Endoscopic submucosal dissection in the West: Current status and future directions

Minimally invasive robotic ureteral reconstruction using endoscopic submucosal dissection harvested colorectal mucosa graft for ureteral stricture

To evaluate the feasibility and safety of using colorectal mucosal grafts (CMG) harvested via endoscopic submucosal dissection (ESD) for ureteral reconstruction in patients with ureteral stricture. Eight patients with ureteral stricture underwent robotic ureteral reconstruction using CMG harvested by ESD. Preoperative assessments included clinical history, physical examination, and various imaging studies. The ESD procedure was performed with standard precautions to obtain sufficient graft material. Postoperative follow-up involved endoscopic examinations and retrograde pyelograms to assess colorectal complication and ureteral patency. The average age of patients was 44 years, and the median BMI was 24.6 kg/m². The causes of stricture included ureteral stones, urinary tract infections, and ureteral polyps. The median stricture length was 3.5 cm. The average size of the harvested CMG was 4 × 2.4 cm. The success rate of the grafting procedure was 100%, with no gastrointestinal complications observed. Endoscopic examination one week postoperatively revealed well-healed wounds. No recurrent ureteral strictures were noted during a median follow-up period of 5 months. The average glomerular filtration rate (GFR) of the affected kidneys was 61 ml/min. Harvesting CMG via ESD for ureteral reconstruction is feasible and safe, with minimal complications and promising short-term outcomes. This technique provides a viable alternative for patients contraindicated for oral mucosal grafts, potentially reducing morbidity associated with traditional intestinal mucosa harvesting methods.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Approaches and considerations in the endoscopic treatment of T1 colorectal cancer

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

Traction-Assisted Endoscopic Submucosal Dissection of a Gastric Subepithelial Tumor: A Case Report

Endoscopic submucosal dissection (ESD) is considered curative for patients with early gastrointestinal cancers. However, it is a technically challenging procedure that can be time-consuming and associated with complications such as bleeding and perforation. Traction devices and techniques have been developed to mitigate these risks and reduce procedure times. Most traction devices are unavailable in New Zealand, and traction techniques have not been widely utilized due to the precision required for successful outcomes. We report the first case of traction-assisted ESD performed in New Zealand for a gastric submucosal tumor. The procedure was successfully performed using the clip with rubber band traction technique. The lesion was resected en bloc, and histology confirmed an R0, curative resection. There were no complications, and the total procedure time was 54 minutes. In conclusion, traction techniques can be effectively employed for ESD in lesions with difficult submucosal access. They contribute to safer dissections and reduced procedure times.

Innovative submucosal injection solution for endoscopic resection with phosphorylated pullulan: a preclinical study

BACKGROUND AND AIMS

A submucosal injection solution is used to assist in endoscopic surgery. The high viscosity of current solutions makes them difficult to inject. In the present study, we developed an extremely low-viscosity, easy-to-use submucosal injection solution using phosphorylated pullulan (PPL).

METHODS

The PPL solutions were prepared at different concentrations, and their viscosities were measured. The mucosal elevation capacity was evaluated using excised porcine stomachs. Controls included 0.4% sodium hyaluronate (SH), 0.6% sodium alginate (SA), and saline. To evaluate the practicality, the catheter injectability of 0.7% PPL was measured, and EMR and endoscopic submucosal dissection (ESD) were performed using the stomach and colorectum of live pigs. As controls, 0.4% SH and saline were used.

RESULTS

The PPL solutions were of extremely low viscosity compared to the solutions of 0.4% SH and 0.6% SA. Nevertheless, the mucosal elevation capacity of PPL solutions for up to 0.7% concentration was similar to that of 0.4% SH, and 0.7% PPL was less resistant to catheter infusion than 0.4% SH and 0.6% SA. In live pig experiments with endoscopic mucosal resection and ESD, snaring after submucosal injection of 0.7% PPL was easier than with 0.4% SH, ESD with 0.7% PPL produced less bubble formation than with 0.4% SH, and the procedure time tended to be shorter with 0.7% PPL than with 0.4% SH because of the shorter injection time.

CONCLUSIONS

The PPL solution is an innovative and easy-to-use submucosal injection solution.

Implementation of esophageal endoscopic submucosal dissection in Spain: Results from the nationwide registry

INTRODUCTION AND AIMS

The outcomes of endoscopic submucosal dissection (ESD) in the esophagus have not been assessed in our country. Our primary aim was to analyze the effectiveness and safety of the technique.

