costosos, lo que potencialmente limita la accesibilidad y aumenta el costo del procedimiento. Alternativamente, la punta de asa endoscópica, que es económica y está disponible universalmente, ha demostrado su uso seguro y eficiente en lesiones gástricas, pero carece de datos suficientes para su uso en lesiones de colon.OBJETIVO:Evaluar los resultados de los pacientes después de la disección submucosa endoscópica de lesiones avanzadas del colon utilizando la punta del asa endoscópica.DISEÑO:Revisión retrospectiva de una base de datos mantenida prospectivamente en un único centro de atención terciaria.AJUSTE:Estudio realizado en un único centro de atención terciaria.PACIENTES:Pacientes adultos con lesiones de colon no susceptibles a polipectomía con asa, fueron evaluados para disección submucosa endoscópica. La resección con punta del asa se realizó en pacientes seleccionados con lesiones que se levantaron adecuadamente después de la inyección submucosa. Se excluyeron pacientes sometidos a resecciones híbridas con disección endoscópica de la mucosa.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron las tasas de resección en bloque, tiempo operatorio, complicaciones perioperatorias y resultados a corto plazo, como la duración de la estancia hospitalaria y la recurrencia de la lesión en la colonoscopia de seguimiento.RESULTADOS:Un total de 121 pacientes se sometieron a disección submucosa endoscópica con punta de asa, con un tamaño medio de lesión de 28,8 ± 9,84 mm. La mayoría de los procedimientos se realizaron en la sala de endoscopia (81,8%). La tasa de resección en bloque fue del 81,8% con un tiempo medio de procedimiento de 37,1 ± 29,8 min. Hubo dos perforaciones (1,70%), una de las cuales fue manejada quirúrgicamente. La recurrencia se observó en 6 pacientes (7,89%) durante la colonoscopia de seguimiento.LIMITACIONES:Estudio retrospectivo, realizado por dos endoscopistas expertos con experiencia en resección endoscópica y el seguimiento de corto plazo.CONCLUSIONES:La disección submucosa endoscópica con punta de asa para lesiones avanzadas del colon demuestra resultados satisfactorios a corto plazo, lo que sugiere su potencial como una alternativa segura y accesible a los bisturíes especializados, lo que posiblemente mejore la adopción de la resección endoscópica y la accesibilidad del paciente. (Traducción - Dr. Fidel Ruiz Healy ).

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.

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.).

Hybrid Versus Conventional Colorectal Endoscopic Submucosal Dissection: A Multicenter Randomized Controlled Trial (Short-Endoscopic Submucosal Dissection)

INTRODUCTION

Hybrid endoscopic submucosal dissection (H-ESD), which utilizes ESD knife along with snare-based resection, has been developed to overcome the technical complexity of conventional ESD (C-ESD). The aim of this study was to compare the therapeutic outcomes of H-ESD vs C-ESD for nonpedunculated colorectal lesions ≥20 mm in size.

METHODS

We conducted a multicenter randomized controlled trial to compare H-ESD and C-ESD (Short-ESD trial). Patients with colorectal lesions between 20 and 50 mm in size were randomly assigned (1:1) to H-ESD or C-ESD. Primary outcome was procedure time/speed. Secondary outcomes were en bloc and complete (R0) resection rates and adverse event rates.

RESULTS

A total of 89 patients (median age 63 years; 49.3% women) with the median polyp size of 30 mm underwent H-ESD (n = 40) and C-ESD (n = 49). The mean procedure time of H-ESD was significantly shorter than that of C-ESD (41.1 ± 16.3 vs 54.3 ± 28.2 minutes; P = 0.007). The en bloc and R0 resection rates trended lower in the H-ESD vs C-ESD groups (77.5% vs 87.8%; P = 0.26% and 72.5% vs 79.6%; P = 0.46) without reaching statistical significance. Adverse event rate was similar between H-ESD and C-ESD (10% vs 8.2%; P = 1.00).

DISCUSSION

Both H-ESD and C-ESD were safe and effective for resection of large colorectal lesions. H-ESD was associated with a shorter procedure time. H-ESD may represent a viable alternative to C-ESD, with the main advantage being easy applicability of a snare-based technique for colorectal lesions. Future studies are needed to further define the most suitable lesions for H-ESD, as to optimize efficiency and safety without compromising resection outcomes. ClinicaTrials.gov NCT NCT05347446.

Long-Term Follow-Up After Non-Curative Endoscopic Submucosal Dissection for Early Gastrointestinal Cancer-A Retrospective Multicenter Analysis

Background: Endoscopic Submucosal Dissection (ESD) has become the standard therapy for early malignant lesions in the gastrointestinal tract and has shown as good oncological surgery results. Approximately 30% of ESDs do not meet the criteria for oncological curability, and upfront surgery is indicated. Hence, about 40% of patients with an indication for surgery are advised against surgery because of comorbidities and an advanced age. Methods: We performed a multicenter retrospective cohort study on the long-term outcomes of non-curative ESDs, performed between 2009 and May 2024, without additional tumor therapy. The primary outcome was the recurrence of malignancy, either local malignancy or lymph node metastasis during follow-up, or death. We compared the outcomes between two cohorts: after non-curative ESD (ncESD) and after curative ESD (cESD). Results: A total of 374 ESDs were analyzed in this study. Overall, the technical success rate was 91%, and the oncological curative resection criteria were met in 70.9% of patients. Severe complications occurred in 5% of cases without procedure-associated mortality. In the ncESD group, 20% (7/35) of patients had a recurrence of malignancy primarily due to positive horizontal margins in the resection specimens, and 3 out of 35 died due to a non-oncological reason during the follow-up (mean length 36.6 months). In the cESD group, 3% (1/33) of patients had tumor recurrence, and 1 patient died because of a non-oncological reason. The tumor recurrence rate between the cohorts was significant (p = 0.017), and overall mortality did not show significance (p = 0.33). Conclusions: Especially in the elderly and multimorbid patients, the recommendation to perform rescue surgery after non-curative ESD remains challenging. Residual malignancy rates in surgical resection specimens are low, recurrence rates of malignancy are low, and mortality rates for non-oncological reasons are high in this population. There is a need for more data for the individualization of patient management after non-curative ESD.

