JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Advances in gastrointestinal endoscopy: A comprehensive review of innovations in cancer diagnosis and management

The field of gastroenterology has experienced revolutionary advances over the past years, as flexible endoscopes have become widely accessible. In addition to enabling faster, less invasive, and more affordable treatment, flexible endoscopes have greatly improved the detection and endoscopic screening of malignancies and prevented many cancer-related deaths. The development and clinical application of new diagnostic endoscopic technologies, such as magnification endoscopy, narrow-band imaging, endoscopic ultrasound with biopsy, and more recently, artificial intelligence enhanced technologies, have made the recognition and detection of various neoplasms and sub-epithelial tumors more possible. This review demonstrates the latest advancements in endoscopic procedures, techniques, and devices applied in the diagnosis and management of gastrointestinal cancer.

The Old: Is There Any Role for Screening Colonoscopy after the Age of 75? The Surgeon's Perspective

Guidelines recommend individualized decision making for screening colonoscopy for colorectal cancer (CRC) in patients after the age of 75 years due to low additional benefits. That should be taken with a grain of salt, as these recommendations are based on expert opinion and simulation models which do not consider (1) the differences in pathogenesis and cancer biology of CRC in elderly; (2) the risks of colonoscopy in this patient population; (3) and the impact of new surgical and nonsurgical therapies for CRC. In this review, our goal is to bring a surgeon's perspective to understand the role of screening colonoscopy in patients older than 75 years.

Prospective randomized trial comparing conventional and underwater endoscopic submucosal dissection for superficial colorectal neoplasms

This study compared procedure-related outcomes of conventional and underwater endoscopic submucosal dissection (ESD) for superficial colorectal neoplasms (SCNs).In this single-center, randomized controlled trial, patients with SCNs meeting the indications of the Japanese guidelines for ESD were randomly assigned to undergo conventional ESD (CESD) or underwater ESD (UESD) performed by an expert. The primary endpoint was dissection speed, defined as the specimen area per ESD time.We analyzed the data of 69 and 70 CESD and UESD cases, respectively; however, no significant differences were found in median dissection speed (17.4 and 19.9 mm2/min, respectively; P=0.19). Multiple regression analysis revealed that the suitable positional relationship between the lesion and the direction of gravity (nongravity side for CESD and gravity side for UESD) was independently and positively associated with dissection speed (P<0.001). En bloc resection was achieved without perforation in all cases. The incidence of post-ESD coagulation syndrome was not significantly different between the two groups (4.3% vs. 2.9%, respectively; P=0.68).UESD did not expedite dissection speed in the overall patient population. CESD and UESD may be complementary in the colorectum depending on the positional relationship between the lesion and the direction of gravity.

Intestinal decompression and drainage in preventing post-endoscopic submucosal dissection electrocoagulation syndrome in colorectal ESD: a prospective study

Background and aims

This study explored the efficacy of a prophylactic intestinal decompression tube in reducing the incidence of post-endoscopic submucosal dissection electrocoagulation syndrome (PECS).

Methods

A total of 157 eligible patients with colorectal mucosal lesions scheduled for endoscopic submucosal dissection (ESD) were prospectively recruited; after drop out 11 patients, 146 patients were randomly assigned to an experimental group (group 1, n = 73) or control group (group 2, n = 73). Patients in the experimental group underwent placement of an intestinal decompression drainage tube after ESD, while the control group received no additional treatment after ESD. The primary outcome was the incidence of PECS. Secondary outcomes included the incidence of postoperative complications, time to removal of the intestinal decompression tube, the degree of abdominal pain as measured by the visual analog scale (VAS), and the participants' self-rated comfort level with the intestinal decompression tube.

Results

A total of 146 patients (n = 73 per group) were finally analyzed between July 2022 and February 2023. All tumors were successfully resected en bloc. A significant difference in the incidence of PECS was found between group 1 and group 2 (5.5% vs 16.4%; P = 0.034). Precisely, 61.6% of patients felt painless for intestinal decompression tube, and no severe or unbearable pain was reported.

Conclusions

The placement of intestinal decompression drainage tube could reduce the incidence of PECS after colorectal ESD, which might play a preventive role in the occurrence of PECS.

Success and safety of conventional endoscopic resection techniques for previously partially resected colorectal polyps at a tertiary referral center

BACKGROUND AND AIMS

Partial resection of colon polyps induces submucosal fibrosis, making subsequent resection attempts more difficult. Some consider that partially resected lesions require specialized techniques such as endoscopic submucosal dissection, full-thickness resection, or surgery. We investigated whether traditional endoscopic resection methods were safe and effective.

METHODS

We report results of endoscopic resection of previously partially resected colorectal polyps by means of conventional resection methods (snare resection with or without injection and/or avulsion) and compare outcomes with lesions without previous partial resection. This is a retrospectively evaluated assessment of a prospectively collected database at a single tertiary academic center.

RESULTS

From August 12, 2019, to May 14, 2024, 1101 referred colorectal lesions underwent conventional resection and at least 1 surveillance colonoscopy. The last follow-up colonoscopy included in the study was performed on July 19, 2024. Out of the 1101 lesions, 220 had previous partial resection by means of snare, hot biopsy forceps, or surgical transanal excision. All of these 220 lesions were successfully resected with the use of conventional methods, and recurrence rates at first follow-up (8.2%) were similar to lesions without previous resection (7.8%; P = .889), as was the perforation rate (0.5% vs 0.3%). Compared with lesions with no previous resection, previously partially resected lesions were more often resected by means of electrocautery (94.1% vs 64.2%; P < .001), and required the cap technique (36.4% v. 17.4%; P < .001) and avulsion (65.5% v 28.8%; P < .001).

CONCLUSIONS

While specialized resection techniques are increasingly advocated to manage fibrotic colorectal lesions, we demonstrate conclusively that experts can successfully and safely manage previously partially resected colorectal lesions with the use of conventional techniques.

Efficacy of water pressure method for colorectal endoscopic submucosal dissection: Propensity-score matching analysis

Background and study aims

Technical difficulty of endoscopic submucosal dissection (ESD) for colorectal neoplasms has not been resolved. The water pressure method (WPM) is a helpful technique for overcome difficulties with colorectal ESD. We evaluated the efficacy and safety of ESD with WPM (WPM-ESD) for colorectal neoplasms compared with conventional ESD (C-ESD).