MATERIAL AND METHODS

Analysis of the prospectively maintained national registry of ESD. We included all superficial esophageal lesions removed by ESD in 17 hospitals (20 endoscopists) between January 2016 and December 2021. Subepithelial lesions were excluded. The primary outcome was curative resection. We conducted a survival analysis and used logistic regression analysis to assess predictors of non-curative resection.

RESULTS

A total of 102 ESD were performed on 96 patients. The technical success rate was 100% and the percentage of en-bloc resection was 98%. The percentage of R0 and curative resection was 77.5% (n=79; 95%CI: 68%-84%) and 63.7% (n=65; 95%CI: 54%-72%), respectively. The most frequent histology was Barrett-related neoplasia (n=55 [53.9%]). The main reason for non-curative resection was deep submucosal invasion (n=25). The centers with a lower volume of ESD obtained worse results in terms of curative resection. The rate of perforation, delayed bleeding and post-procedural stenosis were 5%, 5% and 15.7%, respectively. No patient died or required surgery due to an adverse effect. After a median follow-up of 14months, 20patients (20.8%) underwent surgery and/or chemoradiotherapy, and 9 patients died (mortality 9.4%).

CONCLUSIONS

In Spain, esophageal ESD is curative in approximately two out of three patients, with an acceptable risk of adverse events.

Endoscopic submucosal dissection vs transanal endoscopic surgery for rectal tumors: A systematic review and meta-analysis

BACKGROUND

Endoscopic submucosal dissection (ESD) and transanal endoscopic submucosal dissection (TES) are widely employed surgical techniques. However, the comparative efficacy and safety of both remain inconclusive.

AIM

To comprehensively analyze and discern differences in surgical outcomes between ESD and TES.

METHODS

We conducted a systematic search of the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus, and CINAHL from inception till August 2023. We analyzed outcomes including recurrence rate, en bloc resection, R0 resection rate, perforation rate, procedure length, and hospital stay length applying a random-effects inverse-variance model. We assessed publication bias by conducting an Egger's regression test and sensitivity analyses.

RESULTS

We pooled data from 11 studies involving 1013 participants. We found similar recurrence rates, with a pooled odds ratio of 0.545 (95%CI: 0.176-1.687). En bloc resection, R0 resection, and perforation rate values were also similar for both ESD and TES. The pooled analysis for procedure length indicated a mean difference of -4.19 min (95%CI: -22.73 to 14.35), and the hospital stay was on average shorter for ESDs by about 0.789 days (95%CI: -1.671 to 0.093).

CONCLUSION

Both ESD and TES displayed similar efficacy and safety profiles across multiple outcomes. Our findings show that individualized patient and surgeon preferences, alongside specific clinical contexts, can be considered when selecting between these two techniques.

Predictors of long-term outcomes of endoscopic submucosal dissection of early gastric neoplasia in the West: a multicenter study

BACKGROUND

This study aimed to determine long-term outcomes of gastric endoscopic submucosal dissection (ESD) in Western settings based on the latest Japanese indication criteria, and to examine predictors of outcomes and complications.

METHODS

Data were collected from consecutive patients undergoing gastric ESD at four participating centers from 2009 to 2021. Retrospective analysis using logistic regression and survival analysis was performed.

RESULTS

415 patients were included (mean age 71.7 years; 56.4 % male). Absolute indication criteria (2018 guideline) were met in 75.3 % of patients. Median follow-up was 52 months. Post-resection histology was adenocarcinoma, high grade dysplasia, and low grade dysplasia in 49.9 %, 22.7 %, and 17.1 %, respectively. Perforation, early and delayed bleeding occurred in 2.4 %, 4.3 %, and 3.4 %, respectively. Rates of en bloc and R0 resection, and recurrence on first endoscopic follow-up were 94.7 %, 83.4 %, and 2.7 %, respectively. Relative indication (2018 guideline) for ESD was associated with R1 outcome (P = 0.02). Distal location (P = 0.002) and increased procedure time (P = 0.04) were associated with bleeding, and scarring (P = 0.009) and increased procedure duration (P = 0.003) were associated with perforation. Recurrence-free survival at 2 and 5 years was 94 % and 83 %, respectively.

CONCLUSION

This is the largest Western multicenter cohort and suggests that gastric ESD is safe and effective in the Western setting. A quarter of patients fell outside the new absolute indications for ESD, suggesting that Western practice involves more advanced lesions. We identified the predictors of complications, which should help to inform future Western practice and research.

Is colorectal endoscopic submucosal dissection safe and effective for 15-19-mm tumors?

PURPOSE

The outcomes of colorectal endoscopic submucosal dissection (ESD) in 15-19-mm tumors are unclear. This study compared the effectiveness and safety of colorectal ESD for 15-19-mm tumors and tumors exceeding that size.