Efficacy of Two Kinds of Scissor-Type Knives for Colorectal Endoscopic Submucosal Dissection: A Retrospective Comparative Study

INTRODUCTION

Scissor-type knives are spreading as safe devises in endoscopic submucosal dissection (ESD). We evaluated the efficacy of two kinds of scissor-type knives (Clutch Cutter: CC, Fujifilm Co. and SB Knife Jr2: SB, SB-KAWASUMI Laboratories. Inc.) in colorectal ESD.

METHODS

This single-center retrospective study analyzed 178 ESD cases treated with CC from January 2020 to August 2021 and 91 cases with SB from September 2021 to December 2023. The two groups were compared through propensity score matching. Therapeutic results, such as ESD procedure time, en bloc resection rate, perioperative bleeding frequency, and complications, were analyzed in each group. Risk factors for long ESD procedure time (≥ 90 min) were also examined.

RESULTS

After matching, 87 cases in each group were analyzed. There was no significant difference in the ESD procedure time (min, median [interquartile range]) between the CC and SB groups (54.0 [36.0-72.0] vs. 53.0 [39.0-72.0], p = 0.99). Additionally, there were no differences in the en bloc resection (100% vs. 100%, p = 1.00), perioperative perforation (1.1% vs. 1.1%, p = 1.00), or delayed bleeding (1.1% vs. 0.0%, p = 1.00). There was a significant difference in perioperative bleeding frequency (mean ± standard deviation: 1.8 ± 2.6 vs. 3.0 ± 3.5, p < 0.01). The significant risk factors (odds ratio [95% confidence interval]) for long ESD procedure time in patients treated with CC or SB were antiplatelet (7.51 [1.82-31.00]), large lesion size (1.08 [1.05-1.12]), severe fibrosis (24.30 [7.60-77.90]), and perioperative bleeding frequency (1.34 [1.14-1.56]).

CONCLUSIONS

CC and SB in colorectal ESD enabled high en bloc resection and low complication rates. CC showed significantly less perioperative bleeding than SB.

Outcomes and validity of risk stratification tools for endoscopic submucosal dissection of early gastric cancer in Western Australia

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has become the treatment of choice for many superficial gastric neoplasms. Clinical outcomes are increasingly comparable between Japanese and Western series; however, data are lacking on the validity of risk stratification tools in Western cohorts. We aimed to evaluate clinical outcomes, explore risk stratification, and compare our data with published Western series.

METHODS

We conducted a retrospective, observational cohort study in a single tertiary referral center over a 13-year period. Primary outcomes were rates of en bloc, complete (R0) and curative resection. Secondary outcomes included adverse events, recurrence, metachronous lesions, eCura grades, and ESGE criteria. A comparative analysis was performed with existing published series from Western centers.

RESULTS

Totally 112 patients were included in the study cohort. 50.9% were male, 87.5% Caucasian, and median age was 75.5 years (IQR 14.3 years). Lesions were predominantly antral (36.6%) or body (35.7%); median size 20 mm (IQR 15 mm). Rates of en bloc, R0 resection, and curative resection were 96.4%, 89.3%, and 78.6% (identical between eCura and ESGE), respectively. Adverse events occurred in 5.8%, recurrence in 0%, and metachronous lesions in 9.9%. Our data compared favorably with a review existing Western series, which illustrates increasing adoption of ESD and stable outcomes over time.

CONCLUSION

ESD represents a safe and effective method of treatment for gastric neoplasia in the Western setting. This study highlights the potential for excellent outcomes in a single center with a heterogeneous patient cohort and supports the use of eCura in guiding post procedural management.

Risk factors and a nomogram for predicting local recurrence in adult patients with early gastric cancer after endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective treatment method for early gastric cancers. The aim of this study was to evaluate the risk factors of recurrence for patients with early gastric cancer after ESD and construct a nomogram for predicting recurrence.

METHODS

A retrospective observational study was conducted on patients with early gastric cancer who underwent ESD at Beijing Friendship Hospital between 2013 and 2018. The risk factors of gastric cancer recurrence after ESD were analyzed by univariate and multivariate Cox regression.

RESULTS

A total of 238 patients with a median follow-up period of 70.5-month were enrolled in the study. Risk factors for recurrence included diabetes (HR = 3.68), alcohol consumption history (HR = 5.73), complications (HR = 5.22), lymphatic invasion (HR = 13.09) and multiple lesions (HR = 4.34). The analysis of the receiver operating characteristic curve, calibration curve, and model consistency index demonstrates that the graphical representation exhibits a good predictive capability.

CONCLUSIONS

Based on identified risk factors, this study developed the first nomogram with high accuracy to predict the recurrence of early gastric cancer after ESD. This model offers valuable guidance to clinicians for identifying high-risk patient groups and planning more intensive follow-up strategies.

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.