Patients and methods

This was a single-center, retrospective, observational study. Three hundred and eleven colorectal lesions were allocated into the WPM-ESD and the C-ESD groups, which were compared before and after propensity score matching. The main outcomes were procedure time, proportion of R0 resection, and incidence of adverse events (AEs) in the two groups.

Results

The WPM-ESD and C-ESD groups were allocated 134 and 177 lesions, respectively, and propensity score matching analysis created 92 matched pairs. Mean procedure time was significantly shorter in the WPM-ESD group (49 ± 26 vs. 58 ± 42 min, P = 0.032). All lesions were resected in one piece and there was no difference in the proportion of en bloc resection (100% vs. 100%) and R0 resection (92% vs. 96%, P = 0.536) or in incidence of intraoperative perforation (2.2% vs. 2.2%) in the two groups.

Conclusions

WPM for colorectal ESD may shorten procedure time compared with C-ESD without increasing AEs.

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.

Clinical usefulness of hybrid endoscopic submucosal dissection for T1b colorectal carcinomas ≤20 mm to ensure adequate vertical margins

Objective

To evaluate endoscopic resection strategies for cT1b colorectal carcinomas (CRCs) ≤20 mm to determine strategies that enable adequate vertical margins (VMs).

Methods

We enrolled 128 consecutive patients with cT1b colorectal carcinomas ≤20 mm resected by endoscopic mucosal resection or hybrid endoscopic submucosal dissection (ESD). Tumor lifting conditions after submucosal injection were classified into type A (lifting, soft dome-like), type B (lifting, hard trapezoid-like), and non-lifting (positive non-lifting sign). Predictors of positive VMs (VM 1) and adequate VMs were identified.

Results

All non-lifting tumors were resected by hybrid ESD and VMs were ≥500 µm. Vertical margin 1 tumors were only found in the endoscopic mucosal resection group, in which, the proportion of type B tumors with VM 1 was significantly higher than that of tumors with negative VMs (p < 0.01). Type A tumors showed no significant between-group differences. Among type B tumors, the proportion of VMs ≥500 µm was significantly higher (p < 0.01) and the VM distance was significantly longer (p < 0.01) in the hybrid ESD group than in the endoscopic mucosal resection group.

Conclusions

Hybrid ESD can be selected for type B tumors to ensure adequate VMs.

Feasibility of endoscopic submucosal dissection including papilla (with video)

OBJECTIVES

Endoscopic papillectomy (EP) is a low-invasive treatment for duodenal tumors including papilla. The limit of lesion size and local recurrence have been issues in EP. We developed endoscopic submucosal dissection (ESD) for the duodenal tumors including papilla (ESDIP: ESD including papilla) to overcome the problems. The aim of this study was to evaluate the feasibility of ESDIP.

METHODS

We included the patients who underwent ESDIP from August 2010 to January 2024 in this study. We evaluated the retrospective characteristics of patients and lesions, clinical results of ESDIP and of endoscopic retrograde cholangiopancreatography (ERCP) as prevention for delayed adverse events, and pathological findings. We also calculated the cumulative recurrence rate and overall survival rate at 12 months after ESDIP.

RESULTS

Fifty-four patients were included in this study. The mean lesion size was 39 mm. The third-quarter cases revealed a less than half-circumferential lesion, and the one case with a full-circumferential lesion. Resection was accomplished in 96% (n = 52), and also the en-bloc resection rate was 96%. Of the cases in accomplished resection, 98% of patients were intubated with a pancreaticobiliary drainage tube by ERCP. Intraprocedural perforation occurred in eight cases. Delayed bleeding occurred in 10 cases. Delayed perforation was seen only in one case. The incidence of post-ERCP pancreatitis was 25%. Cumulative local recurrence rate and the overall survival rate were 15% and 96%, respectively.

CONCLUSION

ESDIP may be feasible for duodenal tumors including papilla, and is a potential alternative option to avoid pancreaticoduodenectomy.

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

Aims

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

Methods and Results

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

Conclusions

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

Comparison of traction vs. snare as rescue methods for challenging colorectal endoscopic submucosal dissection: Propensity score-matched study

Background and study aims

To address the challenges of difficult colorectal endoscopic submucosal dissection (ESD), conversion to snare resection (rescue-snare ESD: rSnare), a variant of hybrid ESD, is commonly proposed. However, rSnare is associated with a lower en bloc resection rate compared with conventional ESD. Traction-assisted ESD has emerged as a technique to facilitate dissection, but its effectiveness as a rescue method remains unclear. This study was the first to compare the effectiveness of rSnare and rescue-traction-assisted ESD (rTraction).

Patients and methods

This retrospective study involved 1464 consecutive lesions from 1372 patients with superficial colorectal neoplasms across eight institutions. Among these, 162 lesions required rescue methods of rSnare or rTraction. After propensity score matching, 88 lesions treated with either rSnare or rTraction were analyzed.

Results

The rTraction group exhibited significantly higher en bloc resection and R0 resection rates (93.2% and 77.3%, respectively) compared with the rSnare group (45.5% and 38.6%, respectively). However, average procedure time was significantly longer in the rTraction group (122.3 ± 72.5 min) compared with the rSnare group (92.2 ± 54.2 min). In the rTraction group, univariable and multivariable analyses identified traction initiation time > 75 minutes as the only independent predictor of procedure durations exceeding 120 minutes.

Conclusions

Utilizing a traction device as a rescue technique in difficult colorectal ESD resulted in higher en bloc and R0 resection rates compared with conversion to snare resection. Initiating traction within 75 minutes may contribute to reducing overall procedure time for challenging colorectal ESD cases.

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of colorectal cancer, 2024 update

The 2024 updates of the Chinese Society of Clinical Oncology (CSCO) Clinical Guidelines for the diagnosis and treatment of colorectal cancer emphasize standardizing cancer treatment in China, highlighting the latest advancements in evidence-based medicine, healthcare resource access, and precision medicine in oncology. These updates address disparities in epidemiological trends, clinicopathological characteristics, tumor biology, treatment approaches, and drug selection for colorectal cancer patients across diverse regions and backgrounds. Key revisions include adjustments to evidence levels for intensive treatment strategies, updates to regimens for deficient mismatch repair (dMMR)/ microsatellite instability-high (MSI-H) patients, proficient mismatch repair (pMMR)/ microsatellite stability (MSS) patients who have failed standard therapies, and rectal cancer patients with low recurrence risk. Additionally, recommendations for digital rectal examination and DNA polymerase epsilon (POLE)/ DNA polymerase delta 1 (POLD1) gene mutation testing have been strengthened. The 2024 CSCO Guidelines are based on both Chinese and international clinical research, as well as expert consensus, ensuring their relevance and applicability in clinical practice, while maintaining a commitment to scientific rigor, impartiality, and timely updates.