METHODS

From August 2018 to December 2020, 213 cases of colorectal tumors removed by colorectal ESD at a tertiary hospital were enrolled in this study. The cases were divided into two groups according to the pathologically measured size of the resected lesion: an intermediate group (15-19 mm, n = 62) and a large group (≥ 20 mm, n = 151). The en bloc resection rate, complete resection rate, and complications were investigated retrospectively.

RESULTS

The en bloc resection rate was significantly higher in the intermediate than large group (100% vs. 94%, p = 0.049), and the mean total procedure time was shorter in the intermediate than large group (29.2 [Formula: see text] 12.6 vs. 48.4 [Formula: see text] 28.8 min, p < 0.001). However, the mean procedure speed was significantly lower in the intermediate than large group (0.25 [Formula: see text] 0.10 vs. 0.28 [Formula: see text] 0.11 cm2/min, p = 0.031). The complete resection rate, post-procedural bleeding, and perforation rate were not significantly different between the two groups. In multivariate analyses, the total procedure time and mean procedure speed were significantly associated with lesion size.

CONCLUSION

Colorectal ESD of 15-19-mm lesions is effective, and has a shorter procedure time and higher en bloc resection rate than the same procedure for larger lesions.

Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers

Background and study aims Overcoming logistical obstacles for the implementation of colorectal endoscopic submucosal dissection (ESD) requires accurate prediction of procedure times. We aimed to evaluate existing and new prediction models for ESD duration. Patients and methods Records of all consecutive patients who underwent single, non-hybrid colorectal ESDs before 2020 at three Dutch centers were reviewed. The performance of an Eastern prediction model [GIE 2021;94(1):133-144] was assessed in the Dutch cohort. A prediction model for procedure duration was built using multivariable linear regression. The model's performance was validated using internal validation by bootstrap resampling, internal-external cross-validation and external validation in an independent Swedish ESD cohort. Results A total of 435 colorectal ESDs were analyzed (92% en bloc resections, mean duration 139 minutes, mean tumor size 39 mm). The performance of current unstandardized time scheduling practice was suboptimal (explained variance: R 2 =27%). We successfully validated the Eastern prediction model for colorectal ESD duration <60 minutes (c-statistic 0.70, 95% CI 0.62-0.77), but this model was limited due to dichotomization of the outcome and a relatively low frequency (14%) of ESDs completed <60 minutes in the Dutch centers. The model was more useful with a dichotomization cut-off of 120 minutes (c-statistic: 0.75; 88% and 17% of "easy" and "very difficult" ESDs completed <120 minutes, respectively). To predict ESD duration as continuous outcome, we developed and validated the six-variable cESD-TIME formula ( https://cesdtimeformula.shinyapps.io/calculator/ ; optimism-corrected R 2 =61%; R 2 =66% after recalibration of the slope). Conclusions We provided two useful tools for predicting colorectal ESD duration at Western centers. Further improvements and validations are encouraged with potential local adaptation to optimize time planning.

Endoscopic Submucosal Dissection, Endoscopic Mucosal Resection, and Transanal Minimally Invasive Surgery for the Management of Rectal and Anorectal Lesions: A Narrative Review

Endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and transanal minimally invasive surgery (TAMIS) are modern techniques that now play a crucial role in the treatment of colorectal lesions. ESD is a minimally invasive endoscopic procedure that allows for the resection of lesions of any size in a single piece, with clear advantages regarding oncological outcomes and recurrences. However, it is a complex technique, requiring high endoscopic skills, expertise, and specialized training, with higher rates of adverse events expected compared with EMR. EMR is another endoscopic technique used to remove superficial gastrointestinal tumors, particularly those that are limited to the mucosal layer. It is a faster and more accessible procedure, with fewer adverse events, although it only allows for an en-bloc resection of lesions measuring 15-20 mm. TAMIS is a minimally invasive surgical technique used to remove rectal tumors, involving the insertion of a single-port device through the anus, allowing for a better visualization and removal of the tumor with minimal disruption. This article reviews the current applications and evidence regarding these techniques, in search for the most adequate treatment for the removal of lesions in the rectum and anorectal junction, as these locations possess distinct characteristics that demand a more specific approach.