Underwater Techniques in Gastrointestinal Endoscopy: Diving into the Depths

The endoscopic resection of gastrointestinal tract lesions embraces different types of techniques, ranging from conventional polypectomy/endoscopic mucosal resection (EMR) to the field of third-space endoscopy, including endoscopic submucosal dissection (ESD), full-thickness resection and peroral endoscopic myotomy (POEM). Parallelly, the advent of underwater techniques has served as an add-on for both basic and advanced procedures, since its first report in 2012. We aimed to provide a comprehensive update on the state of the art about the feasibility of underwater basic and advanced techniques for GI endoscopy. Underwater EMR (U-EMR) has proved effective and safe in treating > 10 mm sessile or flat or all-size recurrent colonic lesions. Conversely, although data show good effectiveness and safety for <10 mm lesions, it is preferred when high-grade dysplasia is suspected, favouring cold snare polypectomy for all other cases. Moreover, promising data are emerging regarding the feasibility of U-ESD for difficult-to-resect colonic lesions. U-EMR represents a standard of care for treating < 25 mm superficial non-ampullary duodenal epithelial tumours. Data regarding oesophageal, gastric and ampullary lesions remains limited to small cohorts. Finally, using water immersion for POEM has shown a reduction in procedure time compared to the CO2 insufflation technique for vessel coagulation, albeit in a single-centre experience. Based on these results, U-EMR has become a standard for treating intermediate-size colonic and non-ampullary duodenal lesions, as highlighted also in the European Society of Gastrointestinal Endoscopy guidelines. Promising results have been shown in third-space endoscopy studies, even though further prospective studies are awaited to standardise the technique for both ESD and POEM.

Risk factor analysis and predictive model construction for postoperative bleeding in early esophageal cancer

OBJECTIVE

A multivariate logistic regression model was developed to identify the risk factors for postoperative bleeding in patients undergoing endoscopic submucosal dissection (ESD) for early esophageal cancer.

METHODS

The clinical data of 258 patients with early esophageal cancer who received ESD in Jiujiang Number One People's Hospital from April 2019 to March 2022 were retrospectively analyzed. Patients with or without postoperative bleeding were included into a bleeding group and a control group, respectively, and general information with statistically significant difference between the two groups was included in the multivariate logistic regression model to screen the risk factors for postoperative bleeding in the patients. The risk factors were then used to construct a nomogram prediction model for postoperative bleeding, and internal (training set) and external (validation set) validation was performed.

RESULTS

(1) The incidence of post-ESD bleeding was 12.02% in the 258 patients with early esophageal cancer. (2) History of hypertension, lesion diameter, submucosal fibrosis, C-reactive protein (CRP), and albumin (ALB) were independent risk factors for postoperative bleeding after ESD in the patients (P<0.05). (3) The results of receiver operator characteristic curve (ROC) showed that the area under the curve (AUC) was 0.821 for the training set and 0.740 for the validation set. (4) The correction curve showed that the actual and predicted values of the training and validation sets were well fitted.

CONCLUSION

Hypertension history, lesion diameter, submucosal fibrosis, CRP, and ALB are risk factors for postoperative bleeding in patients with early esophageal cancer undergoing ESD. The nomograms established based on these factors has good predictive value for postoperative bleeding in these patients.

A prospective randomized trial comparing the pocket-creation method and conventional method of endoscopic submucosal dissection in early gastric cancers and precancerous lesions

BACKGROUND

Endoscopic submucosal dissection (ESD) is widely used as a standard treatment regimen for early gastric cancers (EGCs). However, such an approach is time consuming and has a high risk of perforation and bleeding in some corner-site lesions because of the obscured view and difficulty in submucosal lifting. The newly developed pocket-creation method (PCM) provides a clearer view and better traction of the submucosal layer than conventional ESD (c-ESD). Nevertheless, no prospective randomized study has evaluated the efficacy of the PCM in EGCs and precancerous lesions.

METHODS

This was a prospective randomized controlled trial. Patients with superficial gastric neoplastic lesions ≥ 20 mm were randomly assigned to the PCM-ESD group or c-ESD group. The primary outcome was dissection speed.

RESULTS

There were 28 patients in the PCM-ESD group and 27 in the c-ESD group. The median dissection speed was significantly higher in the PCM-ESD group than in the c-ESD group (21.5 mm2/min vs 14.3 mm2/min, P < .001). Meanwhile, the operation time in the PCM-ESD group was significantly shorter than that in the c-ESD group (30 vs 40 min, P = .047). In multiple linear regression analysis, the treatment method was independently associated with the resection speed of ESD.

CONCLUSION

PCM-ESD was an effective and safe treatment for EGCs and precancerous lesions.

Entire traction using clip-and-nylon ring to facilitate endoscopic submucosal dissection of a laterally spreading tumor with fibrosis in the rectum

A 78-year-old woman with hematochezia underwent a colonoscopy and found a 2 × 2-cm laterally spreading tumor (LST) in the rectum, 3 cm from the anus. Because of the risk related to anus preservation and the potential operative trauma, the patient refused surgery and was referred for ESD treatment. Here, we applied a novel entire traction method to deal with this subset of tumors.

Gastric cystica profunda: Another indication for minimally invasive endoscopic resection techniques?