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.

Impact of narrow band imaging in prediction of histology of advanced colorectal neoplasia

We assessed the diagnostic performance of the Narrow-Band Imaging (NBI) International Colorectal Endoscopic Classification (NICE) and the Japan NBI Expert Team classification (JNET) in predicting histological outcomes of advanced colorectal lesions. Additionally, we evaluated the sensitivity and positive predictive value (PPV) of the JNET and NICE classifications individually for high-grade lesions (including HGD adenomas, intramucosal carcinomas, and T1 carcinomas). This was a retrospective analysis of prospectively collected data, involving 211 patients (130 men, mean age 60 years) who underwent colonoscopy with endoscopic resection of advanced colorectal neoplasia (lesions ≥ 10 mm). Lesions were classified using both NICE and JNET criteria, and final histopathological results were used for comparison. Of the 257 lesions analyzed, the NICE classification accurately classifies a large proportion of lesions (93.8%). In JNET classification we observed 77.4% correctly classified lesions. Specifically, the sensitivity and positive predictive value (PPV) of the NICE classification for high-grade lesions were 100% and 24.4%, respectively. For the JNET classification, the sensitivity and PPV for high-grade lesions were 56.6% and 57.7%, respectively. The JNET classification, with a positive predictive value of 57.7% for high-grade colorectal lesions (including HGD adenomas, intramucosal carcinomas, and T1 carcinomas), should be used for decision-making regarding appropriate subsequent endoscopic therapy.

Injectable Hyaluronic Acid-Based Hydrogels for Rapid Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is a widely used procedure for the treatment of early and precancerous gastrointestinal lesions and has become the standard treatment. In this procedure, the commonly used materials have a short retention time and a limited lifting capacity, which will prolong the duration of the ESD procedure. Furthermore, these liquids tend to diffuse after ESD surgery, failing to adequately protect the wound. Therefore, we designed and developed injectable hydrogels based on hyaluronic acid. A series of oxidized hyaluronic acid (OHA) and hydrazide hyaluronic acid (AHA) were synthesized, and 16 kinds of injectable hydrogels were fabricated to investigate the effects of molecular structures on the properties of the hydrogels. Among these, the O1A3 hydrogel exhibited a suitable injection performance, gelation time, and mechanical properties, along with good blood and cell compatibility in vitro. Subsequently, in a porcine model of the ESD procedure, the results demonstrated that the O1A3 hydrogel exhibited a good retention time and lifting performance while also significantly reducing the operation time from 1-2 h to ∼10 min. Furthermore, the adhesive property of the O1A3 hydrogel on small bleeding spots and wounds could be observed, which was beneficial in protecting the wound from the complex environment of the gastrointestinal tract. The present work of injectable hyaluronic acid-based hydrogels could be promising to improve the efficiency of ESD surgery.

Endoscopic Resection of Stage T1 Colorectal Adenocarcinoma Followed by Surgical Intervention: a Single-center Retrospective Study

BACKGROUND

Domestic and international guidelines recommend endoscopic resection for stage T1 colorectal adenocarcinoma with indications. However, completion surgery remains imperative for patients exhibiting high-risk factors subsequent to endoscopic procedures.

OBJECTIVE

To investigate the evidence, pathological features, and surgical outcomes of completion surgery in patients with T1 colorectal adenocarcinoma following endoscopic resection.

METHODS

We retrospectively collect data on the clinical features and treatment outcomes of patients with stage T1 colorectal adenocarcinoma who underwent endoscopic resection followed by surgical resection and those who initially completed surgical intervention at Peking University International Hospital between January 2019 and October 2022, with the aim of assessing the necessity and feasibility of surgical intervention.

RESULTS

Seventeen patients (Group A) with high-risk factors following endoscopic procedure, especially with deep submucosal invasion and vascular or lymphatic invasion, experienced further surgical resection. The median interval between endoscopic resection and completion surgery was 23.71 days ± 15.89. Sixteen patients (Group B) underwent radical resection without any prior interventions. The surgical approach involves integration of laparoscopy and colonoscopy for precise localization and quantitative diagnosis, followed by radical surgery. The two groups demonstrated significant differences statistically with reference to tumor diameter (1.65 cm ± 0.77 vs 3.36 cm ± 1.39, P = 0.000) and the attainment of standard lymph node count (cases of detected lymph nodes larger than or equal to 12, 5 vs 12, P = 0.015). Postoperative complications and hospital stay manifested no significant disparity statistically in two groups. Patients who underwent completion surgery had no inferior outcomes compared with those who underwent direct surgery in terms of 5-year disease-free survival (Log rank test: P = 0.083, Breslow test: P = 0.089). The two groups also exhibited no significant differences statistically in the context of overall survival (Log rank test: P = 0.652, Breslow test: P = 0.758).

CONCLUSION

Completion surgery is a safe and feasible treatment option for T1 colorectal adenocarcinoma patients with high-risk factors, particularly those with deep submucosal invasion and vascular or lymphatic invasion following endoscopic treatment. Furthermore, subsequent treatment should be chosen based on a comprehensive analysis of the patient's history of abdominal surgery, willingness, and pathological features.

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.

