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

Endoscopic resection of gastrointestinal tumors: Training levels and professional roles explored

In this editorial, we provide commentary on a recently published study by Zhao et al in the World Journal of Gastrointestinal Oncology. The study discusses the clinical characteristics of patients undergoing endoscopic resection for gastric cancers. We feel it is important to engage our endoscopy community in a discussion on the current evidence in the literature on the necessary number of cases for training in endoluminal surgery techniques, particularly endoscopic submucosal dissection. This includes the latest recommendations from the European Society of Gastrointestinal Endoscopy, as well as a summary of key studies on the learning curve for these techniques. Additionally, we explore the impact of an endoscopist's specialty on endoscopy outcomes, drawing from current evidence in the literature to shape our perspective in this evolving field.

Endoscopic Submucosal Dissection (ESD) for the Management of Fibrotic Non-Lifting Colorectal Lesions (NLCLs): Results from a Large Multicenter Retrospective Study

Background/Objectives: The management of non-lifting colorectal lesions (NLCLs), often resulting from previous unsuccessful treatments or biopsies, remains challenging due to submucosal fibrosis that prevents adequate lifting. Endoscopic submucosal dissection (ESD) is a viable option for achieving complete resection in such cases. However, when standard ESD is not feasible, conversion to hybrid ESD (H-ESD) has been proposed as a rescue strategy. This study aimed to assess ESD's feasibility, effectiveness, and safety for NLCLs, including cases requiring conversion to H-ESD, when performed by experienced endoscopists in tertiary referral centers. Methods: In this multicenter retrospective study, data from patients with NLCLs treated by ESD/H-ESD between January 2009 and September 2022 were analyzed. The primary endpoint was the recurrence rate (RR). Secondary endpoints included the adverse event (AE) rate, technical success (TS) rate (en bloc resection regardless of technique), complete resection (CR), curative resection (cR) rates, and surgical intervention rate. Predictors of ESD technical success were identified. Results: In total, 178 patients with NLCLs were included (52 previously biopsied, 126 recurrent after previous resection). ESD was used in 111 (62.4%) and H-ESD in 67 (37.6%) cases. During a median follow-up of 373 days (IQR 540), the overall RR was 3.6%. The overall AE rate was 13.4%, and perforation was the most frequent (8.4%). All AEs were successfully managed endoscopically. The TS rate was 71.9%, significantly higher in previously biopsied lesions compared to recurrent ones (78.8% vs. 55.6%, p = 0.04). On multivariate analysis, rectal location (p < 0.001), F1 fibrosis (p = 0.026), and previously biopsied lesions (p = 0.006) predicted ESD TS without the need for conversion to H-ESD. Conclusions: ESD/H-ESD is feasible and safe for NLCLs when performed by experienced operators, with low RR amenable to endoscopic treatment. Previously biopsied lesions, rectal location, and low fibrosis predict ESD TS.

Retrospective Analysis of Rectal Endoscopic Submucosal Dissection at Ordensklinikum Linz and Kepler Universitätsklinikum Linz

Background and study aim: Endoscopic submucosal dissection is a minimally invasive endoscopic procedure for the removal of neoplastic benign and early malignant lesions in the gastrointestinal tract. In this study, we analyse the success and safety of rectal ESD at Linz hospitals, focusing on a specific endoscopist. Additionally, we examine whether there is a learning curve regarding success parameters. Methods: This retrospective study included all 102 patients who underwent endoscopic submucosal dissection of the rectum by a defined endoscopist at Ordensklinikum Hospital and Kepler University Hospital between December 2010 and May 2021. With the collected data, a descriptive statistic was carried out and regression analyses were performed. Results: The en bloc resection rate was 78.4% and the rate of lesions removed in healthy tissue was 55.6%. The average procedure time was 179 min and the complication rate was 7.8%. In total, 26.4% of cases showed carcinoma; in 25.9% of these cases, an oncologically curative resection was achieved with ESD. Follow-up data were available for 61.1% of cases, with recurrence being diagnosed in 3.6% of cases. A learning curve was observed regarding the rate of lesions removed in healthy tissue and the procedure time, but not regarding the en bloc resection rate. Conclusions: Endoscopic submucosal dissection is a safe method for the removal of large rectal adenomas and early carcinomas. The en bloc resection rate of the analysed procedures is within the range of comparable European studies. The rate of lesions removed in healthy tissue is below the R0 resection rate of the comparative literature; however, a learning curve could be observed in this parameter.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy

AIM

The performance of therapeutic procedures in lower gastrointestinal endoscopy (LGI) can be challenging and carries an increased risk of adverse events. There is increasing demand for the training of endoscopists in these procedures, but limited guidelines exist concerning procedural competency. The aim of this study was to assess the learning curves for LGI polypectomy, colorectal endoscopic mucosal resection (EMR) and colorectal endoscopic submucosal dissection (ESD).

METHOD

A systematic review of electronic databases between 1946 and September 2019 was performed. Citations were included if they reported learning curve data. Outcome measures that defined the success of procedural competency were also recorded.

RESULTS

A total of 34 out of 598 studies met the inclusion criteria of which 28 were related to ESD, three to polypectomy and three to EMR. Outcome measures for polypectomy competency (en bloc resection, delayed bleeding and independent polypectomy rate) were achieved after completion of between 250 and 400 polypectomies and after 300 colonoscopies. EMR outcome measures, including complete resection and recurrence, were achieved variably between 50 and 300 procedures. Outcome measures for ESD included efficiency (resection rates and procedural speed) and safety (adverse events). En bloc resection rates of over 80% and R0 resection rates of over 70% were achieved at 20-40 cases and procedural speed increased after 30 ESD cases. Competency in safety metrics was variably achieved at 20-200 cases.

CONCLUSION

There is a paucity of data on learning curves in LGI polypectomy, EMR and ESD. Despite limited evidence, we have identified relevant outcome measures and threshold numbers for the most common LGI polyp resection techniques for potential inclusion in training programmes/credentialing guidelines.