Gastric cancer presents a significant global health burden, as it is the fifth most common malignancy and fourth leading cause of cancer mortality worldwide. Variations in incidence rates across regions underscores the multifactorial etiology of this disease. The overall 5-year survival rate remains low despite advances in its diagnosis and treatment. Although surgical gastrectomy was previously standard-of-care, endoscopic resection techniques, including endoscopic mucosal resection and endoscopic submucosal dissection (ESD) have emerged as effective alternatives for early lesions. Compared to surgical resection, endoscopic resection techniques have comparable 5-year survival rates, reduced treatment-related adverse events, shorter hospital stays and lower costs. ESD also enables en bloc resection, thus affording organ-sparing curative endoscopic resection for early cancers. In this editorial, we comment on the recent publication by Geng et al regarding gastric cystica profunda (GCP). GCP is a rare gastric pseudotumour with the potential for malignant progression. GCP presents a diagnostic challenge due to its nonspecific clinical manifestations and varied endoscopic appearance. There are several gaps in the literature regarding the diagnosis and management of GCP which warrants further research to standardize patient management. Advances in endoscopic resection techniques offer promising avenues for GCP and early gastric cancers.

Hybrid endoscopic approaches for complex colorectal polyps with a non-lifting sign: the Greek experience

Background

Hybrid approaches combining endoscopic full-thickness resection (EFTR) with conventional techniques (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) have enabled the resection of difficult fibrotic colorectal adenomas exhibiting a "non-lifting" sign, and polyps in difficult positions. We present our cohort treated with either EMR+EFTR or ESD+EFTR as salvage hybrid endoscopic approaches for complex colorectal polyps not amenable to conventional techniques.

Methods

Retrospective analysis included technical success, histological confirmation of margin-free resection, assessment of adverse events and follow up with histological assessment. All patients underwent follow-up endoscopy at least 6 and 12 months post-resection.

Results

Fourteen patients underwent hybrid EFTR procedures (11 EMR+EFTR and 3 ESD+EFTR). Technical success was achieved in all cases where the full-thickness resection device (FTRD) was advanced to the site of the resection (100%). In 2 cases, the FTRD system could not be passed through the sigmoid colon because of severe chronic diverticulitis, subsequent fibrosis and stiffness. The mean lesion size in the EMR+EFTR group (41.7 mm; range 20-50 mm) was larger than the ESD+EFTR group (31.7 mm; range 30-35 mm). Six patients (42.9%) were histologically diagnosed with T1 carcinoma. The mean duration of hospitalization was 1.4 days. Follow-up endoscopy was available in all patients and no recurrence was observed with histological confirmation during a mean follow-up period of 15.4 months.

Conclusion

Hybrid procedures appear to be safe and effective treatments for complex colorectal lesions not amenable to EMR, ESD or EFTR alone, because of the lesion size, positive non-lifting sign, and difficult positions.

Effectiveness of Strategy-Focused Training in Colorectal Endoscopic Submucosal Dissection: A Retrospective Observational Study

BACKGROUND

Colorectal ESD, an advanced minimally invasive treatment, presents technical challenges, with globally varying training methods. We analyzed the learning curve of ESD training, emphasizing preoperative strategies, notably gravity traction, to guide ESD instructors and trainee programs.

METHOD

This retrospective study included 881 cases guided by an experienced supervisor. Six trainees received "strategy-focused" instruction. To evaluate the number of ESD experiences in steps, the following phases were classified based on ESD experiences of each trainees: Phase 0 (0-50 ESD), Phase 1 (51-100 ESD), Phase 2 (101-150 ESD), and Phase 3 (151-200 ESD). Lesion background, outcomes, and safety were compared across phases. Factors contributing to technical difficulty in early (Phase 0 and 1) and late phases (Phase 2 and 3) were identified, along with the utility of traction ESD with device assistance.

RESULT

Treatment outcomes were favorable, with 99.8% and 94.7% en bloc resection and curative resection rates, respectively. Approximately 90% self-completion rate could be achieved after experiencing about 50 cases (92.7% in Phase 1), signifying proficiency growth despite increased case difficulty. In early phases, factors such as left-sided colon, LST-NG morphology, and severe fibrosis pose challenges. In late phases, LST-NG morphology, mild and severe fibrosis remained significant. Traction-assisted ESD, utilized in 3% of cases, comprised planned (1.1%) and rescue (1.9%) methods. Planned traction aided specific lesions, while rescue traction was common in the right colon.

CONCLUSION

"Strategy-focused" ESD training consistently yields successful outcomes, effectively adapting to varying difficulty factors in different proficient stages.

AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia

BACKGROUND & AIMS

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia.

METHODS

The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations.

RESULTS

The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics.

CONCLUSIONS

This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.

Outcomes in colorectal endoscopic submucosal dissection for large protruded lesions: A retrospective multicenter study

Background and study aims Colorectal endoscopic submucosal dissection (ESD) is increasingly used for treating early-stage colorectal cancer, including large, protruded lesions (LPL). However, the challenges posed by LPLs, especially those accompanied by severe fibrosis or muscle-retracting sign (MRS), remain unclear. This study aims to investigate ESD outcomes for LPL, focusing on factors such as tumor size and, submucosal fibrosis. Patients and methods In a multicenter retrospective study (June 2012 to May 2023), data from 526 patients with 542 LPL lesions (≥ 2 cm) were analyzed. Parameters included lesion size, procedure time, dissection speed, physician experience, submucosal fibrosis, and adverse events. The tunnel method, including the double tunnel method, was used for cases with severe fibrosis or MRS. Multivariate analysis assessed factors affecting procedure difficulty, particularly LPLs ≥ 4 cm. Results The study revealed an impressive en bloc resection rate of 97.8% and a curative resection rate of 78.6% for LPLs. Notably, fibrosis and MRS were present in 25% and 18% of 4-cm LPLs, respectively, and their frequency tended to increase as the tumor diameter increased. One treatment strategy for LPLs was the tunneling method, which was used most frequently (41 cases, 7.6%). Factors affecting dissection speed included larger tumor size, submucosal fibrosis, MRS, and physician experience. Conclusions Treating LPLs through colorectal ESD presents significant challenges, especially in patients with fibrosis and MRS. This study highlights the importance of recognizing these complexities, and that more reliable resection strategy must be established for accurate pathological evaluation.