Experience, Outcomes, and Insights on Endoscopic Colonic Polyp Excision: A Retrospective Cohort Study

Introduction Colorectal cancer (CRC) continues to pose a major public health challenge, ranking among the most common malignancies globally and being a leading cause of cancer-related mortality. Most CRCs originate from adenomatous polyps, underscoring the importance of detecting and removing these precancerous growths as a key preventive measure against CRC. In particular, large colonic polyps (≥10 mm) warrant special attention due to their increased risk of progressing to malignancy compared to smaller polyps. This retrospective study aims to evaluate the outcomes of large polyp excision within a single NHS trust. By analysing patient demographics, polyp characteristics, procedural details, and clinical outcomes, this study seeks to provide comprehensive data on the efficacy and safety of endoscopic polyp excision. Patients and methods This retrospective cohort study was conducted at Maidstone and Tunbridge Wells NHS Trust, a district general hospital in Tunbridge Wells, England, with data collected for all patients who had endoscopic polypectomy from 2010 to 2022. Data collected from medical records included age, sex, polyp size and characteristics, and previous polyp removal attempts. Results A total of 350 participants were included in this study. The cohort comprised 224 males (64%) and 126 females (36%), with a mean age of 70 ± 12 years. Complications were observed in eight participants (2.3%), while 340 participants (97.7%) did not experience any complications. Participants who experienced complications had a mean polyp size of 49.38 ± 7.3 mm, whereas those without complications had a mean polyp size of 44.85 ± 16.5 mm (p = 0.440). All complications occurred in participants with polyps ≥40 mm. However, this association was not statistically significant (p = 0.352). Conclusion Our study has shown that large polyps can be safely excised in a local district hospital. The incidence of complications is related to the polyp size. A cutoff size of 40 mm was found to be related to increased complications. However, this was still statistically insignificant and won't affect the efficacy and safety of these procedures being carried out in a local district hospital, decreasing the load on tertiary and specialised hospitals.

Endoscopic submucosal dissection of colorectal pedunculated polyps

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

Association between pathological T1 colorectal cancer with lymphoid follicular replacement and risk of lymph node metastasis

BACKGROUND AND AIM

Endoscopic resection (ER) is widely performed to treat early colorectal cancer. However, additional surgery for pathological T1 colorectal cancer (pT1CRC) after ER is controversial because of the imprecise prediction of lymph node metastasis (LNM). Recently, several patients of pT1CRC with lymphoid follicular replacement (LFR) without LNM have been reported. This study aimed to investigate the clinicopathological features and risk of LNM in patients with pT1CRC with LFR.

METHODS

We retrospectively analyzed patients who underwent ER or surgical resection and were diagnosed with pT1CRC between January 2010 and December 2020. We defined pT1CRC with LFR as the replacement of a part of the lymphoid follicular component within the submucosal area by adenocarcinoma, with no invasion into other submucosal areas.

RESULTS

Among the 600 eligible patients, the incidence rate of pT1CRC with LFR was 6.7% (40/600). Patients with pT1CRC with LFR represented 14.3% (37/258) of the endoscopically treated patients and 0.9% (3/342) of the surgically treated patients. For patients with pT1CRC with LFR, 80.0% (32/40) had flat and depressed lesions, and 35.0% (14/40) had submucosal invasion depth ≥1000 μm. Patients with pT1CRC with LFR had negative lymphovascular invasion, differentiated type, and budding grade 1. In the median follow-up of 61 months, patients with pT1CRC with LFR had no LNM.

CONCLUSIONS

The presence of LFR in pT1CRC may be associated with a low risk of LNM. In patients with pT1CRC with LFR, follow-up without additional surgery is possible even if the submucosal invasion depth is ≥1000 μm.

Advances in Endoscopic Resection

This article provides an overview of recent advances in endoscopic resection techniques. It includes the brief overview of endoscopic submucosal dissection, regional differences in ESD indications, innovation of ESD techniques, and expansion to full-thickness resection. The article covers cold snare polypectomy for small polyps with tips, underwater endoscopic mucosal resection (U-EMR) for sessile lesions with tips and expanding role of U-EMR, and the key assistive techniques for ESD that have improved the safety and efficacy. Furthermore, it discusses the emerging field of endoscopic full-thickness resection including device-assisted and freehand exposure techniques.

Clinical outcome and long‑term prognosis after endoscopic submucosal dissection for colorectal tumors in patients aged 75 years or older: a retrospective observational study

PURPOSE

To determine the clinical outcomes of endoscopic submucosal dissection (ESD) for colorectal tumors in older patients and predictors of mortality.

METHODS

We retrospectively evaluated 207 lesions in 195 consecutive older patients aged ≥ 75 years who underwent ESD for colorectal tumors between January 2007 and December 2018. Outcomes of ESD were evaluated, and the prognosis was assessed in terms of both curability and the patient's baseline physical condition as determined by several indices. Cox regression analyses were performed to identify factors associated with reduced overall survival (OS).

RESULTS

Treatment outcomes included a median procedure time of 55 min, en bloc resection rate of 97%, histological en bloc resection rate of 92%, postoperative bleeding rate of 2.4%, and intraoperative perforation rate of 3.4%. Postoperative bleeding and intraoperative perforation could be treated conservatively. Delayed perforation occurred in one patient and required emergency surgery. Three-year OS was 99.4% and 5-year OS was 95.8%. Overall, three patients experienced recurrence (one local, two distant metastasis), and one patient died of primary cancer. Multivariate analysis identified the Charlson Comorbidity Index (CCI) score ≥ 3 as the only independent predictor of reduced OS (hazard ratio 4.26; 95% confidence interval 1.60-11.38; P = 0.004).

CONCLUSION

Our results suggest that colorectal ESD is safe and effective in older patients aged ≥ 75 years. There was a significant independent association of reduced OS with high CCI score, but not with curability by ESD. The CCI score should be considered when determining the indications for ESD in older patients.

Survival and Endoscopic/Clinical Features of Patients with Colorectal Cancer Resected by Cold Snare Polypectomy: The Importance of Chronic Kidney Disease

BACKGROUND AND AIMS

Colorectal polyps resected by cold snare polypectomy (CSP) are rarely diagnosed as colorectal cancer (CRC). We aimed to investigate the prevalence, clinical features, and prognosis of patients with CRC resected by CSP.

SUBJECTS

Patients with colorectal polyps treated with CSP between 2018 and 2022 were enrolled and regularly followed up (median observation period: 30.6 months). Logistic regression analysis and decision tree analysis were employed to investigate the clinical features of the patients.

RESULTS

A total of 5,064 colorectal polyps from 2,530 patients were resected by CSP. Of these, 0.24% were diagnosed as CRC; however, no patients died due to CRC. eGFR was an independent risk factor for the presence of CRC (unit 10, OR 0.716, 95%CI 0.525-0.973, P=0.0323) and its optimal cut-off value was 59.9 mL/min/1.73 m2. The decision-tree analysis revealed that 2.03% of patients with creatinine ≥ 1.0 mg/dL had CRC.