Outcomes of endoscopic submucosal dissection in cirrhotic patients: First American cohort

BACKGROUND

Among patients with cirrhosis and pre-malignant or early malignant mucosal lesions, surgical intervention carries a much higher bleeding risk. When such lesions are discovered, endoscopic submucosal dissection (ESD) may offer curative therapy with lower risks than surgery and improved outcomes compared to traditional endoscopic resection.

AIM

To evaluate the outcomes of ESD in patients with cirrhosis.

METHODS

Patients with cirrhosis undergoing ESD between July 2015 and August 2022 were retrospectively matched in 1:2 fashion to controls based on lesion location, size, and anticoagulation use. Procedural outcomes were compared between groups.

RESULTS

A total of 64 Lesions from 59 patients were included (16 cirrhosis, 43 control). There were no differences in patient or lesion characteristics between groups. En bloc and curative resection was achieved in 84.21%, 78.94% of the cirrhosis group and 88.89%, 68.89% of controls, respectively, with no significant differences. Cirrhotic patients had significantly higher rates of intra-procedural coagulation grasper use for control of bleeding (47.37% vs 20%; P = 0.02). There were otherwise no significant differences in adverse event rates. In the 29 patients with follow up, we found higher rates of recurrence in the cirrhosis group compared to controls (40% vs 5.26%; P = 0.019), however this effect did not persist on multivariable analysis controlling for known confounders.

CONCLUSION

ESD may be safe and effective in patients with cirrhosis. Most procedure related outcomes were not significantly different between groups. Intra-procedural bleeding requiring use of the coagulation grasper use was expectedly higher in the cirrhosis group given the known effects of liver disease on hemostasis.

Novel devices for third-space endoscopy procedures

Third-space endoscopy (TSE) is a subspecialty in interventional endoscopy that exploits the submucosa as a working space for the management of various gastrointestinal diseases. Over recent years, TSE has emerged as a viable alternative to surgery for the treatment of various conditions. The rapid dissemination and adoption of TSE has been largely supported by the advent of novel devices aimed to improve the efficacy and safety of these procedures. In this article, we review some of the recent developments in TSE devices and provide our initial experience with these instruments in clinical practice.

Present situation of minimally invasive surgical treatment for early gastric cancer

Minimally invasive surgery is a kind of surgical operation, which is performed by using professional surgical instruments and equipment to inactivate, resect, repair or reconstruct the pathological changes, deformities and wounds in human body through micro-trauma or micro-approach, in order to achieve the goal of treatment, its surgical effect is equivalent to the traditional open surgery, while avoiding the morbidity of conventional surgical wounds. In addition, it also has the advantages of less trauma, less blood loss during operation, less psychological burden and quick recovery on patients, and these minimally invasive techniques provide unique value for the examination and treatment of gastric cancer patients. Surgical minimally invasive surgical techniques have developed rapidly and offer numerous options for the treatment of early gastric cancer (EGC): endoscopic mucosal resection (EMR), underwater EMR (UEMR), endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR), endoscopic submucosal excavation (ESE), submucosal tunnel endoscopic resection), laparoscopic and endoscopic cooperative surgery (LECS); Among them, EMR, EFTR and LECS technologies have a wide range of applications and different modifications have been derived from their respective surgical operations, such as band-assisted EMR (BA-EMR), conventional EMR (CEMR), over-the-scope clip-assisted EFTR, no-touch EFTR, the inverted LECS, closed LECS, and so on. These new and improved minimally invasive surgeries are more precise, specific and effective in treating different types of EGC.

The role of advanced endoscopy in appendiceal polyp management and outcomes

BACKGROUND

Appendiceal orifice lesions are often managed operatively with limited or oncologic resections. The aim is to report the management of appendiceal orifice mucosal neoplasms using advanced endoscopic interventions.

METHODS

Patients with appendiceal orifice mucosal neoplasms who underwent advanced endoscopic resections between 2011 and 2021 with either endoscopic mucosal resection (EMR), endoscopic mucosal dissection (ESD), hybrid ESD, or combined endoscopic laparoscopic surgery (CELS) were included from a prospectively collected dataset. Patient and lesion details and procedure outcomes are reported.

RESULTS

Out of 1005 lesions resected with advanced endoscopic techniques, 41 patients (4%) underwent appendiceal orifice mucosal neoplasm resection, including 39% by hybrid ESD, 34% by ESD, 15% by EMR, and 12% by CELS. The median age was 65, and 54% were male. The median lesion size was 20 mm. The dissection was completed piecemeal in 49% of patients. Post-procedure, one patient had a complication within 30 days and was admitted with post-polypectomy abdominal pain treated with observation for 2 days with no intervention. Pathology revealed 49% sessile-serrated lesions, 24% tubular adenomas, and 15% tubulovillous adenomas. Patients were followed up for a median of 8 (0-48) months. One patient with a sessile-serrated lesion experienced a recurrence after EMR which was re-resected with EMR.

CONCLUSION

Advanced endoscopic interventions for appendiceal orifice mucosal neoplasms can be performed with a low rate of complications and early recurrence. While conventionally lesions at the appendiceal orifice are often treated with surgical resection, advanced endoscopic interventions are an alternative approach with promising results which allow for cecal preservation.

Nomogram for predicting electrocoagulation syndrome after endoscopic submucosal dissection of esophageal tumors

BACKGROUND

Endoscopic submucosal dissection (ESD) was widely used for the removal of esophageal tumors, and post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) was one of the postoperative adverse events. The aim of this research was to develop and validate a model to predict electrocoagulation syndrome after endoscopic submucosal dissection of esophageal tumors.

MATERIALS AND METHODS

Patients who underwent esophageal ESD in our hospital were retrospectively included. A predictive nomogram was established based on the results of multivariate logistic regression analysis, and bootstrapping resampling was used for internal validation. Besides, the clinical usefulness of the nomogram was evaluated using decision curve analysis (DCA) and clinical impact curve.

RESULTS

A total of 552 patients who underwent esophageal ESD were included in the study, and the incidence of PPECS was 12.5% (69/552). Risk factors associated with PEECS (p < 0.1) were analyzed by multivariate logistic regression analysis, and the final model included four variables, namely gender, diabetes, tumor size and operation time. The predictive nomogram was constructed based on the above four variables, and the area under the ROC curve (AUC) was 0.811 (95% CI 0.767-0.855). The calibration curve of the nomogram presented good agreement between the predicted and actual probabilities. DCA showed that the model improved patient outcomes by helping to assess the risk of PEECS in patients compared to an all-or-no treatment strategy. In addition, the clinical impact curve of the model also indicates that the nomogram has a high clinical net benefit.

CONCLUSION

In conclusion, we have developed a predictive nomogram for PEECS after ESD for esophageal tumors with good predictive accuracy and discrimination. This predictive nomogram can be effectively used to identify high-risk patients with PEECS, which will help clinicians in clinical decision-making and early intervention.

Validation and update of a clinical score model to predict technical difficulty of colorectal endoscopic submucosal dissection: a multicenter prospective cohort study

BACKGROUND AND AIMS

The Zhongshan colorectal endoscopic submucosal dissection (CR-ESD) score model was proposed to grade the technical difficulty of CR-ESD. The objective of this study was to prospectively validate and update the score model.

METHODS

A multicenter prospective cohort analysis of CR-ESD was conducted. Individual data on patients, lesions, and outcomes of CR-ESD were used to validate the original model and further refine the difficulty of the prediction model. Data were randomly divided into discovery and internal validation cohorts. A multivariate Cox regression analysis was conducted on the discovery cohort to develop an updated risk-scoring system, which was then validated.

RESULTS

Five hundred forty-eight patients with 565 colorectal lesions treated by ESD from 4 hospitals were included. In the prospective validation cohort, the area under the receiver-operating characteristic (ROC) curve for the original model was .707. Six risk factors were identified and assigned point values: tumor size (2 points for 30-50 mm, 3 points for ≥50 mm), at least two-thirds circumference of the lesion (3 points), tumor location in the cecum (2 points) or flexure (2 points), laterally spreading tumor-nongranular lesions (1 point), preceding biopsy sampling (1 point), and NBI International Colorectal Endoscopic type 3 (3 points). The updated model had an area under the ROC curve of .738 in the discovery cohort and of .782 in the validation cohort. Cases were categorized into easy (score = 0-1), intermediate (score = 2-3), difficult (score = 4-6), and very difficult (score ≥7) groups. Satisfactory discrimination and calibration were observed.

CONCLUSIONS

The original model achieved an acceptable level of prediction in the prospective cohort. The updated model exhibited superior performance and can be used in place of the previous version. (Clinical trial registration number: ChiCTR2100047087.).

Randomized trial of gastric and colorectal endoscopic submucosal dissection defect closure comparing a novel through-the-scope suturing system with an over-the-scope suturing system (with video)

BACKGROUND AND AIMS

Mucosal closure adds time but reduces adverse events associated with endoscopic submucosal dissection (ESD). We aimed to assess the closure time (CT), technical success, and cost-effectiveness between a novel through-the-scope helix tack suture system (TTSS) and the over-the-scope suturing system (OTSS).

METHODS

In this single-center, prospective, randomized trial, all patients undergoing ESD with anticipated closure were randomized 1:1 to TTSS (study group) or OTSS (control group). Primary outcomes were CT and overall CT (OCT; CT + setup time). Secondary outcomes were rates of technical success, adverse events, and cost-effectiveness.

RESULTS

Forty patients were randomized to OTSS (n = 20) or TTSS (n = 20). OTSS and TTSS groups were similar with respect to age, gender, proportion of colorectal polyps, proximal colon polyps, and mean size of the resected specimen (40.9 mm vs 40.4 mm). The mean CT was 18.4 minutes for OTSS and 23.3 minutes for TTSS (P = .36). The mean OCT was 32 minutes for OTSS and 39.5 minutes for TTSS (P = .36). Closure with a primary device was successful in 17 cases (85%) with OTSS and 18 cases (90%) with TTSS (P = .63). No closure-related intraprocedural adverse events or delayed perforations were noted. Mean cost of closure was significantly lower in the TTSS group for lesions <35 mm (P = .008).

CONCLUSIONS

TTSS was not found to be superior to OTSS with respect to CT and technical and clinical success for closure of gastric and colorectal ESD defects. TTSS is more cost-effective for closure of lesions <35 mm. (Clinical trial registration number: NCT04925271.).

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.

Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasia in close proximity to esophageal varices: a multicenter international experience

BACKGROUND : There are limited data on the feasibility of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasia (SEN) located at or adjacent to esophageal varices. We aimed to evaluate the outcomes of ESD in these patients.