CONCLUSION

CRC was diagnosed in 0.24% of the polyps; however, no patients died due to CRC. eGFR <60 mL/min/1.73 m2 and creatinine >1.0 mg/dL were associated with CRC. Thus, colorectal polyps should be carefully examined in patients with chronic kidney disease.

Novel perfusion system using continuous liquid-suction catheter attachment in colorectal endoscopic submucosal dissection with water pressure method (with video)

Water pressure method (WPM) is useful for colorectal endoscopic submucosal dissection (ESD), characterized not only by underwater conditions but also by active water pressure via the waterjet function. However, the extension of the colorectum by injecting excess water and contaminating the operative field by stool and bleeding have been issues. This study aimed to evaluate the feasibility of a novel perfusion system using a continuous liquid-suction catheter attachment (CLCA) in colorectal ESD with WPM. We retrospectively reviewed cases in which the perfusion system was used in colorectal ESD with WPM between August 2022 and September 2023. We evaluated clinical characteristics, treatment outcomes, volume of injection by the waterjet function, volume of suction by the endoscope and CLCA, and concentration of floating matter in the operative field over time. Thirty-one cases were enrolled. The median lesion size was 30 (range, 15-100) mm. In all cases, en bloc resection was achieved without perforation. The median injection volume was 2312 (range, 1234-13,866) g. The median suction volumes by the endoscope and CLCA were 918 (range, 141-3162) and 1147 (range, 254-11,222) g, respectively. The median concentration of floating matter in the operative field (measured in 15 cases) was 15.3 (range, 7.3-112) mg/mL when the endoscope arrived at the lesion and 8.0 (range, 3.2-16) mg/mL after endoscopically washing at the beginning of the ESD. It ranged from 7.6 to 13.4 mg/dL every 20 min during ESD. This perfusion system could prevent the extension of the lumen and maintain a good field of view in colorectal ESD with WPM.

Efficacy of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulant therapy: Multicenter prospective study

OBJECTIVES

The high rate of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) in patients undergoing anticoagulant therapy remains a problem. Whether prophylactic clip closure reduces the rate of delayed bleeding in these patients is unclear. This study aimed to evaluate the efficacy of prophylactic clip closure in patients receiving anticoagulants.

METHODS

This multicenter prospective interventional trial was conducted at nine referral centers in Japan. Patients regularly taking anticoagulants, including warfarin potassium or direct oral anticoagulants, and undergoing ESD for colorectal neoplasms were enrolled. The discontinuation of anticoagulants was minimized according to recent guidelines. After the ESD, post-ESD ulcers were prophylactically closed using endoclips. The primary end-point was the incidence of delayed bleeding. The sample size was 45 lesions, and prophylactic clip closure was considered effective when the upper limit of the 90% confidence interval (CI) for delayed bleeding did not exceed 20%.

RESULTS

Forty-five lesions were used, and three were excluded. Complete closure was achieved in 41/42 lesions (97.6%). The overall delayed bleeding rate was low, at 4.9% (2/41; 90% [CI] 0.8-14.5), which was significantly lower than that at the prespecified threshold of 20% (P = 0.007). The median closure procedure time was 17 min, and the median number of clips was nine. No massive delayed bleeding requiring transfusion, interventional radiology, or surgery was observed, and no thromboembolic events were observed.

CONCLUSION

Prophylactic clip closure may reduce the risk of delayed bleeding following colorectal ESD in patients receiving anticoagulants.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (UMIN000036734).

Endoscopic removal of gastrointestinal lesions by using third space endoscopy techniques

The concept of submucosal space, or rather the "third space", located between the intact mucosal flap and the muscularis propria layer of the gastrointestinal tract, represents a tunnel that the endoscopist could use to perform interventions in the muscularis propria layer or breech it to enter the mediastinum or the peritoneal cavity without full thickness perforation. The tunnel technique can be used both for the removal of mucosal tumours, called endoscopic submucosal tunnel dissection (ESTD), for the removal of subepithelial tumours (SELs), called submucosal tunnelling endoscopic resection (STER), and for the removal of extra-luminal lesions (for example in the mediastinum or in the rectum), called submucosal tunnelling endoscopic resection for extraluminal tumours (STER-ET). Aim of this updated narrative review, is to summarize the evidences that analyses indications, and outcomes of tunnelling techniques for the treatment of above mentioned lesions.

Loop9 closure technique for mucosal defects after colorectal endoscopic submucosal dissection (with video)

Background and study aims Mucosal defect closure after colorectal endoscopic submucosal dissection (ESD) has the potential to reduce the occurrence of delayed adverse events (AEs) such as bleeding and perforation. This study aimed to assess the feasibility and effectiveness of the Loop9 method for closing mucosal defects following colorectal ESD. Patients and methods A retrospective single-center study was conducted using prospectively collected data from May 2020 to March 2023. Loop9 was deployed through a single instrument channel and anchored with clips at the defect site. Closure was accomplished by tightening the loop and deploying additional conventional clips as needed for complete closure. The primary outcome was complete closure rate, with secondary outcomes including the sustained closure rate at 4 to 5 days post-ESD, closed defect size, closure time, number of additional clips, and incidence of delayed AEs. Results This study included 118 cases. Complete closure was achieved in 96.6% of cases (114/118) with a sustained closure rate of 93.9% (107/114). The median size of the closed mucosal defects was 30 mm (interquartile range [IQR]: 25-38, range: 15-74). The median closure time was 14 minutes (IQR: 11.25-17), and the median number of additional clips deployed was six (IQR: 4-7). Stenosis requiring balloon dilatation was observed in one patient; however, there were no instances of post-ESD bleeding or delayed perforation. Conclusions The Loop9 method proved feasible and effective for closing mucosal defects following colorectal ESD, achieving high rates of complete and sustained closure.

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

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

Delays in definitive endoscopic resection of previously manipulated colorectal polyps as a risk factor for inferior resection outcomes

BACKGROUND AND AIMS

Manipulation of colorectal polyps by biopsy, incomplete resection, or tattoo placement under the lesion has been shown to cause submucosal fibrosis and associated inferior outcomes. The effect of delays between index manipulation and definitive resection on the incidence of fibrosis is unknown.