METHODS

 This multicenter retrospective study included cirrhotic patients with a history of esophageal varices with SEN located at or adjacent to the esophageal varices who underwent ESD.

RESULTS

 23 patients with SEN (median lesion size 30 mm; 16 squamous cell neoplasia and seven Barrett's esophagus-related neoplasia) were included. The majority were Child-Pugh B (57 %) and had small esophageal varices (87 %). En bloc, R0, and curative resections were achieved in 22 (96 %), 21 (91 %), and 19 (83 %) of patients, respectively. Severe intraprocedural bleeding (n = 1) and delayed bleeding (n = 1) were successfully treated endoscopically. No delayed perforation, hepatic decompensation, or deaths were observed. During a median (interquartile range) follow-up of 36 (22-55) months, one case of local recurrence occurred after noncurative resection.

CONCLUSION

 ESD is feasible and effective for SEN located at or adjacent to esophageal varices in cirrhotic patients. Albeit, the majority of the esophageal varices in our study were small in size, when expertise is available, ESD should be considered as a viable option for such patients.

Lesion size affects the risk of technical difficulty in gastric endoscopic submucosal dissection

Current evidence shows an inter-country inconsistency in the effect of lesion size on the technical difficulty of gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the specific correlation and quantify the ensuing risks. This retrospective study consisted of 405 ESD cases with gastric single lesion from April 2015 to April 2023. The correlation and risk prediction of lesion size with technical difficulty was explored to provide further clinical evidence. An additive generalized model and recursive algorithm were used to describe the non-linear association, and a linear two-piece regression was constructed to analyze the inflection point. Subgroup analysis and interaction were used to explore intergroup characteristics. Overall, difficult cases had larger lesion sizes, and the more significant the increase, the higher the risk of technical difficulty. In the full model, after adjusting for all covariates, each 1 mm, 3 mm, 5 mm, 7 mm, and one standard increase in lesion size increased the risk of technical difficulty by 8%, 26%, 42%, 72%, and 125%, respectively. There is a nonlinear positive correlation between lesion size and risk of technical difficulty, and the premeditated inflection point was 40 (mm) via two-piecewise linear regression and recursive algorithm. Subgroup analysis showed a stronger correlation between lesion size and difficult ESD in the upper site and submucosal fibrosis groups. Available evidence suggests that lesion size as a risk signal nonlinearly increases the technical difficulty of gastric ESD procedure, especially in cases of upper site and submucosal fibrosis, which deserves further investigation.

Precutting endoscopic band ligation-assisted resection versus endoscopic submucosal dissection in patients with small gastric submucosal tumors originating from the muscularis propria: study protocol of a randomized controlled trial

BACKGROUND

The management of small gastric submucosal tumors (SMTs) originating from the muscularis propria layer (SMT-MPs) remains a subject of debate. Endoscopic submucosal dissection (ESD) is currently considered the optimal treatment for resection. However, high expenses, complex procedures, and the risk of complications have limited its application. Our previously proposed novel operation, precutting endoscopic band ligation (precutting EBL), has been demonstrated in a long-term, single-arm study to be an effective and safe technique for removing small gastric SMTs. However, the absence of a pathological examination and the potential for delayed perforation have raised concerns. Thus, we modified the precutting EBL by adding endoscopic resection to the snare after ligation and closure, yielding the precutting endoscopic band ligation-assisted resection (precutting EBLR). Moreover, the initial pilot study confirmed the safety and efficacy of the proposed approach and we planned a randomized controlled trial (RCT) to further validate its clinical feasibility.

METHODS

This was a prospective, single-center, open-label, parallel group, and randomized controlled trial. Approximately 40 patients with SMT-MPs will be included in this trial. The patients included were allocated to two groups: ESD and precutting EBLR. The basic clinical data of the patients were collected in detail. To better quantify the difference between ESD and precutting EBLR, the primary outcome was set as the operation duration. The secondary outcomes included total operation cost and hospitalization, intraoperative adverse events, and postoperative recurrence. The primary outcome was tested for superiority, while the secondary outcomes were tested for noninferiority. SPSS is commonly used for statistical analysis.

DISCUSSION

This study was designed to validate the feasibility of a novel operation for removing gastric SMT-MPs. To intuitively assess this phenomenon, the operation durations of precutting EBLR and ESD were compared, and other outcomes were also recorded comprehensively.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200065473 . Registered on November 5, 2022.

Esophageal Endoscopic Submucosal Dissection in Older Patients Is Safe and Feasible: A Retrospective Single-Center Cohort Study in the United States

BACKGROUND

Endoscopic submucosal dissection (ESD) is a well-established method for treating early esophageal carcinomas. However, data on the safety and efficacy of esophageal ESD in older patients in the United States are limited.

METHODS

This retrospective study investigated the outcomes of esophageal ESD in patients aged ≥80 years and included those who underwent esophageal ESD between June 2018 and April 2023 at a single center in the United States. Patients were divided into two age groups for comparison: ≥80 and <80 years. Treatment outcomes and complications were evaluated and compared between these groups.

RESULTS

A total of 53 cases of esophageal ESD for malignant neoplasms were included, with 12 patients in the ≥80 years age group. No significant differences were observed in the patients' background and characteristics, except for a prior history of interventions (p = 0.04). The en bloc resection rate was 100% in both groups. The R0 resection rate was lower in the ≥80 years age group (75% vs. 88%). There were no complications requiring additional intervention in the ≥80 years age group, such as post-ESD bleeding, perforation, mediastinal emphysema, or pneumonia.