METHODS

Patients undergoing EMR of previously manipulated colorectal polyps ≥10 mm from 2016 to 2021 at a tertiary referral center were included. Time from index manipulation to definitive resection and the presence of fibrosis were noted. The effects of fibrosis on EMR outcomes were assessed.

RESULTS

Among 221 previously manipulated lesions (180 biopsy, 23 incomplete/failed resection, 1 tattoo under lesion, 17 multiple types of manipulation), 51 (23%) demonstrated fibrosis. Fibrotic lesions were found to have been resected significantly later than nonfibrotic lesions (76 vs 61 days; P = .014). In a multivariate analysis controlling for other predictors of fibrosis, each 2-week delay was associated with a 14% increase in the odds of fibrosis. Fibrotic lesions had inferior outcomes with a lower en-bloc resection rate (8% vs 24%; P = .014) and longer procedure time (71 vs 52 minutes; P < .001). Adverse event and recurrence rates were similar between groups.

CONCLUSIONS

Delays in definitive resection of previously manipulated polyps are associated with an increased incidence of fibrosis with time and associated inferior outcomes. Manipulation should be discouraged, and if it occurs, prompt referral and scheduling for definitive resection should be prioritized.

Development of a novel multipoint traction device for gastric and colorectal endoscopic submucosal dissection and evaluation of its efficacy and safety

BACKGROUND

Proper traction allows safer and easier endoscopic submucosal dissection; however, single-point traction may not be sufficient. In this study we assessed the safety, efficacy, and feasibility of our newly developed multipoint traction device.

METHODS

During an ex vivo study using a Konjac training model, two experts and two trainees resected 80 mock lesions of 20-mm diameter by performing endoscopic submucosal dissection with and without multipoint traction. The primary outcome was the success rate of the procedure involving traction. The secondary outcomes were the submucosal dissection time, dissection speed, and perforation during endoscopic submucosal dissection. During the in vivo study, to clarify the initial clinical outcomes, we used data from the electronic medical record of patients at our institution who underwent gastric and colorectal endoscopic submucosal dissection, which was performed by experts with our newly developed multipoint traction device, from March to December 2022.

RESULTS

The ex vivo study indicated that all traction procedures were successful. Higher resection speeds were observed with endoscopic submucosal dissection with traction than without traction (P < 0.001). Perforations were not observed. During the first in vivo clinical study, traction was feasible during 20 gastric and colorectal endoscopic submucosal dissection procedures. No adverse events occurred.

CONCLUSIONS

Our multitraction device can increase the submucosal dissection speed and simplify endoscopic submucosal dissection techniques, thus safely reducing technical challenges. The application of this device for endoscopic submucosal dissection could lead to safer and more efficient procedures. Clinical registration UMIN Clinical Trials Registry, Japan (registration number UMIN000053384).

Substratifying the risk of covert malignancy in significant rectal polyps: Outcomes from a specialist multidisciplinary team (MDT)

AIM

A treatment strategy for patients with a significant polyp or early colon cancer (SPECC) of the rectum presents a challenge due to the significant rate of covert malignancy and lack of standardized assessment. For this reason, NICE recommends multidisciplinary meetings to improve outcomes. The primary aim of the present study was to report the performance of our specialist early rectal cancer (SERC) multidisciplinary team (MDT) in correctly substratifying the risk of cancer and to discuss the limitations of staging investigations in those patients with "poor outcomes".

METHOD

This was a retrospective review of patients referred to our SERC MDT from 2014 to 2019. Lesions were assigned by the MDT to three pre-resection categories (low, intermediate, high) according to the risk of covert malignancy. Resection method and final histology were compared to the pre-resection categories.

RESULTS

Of 350 SPECC lesions, 174 were assessed as low-risk, 108 intermediate-risk and 68 high-risk. The cancer incidence was 4.8%, 8.3% and 53%, respectively (15.5% overall). Eight lesions were categorized as low-risk but following piecemeal resection were found to be malignant. Five lesions, three of which were categorized as high-risk, were ultimately benign following conventional surgery. One pT1sm1 cancer, removed by anterior resection, may have been treated by local excision.

CONCLUSION

A total of 83% of malignant polyps were triaged to an en bloc resection technique and surgical resection avoided for nearly all benign lesions. However, 12 patients from this cohort were deemed to have a poor outcome because of miscategorization. Further comparative research is needed to establish the optimum strategy for rectal SPECC lesion assessment.

ORIGINALITY STATEMENT

There is currently no consensus for staging significant polyps of the rectum. This paper reports the effectiveness of a specialist early rectal cancer MDT to correctly risk-stratify significant rectal polyps. It underscores the importance of accurate categorization for treatment decision-making, while acknowledging the limitations of current staging modalities.

Endoscopic submucosal dissection (ESD) for gastritis cystica profunda (GCP) with early gastric cancer: A propensity score matching analysis

Background and aim

Cystic dilatation of the gastric glands within the mucosal layer is the hallmark of the rare condition known as gastritis cystica profunda (GCP). Although it has been proved that GCP is the precursor lesion for early gastric cancer (EGC), the management strategy of GCP-related EGC is not well established.The purpose of this research was to determine if ESD is effective and safe for GCP-related EGC.

Methods

Patients with EGC who had ESD at Beijing Friendship Hospital between January 2015 and May 2023 were retrospectively included. All patients were divided into two groups: those with GCP-related EGC, and those with EGC alone. The two groups were matched 1:1 using the propensity score matching (PSM) method. Curative resection rate, postoperative adverse outcome rate (bleeding, perforation, stricture), and recurrence rate were the primary measures used to evaluate the efficacy and safety of ESD.

Results

There were a total of 386 participants (44 with GCP and 342 with EGC alone). Following PSM, 44 patients were paired and analyzed separately. Except for the presence of cysts in EUS (multiple/single/none cyst: 12/2/5 versus 1/0/25, P < 0.0001), there was no change in baseline characteristics, EUS appearance, or histology results between groups. Overall, there was no significant difference in curative resection rates between the GCP group (70.5 %) and the control group (81.8 %) (P = 0.211). Postoperative complications were comparative (9/44 vs 5/44, P = 0.244), as were rates of local recurrence (1/44 vs 0/44, P = 1.0), metachronous gastric cancer (1/44 vs 0/44, P = 1.0), and mortality (0/44 vs 0/44, P = 1.0).