CONCLUSIONS

Esophageal ESD may be a safe and feasible procedure for treating esophageal carcinomas in older patients.

Inflammatory Bowel Disease Is not Linked to a Higher Rate of Adverse Events in Colonoscopy-a Nationwide Population-based Study in Sweden

BACKGROUND AND AIMS

Inflammatory bowel disease may cause long-standing inflammation and fibrosis and may increase the risk of adverse events in colonoscopy. We evaluated whether inflammatory bowel disease and other potential risk factors are associated with bleeding or perforation in a nationwide, population-based, Swedish study.

METHODS

Data from 969 532 colonoscopies, including 164 012 [17%] on inflammatory bowel disease patients, between 2003 and 2019, were retrieved from the National Patient Registers. ICD-10 codes for bleeding [T810] and perforation [T812] within 30 days of the colonoscopy were recorded. Multivariable logistic regression was used to test if inflammatory bowel disease status, inpatient setting, time period, general anaesthesia, age, sex, endoscopic procedures, and antithrombotic treatment were associated with higher odds for bleeding and perforation.

RESULTS

Bleeding and perforation were reported in 0.19% and 0.11% of all colonoscopies, respectively. Bleeding [odds ratio 0.66, p <0.001] and perforation [odds ratio 0.79, p <0.033] were less likely in colonoscopies in individuals with inflammatory bowel disease status. Bleeding and perforation were more common in inpatient than in outpatient inflammatory bowel disease colonoscopies. The odds for bleeding but not perforation increased between 2003 to 2019. General anaesthesia was associated with double the odds for perforation.

CONCLUSIONS

Individuals with inflammatory bowel disease did not have more adverse events compared with individuals without inflammatory bowel disease status. However, the inpatient setting was associated with more adverse events, particularly in inflammatory bowel disease status. General anaesthesia was associated with a greater risk of perforation.

Biennial Endoscopic Surveillance of Gastrointestinal Metaplasia and Its Subtypes Reduces Gastric Cancer Mortality and Is Cost-Effective in a Markov State Transition Model

OBJECTIVES

Gastric cancer in the United States has a low survival rate mainly because of the late stage of diagnosis. Furthermore, there are no well-established guidelines concerning screening and surveillance even for higher risk patients such as those with nondysplastic noncardia gastrointestinal metaplasia (GIM), and thus they are not routinely performed. This study was designed to provide new evidence-based data that can be used to support the implementation of biennial surveillance guidelines in individuals with nondysplastic noncardia GIM. This practice can help detect early malignant lesions, thereby decreasing morbidity and mortality. We evaluated the cost-effectiveness of surveillance endoscopies for noncardia gastric cancer in populations with two different pathological diagnoses: mixed GIM and incomplete GIM (iGIM).

METHODS

Markov state transition models were developed using a cohort simulation of 1000 hypothetical patients. Analysis was conducted for both mixed and iGIM. Quality-adjusted life-years and transition probabilities were derived from the published medical literature. Costs associated with endoscopy, cancer care, and surgery were based on Medicare reimbursement. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used to determine cost-effectiveness.

RESULTS

Our study determined that it is significantly cost-effective to perform biennial endoscopy surveillance in patients who have been incidentally found to have noncardia mixed GIM, with a cost savings of $5783.84 per person, and in those with iGIM, with a cost savings of $8093.08 per person.

CONCLUSIONS

Biennial endoscopy surveillance should be considered in all individuals found to have mixed or incomplete noncardia GIM on endoscopy. Furthermore, screening specifically for iGIM after differentiating between the two groups can lead to further cost savings. As such, we recommend that pathologists routinely differentiate between the two and recommend robust routine surveillance of iGIM.

Endoscopic Submucosal Dissection in the Upper Gastrointestinal Tract and the Need for Rescue Surgery-A Multicenter Analysis

Endoscopic submucosal dissection (ESD) has become the standard treatment for early malignant lesions in the upper gastrointestinal (GI) tract. Its clinical results have been reported to be as good as surgery. The outcomes of rescue surgery after non-curative ESD have been reported to be as good as first-line surgery. The aim of this study was to evaluate the outcomes of ESD in the upper GI tract and the outcomes of rescue surgery after non-curative ESD performed in Linz, Austria, between 2009 and January 2023. A total of 193 ESDs were included and divided into 104 esophageal ESD and 89 gastric ESD procedures. The criteria for curative ESD were in line with established guidelines' recommendations. For esophageal lesions, the mean lesion size was 40.3 mm and the rate of curative ESD was 56.7%. In the non-curative ESD, the rate of technical failure as the reason for non-curative ESD was 13.3% and the oncological failure rate was 86.7%. Only 48.7% of indicated rescue surgeries were performed. The main reason for not performing surgery was interdisciplinary consensus due to comorbidity. Perioperative complications Dindo-Clavien ≥ 3 occurred in 22.2% of cases with an in-hospital mortality rate of 0. In gastric lesions, the mean size was 39 mm and the rate of curative ESD was 69.7%. The rate of technical failure as a reason for non-curative ESD was 25.9% and the oncological failure rate was 74.1% for non-curative ESD. Rescue surgery was performed in 48.2% of indicated cases. The perioperative rate for major complications was 0. The outcome of ESD in the upper GI tract is in line with the published literature, and non-curative ESD does not worsen surgical outcomes. The available follow-up data are in line with the international published literature, showing a low rate of residual malignancy in surgical resection specimens. Therefore, the indication of rescue surgery for oncological failure remains challenging. Furthermore, the learning curve of ESD has shown a trend towards improving outcomes over time.