Conclusions

Existence of cysts in EUS is a characteristic presentation to distinguish GCP-related EGC from EGC-alone lesions. ESD might be a safe and effective therapy for patients with GCP-related EGC.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Endoscopic Submucosal Dissection: A Safe and Effective Alternative to Surgical Intervention for Esophageal Hemangioma

BACKGROUND

Hemangiomas represent 3% of all benign esophageal tumors. Conventional esophagectomy is the standard treatment with its invasive nature and possible surgical complications. Now, less invasive techniques are used with better results. Endoscopic submucosal dissection (ESD) is one of the novel noninvasive methods used for en bloc removal of tumors. No available data about the use of ESD in removing esophageal hemangioma. Here, we studied the validity and safety of ESD as a minimally invasive procedure to remove esophageal hemangioma.

METHODS

Three patients were diagnosed with esophageal hemangioma and underwent ESD with en bloc resection. Endoscopic ultrasound (EUS) was performed before ESD to better evaluate the layer of origin and vascularity and guard against perforation. Patients were followed up postintervention to document possible complications.

RESULTS

Among the 3 studied patients, one presented with chronic abdominal pain, the second was complaining of dysphagia, and the third patient was diagnosed accidentally. Pathology reports confirmed the diagnosis of hemangiomas in all cases with no atypia and complete removal of the lesions. No complications were reported during the procedure or over the follow-up period.

CONCLUSIONS

ESD is a proper, minimally invasive method with good en bloc resection that can be used in cases of esophageal hemangiomas.

Endoscopic resection of large non-pedunculated colorectal polyps: current standards of treatment

Colorectal cancer is a significant public health concern, and large non-pedunculated colorectal polyps pose a substantial risk for malignancy and incomplete resection, which may lead to interval cancer. The choice of resection technique is influenced by various factors, including polyp size, morphology, location, submucosal invasion depth and endoscopist expertise. For non-cancerous superficial large non-pedunculated polyps, conventional hot or cold snare polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection are common techniques for non-surgical therapeutic endoscopic resection of these polyps. This manuscript provides a comprehensive review of literature on current endoscopic resection techniques for large non-pedunculated colorectal polyps, emphasising indications, advantages, limitations and outcomes.

The Risk of Metastatic Recurrence after Non-Curative Endoscopic Resection with Negative Deep Margins for Early Colorectal Cancer: Two-Center Retrospective Cohort Study

INTRODUCTION

Non-curative endoscopic resection of T1 colorectal cancer (CRC) carries a substantial risk of recurrence. However, previous studies have reported a significant proportion of cases in which the deep margin of endoscopic resection was positive for cancer due to the technical difficulties of colorectal endoscopic submucosal dissection (ESD). With the advancement of endoscopic technology and techniques resulting in the reduction of positive resection margins, it is important to reassess the long-term prognosis and major risk factors for recurrence in cases of negative deep margins.

METHODS

We conducted a retrospective cohort study of consecutive patients with T1 CRC who underwent endoscopic resection between January 2006 and December 2021 with negative deep margins. The histological findings of the resected specimens were analyzed to determine the risk factors associated with the primary outcomes of this study, including recurrence and cancer-related deaths.

RESULTS

The median age of the 190 patients was 70 years, of which 63% were male, and endoscopic treatment was performed in 64% by endoscopic mucosal resection and 36% by ESD. Eighty-two patients were in the curative resection (CR) group and 108 were in the non-curative resection (NCR) group, wherein the latter comprised 79 patients who underwent additional surgery (AS) and 29 patients who did not receive AS. Five-year recurrence-free survival rates were 98.4% (95% CI: 89.3-99.8) for CR, 98.3% (95% CI: 88.8-99.8) for NCR with AS, and 73.7% (95% CI: 46.5-88.5) for NCR without AS. Lymphatic invasion and budding grade 2/3 were the major risk factors for recurrence, with hazard ratios of 40.7 (p < 0.001) and 23.1 (p = 0.007), respectively. Of the patients in the NCR group without AS, the 5-year recurrence-free rate was 85.6% (95% CI: 52.5-96.3) if there were no major risk factors (i.e., no lymphatic invasion or budding grade 2/3) (n = 21), whereas the prognosis was poor in the presence of one or more of the major risk factors, with a median recurrence-free survival and disease-specific survival of 2.5 and 3.1 years, respectively (n = 8).

DISCUSSION

In endoscopically resected T1 CRC with negative deep margins, lymphatic invasion or budding grade 2/3 may indicate a higher risk of recurrence when followed up without AS.

Underwater versus conventional endoscopic mucosal resection for ≥10 mm sessile or flat colorectal polyps: A systematic review and meta-analysis

BACKGROUND AND AIM

Underwater endoscopic mucosal resection (UEMR) has been an emerging substitute for conventional EMR (CEMR). This systematic review and meta-analysis aimed at comparing the efficiency and safety of the two techniques for removing ≥10 mm sessile or flat colorectal polyps.

METHODS

PubMed, Cochrane Library and Embase databases were searched up to February 2023 to identify eligible studies that compared the outcomes of UEMR and CEMR. This meta-analysis was conducted on the en bloc resection rate, R0 resection rate, complete resection rate, procedure time, adverse events rate and recurrence rate.

RESULTS

Nine studies involving 1,727 colorectal polyps were included: 881 were removed by UEMR, and 846 were removed by CEMR. UEMR was associated with a significant increase in en bloc resection rate [Odds ratio(OR) 1.69, 95% confidence interval(CI) 1.36-2.10, p<0.00001, I2 = 33%], R0 resection rate(OR 1.52, 95%CI 1.14-2.03, p = 0.004, I2 = 31%) and complete resection rate(OR 1.67, 95%CI 1.06-2.62, p = 0.03, I2 = 0%) as well as a significant reduction in procedure time(MD ‒4.27, 95%CI ‒7.41 to ‒1.13, p = 0.008, I2 = 90%) and recurrence rate(OR 0.52, 95%CI 0.33-0.83, p = 0.006, I2 = 6%). Both techniques were comparable in adverse events rate.

CONCLUSION

UEMR can be a safe and efficient substitute for CEMR in removing ≥10 mm sessile or flat colorectal polyps. More studies verifying the advantages of UEMR over CEMR are needed to promote its application.

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.).

Predictors of severe submucosal fibrosis during endoscopic submucosal dissection in patients with ulcerative colitis: Retrospective cohort study

OBJECTIVES

Severe submucosal fibrosis is a crucial technical difficulty encountered during endoscopic submucosal dissection (ESD) in patients with ulcerative colitis (UC). We aimed to identify predictors of severe submucosal fibrosis in patients with UC.

METHODS

We retrospectively included 55 tumors resected using ESD from 48 consecutive patients with UC. We analyzed the clinicopathological characteristics and treatment outcomes between the F0/1 (none to mild submucosal fibrosis) group (n = 28) and F2 (severe submucosal fibrosis) group (n = 27).

RESULTS

No significant difference was found between the F0/1 and F2 groups in en bloc resection rate (100% vs. 96%, P = 0.49), the R0 resection rate (100% vs. 93%, P = 0.24), and the dissection speed (0.18 vs. 0.13 cm2 /min, P = 0.07). Intraoperative perforation was more common in the F2 group (30%) than in the F0/1 group (8%; P = 0.01). Multivariable analysis showed that a longer duration of UC (≥10 years; odds ratio [OR] 6.11; 95% confidence interval [CI] 1.20-31.03; P = 0.03) and scarring of background mucosa of the tumor (OR 39.61; 95% CI 3.91-400.78; P < 0.01) were independent predictors of severe submucosal fibrosis.

CONCLUSION

Long UC duration and scarring background mucosa were predictors of severe submucosal fibrosis associated with perforation during ESD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outline of Japanese Guidelines for Colorectal Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection with a Short Reference to the Western Recommendations

The Japan Gastroenterological Endoscopy Society published the latest English versions of the guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for colorectal neoplastic lesions and colorectal cold polypectomy in 2020 and 2022, respectively. In this article, I present a comprehensive overview of these guidelines, including a comparison with the Western recommendations.

Trends in colorectal cancer incidence according to an increase in the number of colonoscopy cases in Korea

BACKGROUND

The incidence of colorectal cancer (CRC) and preinvasive CRC (e.g., early colon cancer and advanced adenoma) is gradually increasing in several countries.

AIM

To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.

METHODS

This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC, and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies. Colonoscopy-related complications by age group were also determined.

RESULTS

The incidence of CRC showed a rapid increase, then decreased after 2012 in the 50-75 year-age group. During the study period, the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age. Since 2009, the increase has been rapid, showing a pattern similar to the increase in colonoscopies. The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007. The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.

CONCLUSION

The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed. As the risk of colonoscopy-related hospitalization and death is high in the elderly, if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75, colonoscopy-related complications can be reduced for those aged 76 years or over.

Risk factors of unintentional piecemeal resection in endoscopic mucosal resection for colorectal polyps ≥ 10 mm

This study aimed to investigate the lesion and endoscopist factors associated with unintentional endoscopic piecemeal mucosal resection (uniEPMR) of colorectal lesions ≥ 10 mm. uniEPMR was defined from the medical record as anything other than a preoperatively planned EPMR. Factors leading to uniEPMR were identified by retrospective univariate and multivariate analyses of lesions ≥ 10 mm (adenoma including sessile serrated lesion and carcinoma) that were treated with endoscopic mucosal resection (EMR) at three hospitals. Additionally, a questionnaire survey was conducted to determine the number of cases treated by each endoscopist. A learning curve (LC) was created for each lesion size based on the number of experienced cases and the percentage of uniEPMR. Of 2557 lesions, 327 lesions underwent uniEPMR. The recurrence rate of uniEPMR was 2.8%. Multivariate analysis showed that lesion diameter ≥ 30 mm (odds ratio 11.83, 95% confidence interval 6.80-20.60, p < 0.0001) was the most associated risk factor leading to uniEPMR. In the LC analysis, the proportion of uniEPMR decreased for lesion sizes of 10-19 mm until 160 cases. The proportion of uniEPMR decreased with the number of experienced cases in the 20-29 mm range, while there was no correlation between the number of experienced cases and the proportion of uniEPMR ≥ 30 mm. These results suggest that 160 cases seem to be the minimum number of cases needed to be proficient in en bloc EMR. Additionally, while lesion sizes of 10-29 mm are considered suitable for EMR, lesion sizes ≥ 30 mm are not applicable for en bloc EMR from the perspective of both lesion and endoscopist factors.

Endoscopic full-thickness resection versus endoscopic submucosal dissection for challenging colorectal lesions: a randomized trial

BACKGROUND AND AIMS

The optimal endoscopic resection method of challenging colorectal lesions (ie, adenomatous recurrences, nongranular laterally spreading tumors [LST-NGs], lesions without lifting sign <30 mm) is still under debate. The aim of this study was to directly compare endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) for the resection of challenging colorectal lesions in a randomized trial.

METHODS

A multicenter, prospective, randomized study was performed in 4 Italian referral centers. Consecutive patients referred for endoscopic resection of challenging lesions were randomly assigned to undergo EFTR or ESD. Primary outcomes were complete (R0) resection and en bloc resection of lesions. Technical success, procedure time, procedure speed, area of the resected specimen, adverse event rate, and local recurrence rate at 6 months were also compared.

RESULTS

Overall, 90 patients were included in the study, equally representing the 3 challenging lesion types. Age and sex were comparable in the 2 groups. En bloc resection was obtained in 95.5% of the EFTR group and in 93.3% of the ESD group. R0 resection rate was comparable in the 2 groups (EFTR vs ESD, 42 [93.3%] vs 36 [80%]; P = .06). The EFTR group exhibited a significantly shorter total procedure time (25.6 ± 10.6 minutes vs 76.7 ± 26.4 minutes, P ≤ .01), as well as overall procedure speed (16.8 ± 11.8 mm2/min vs 11.9 ± 9.2 mm2/min, P = .03). The EFTR group had a significantly smaller mean lesion size (21.6 ± 8.3 mm vs 28.7 ± 7.7 mm, P ≤ .01). Adverse events were reported less frequently in patients in the EFTR group (4.44% vs 15.5%, P = .04).

CONCLUSIONS

EFTR is comparable to ESD in the treatment of challenging colorectal lesions in terms of safety and efficacy. EFTR is considerably faster than ESD in the treatment of nonlifting lesions and adenoma recurrences. (Clinical trial registration number: NCT05502276.).

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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