Difficult colorectal polypectomy: Technical tips and recent advances

Colonoscopy has been shown to be an effective modality to prevent colorectal cancer (CRC) development. CRC reduction is achieved by detecting and removing adenomas, which are precursors of CRC. Most colorectal polyps are small and do not pose a significant challenge for trained and skilled endoscopists. However, up to 15% of polyps are considered "difficult", potentially causing life-threatening complications. A difficult polyp is defined as any polyp that is challenging for the endoscopist to remove owing to its size, shape, or location. Advanced polypectomy techniques and skills are required to resect difficult colorectal polyps. There were various polypectomy techniques for difficult polyps such as endoscopic mucosal resection (EMR), underwater EMR, Tip-in EMR, endoscopic submucosal dissection (ESD), or endoscopic full-thickness resection. The selection of the appropriate modality depends on the morphology and endoscopic diagnosis. Several technologies have been developed to aid endoscopists in performing safe and effective polypectomies, especially complex procedures such as ESD. These advances include video endoscopy system, equipment assisting in advanced polypectomy, and closure devices/techniques for complication management. Endoscopists should know how to use these devices and their availability in practice to enhance polypectomy performance. This review describes several useful strategies and tips for managing difficult colorectal polyps. We also propose the stepwise approach for difficult colorectal polyps.

Advancing endoscopic traction techniques in endoscopic submucosal dissection

Traction techniques have emerged as a desirable "second-hand" while performing endoscopic submucosal dissection (ESD), enabling adequate visualization of submucosal tissue and vasculature, which allows for safe and efficient dissection. Multiple traction techniques have been developed over the years, and these can be broadly divided into internal and external traction techniques. This arsenal of techniques allows for traction that is personalized to the location of the lesion undergoing ESD. Mastering traction techniques requires structured training, and understanding of the benefits and pitfalls of each technique. Future research and development efforts need to focus on pathways and curriculums for trainees to master the currently available endoscopic traction techniques and provide avenues for the development of newer traction modalities.

Kolorektal lateral yayılımlı tümörlerde başarısız endoskopik mukozal rezeksiyon sonrası endoskopik submukozal diseksiyonun uygulanabilirliği: tek merkez deneyimi

Aim: Endoscopic mucosal resection might technically be unsuccessful (interrupted endoscopic mucosal resection) in some cases when treating large colorectal laterally spreading tumors. In the literature, data on the outcomes of the endoscopic submucosal dissection method in endoscopic mucosal resection interrupted tumors are lacking. In this study, we evaluated the results of patients who underwent endoscopic submucosal dissection for endoscopic mucosal resection interrupted laterally spreading tumors. Materials and Methods: Between February 2019 and April 2021, 8 patients with endoscopic mucosal resection interrupted colorectal laterally spreading tumors underwent endoscopic submucosal dissection. The primary endpoint was en bloc, R0, and curative resection rates of endoscopic submucosal dissection. Results: In all cases, endoscopic submucosal dissection was successfully completed. The mean tumor size was 61.5 mm (35–100 mm). The rate of en bloc resection, R0 resection and curative resection was 100%, 87.5% and 87.5% respectively. Intra-procedural perforation occurred in 1 patient (12.5%) and was successfully treated with clip application. Delayed bleeding occurred in 1 patient (12.5%), and was successfully treated with endoluminal hemostasis. Furthermore, histopathological examination revealed that laterally spreading tumors in 4 patients (50.0%) had submucosal invasion. Surgical resection was performed after endoscopic submucosal dissection in 1 patient owing to the presence of deep submucosal invasion. Conclusion: Endoscopic submucosal dissection is an effective and relatively safe method in endoscopic mucosal resection interrupted colorectal laterally spreading tumors.

The usefulness of combining the pocket-creation method with a traction device using a scissor-type knife for colorectal endoscopic submucosal dissection

INTRODUCTION

Technical issues and long procedure time still remain a concern in colorectal endoscopic submucosal dissection (ESD). We examined the usefulness of combining the pocket-creation method (PCM) with a traction device (S-O clip; SO) using a scissor-type knife (Clutch Cutter 3.5 mm; CC) for decreasing ESD procedure time.

METHODS

We retrospectively analyzed 95 ESD cases of PCM + SO + CC managed from August 2017 to April 2020 and 103 cases of PCM + CC treated from July 2016 to July 2017. We compared these two groups through propensity score matching. The main outcome was the analysis of the ESD procedure times under various conditions in each group.

RESULTS

After matching, 52 cases in the PCM + SO + CC and PCM + CC groups were analyzed. The PCM + SO + CC group showed a significantly shorter ESD procedure time than the PCM + CC group (57.8 ± 31.4 vs. 81.7 ± 33.5 min, p < 0.01). Additionally, the ESD procedure time was significantly shorter in the PCM + SO + CC group than in the PCM + CC group: tumor size (tumor size < 40 mm: 45.6 ± 15.8 vs. 72.7 ± 22.9 min, p < 0.01; tumor size ≥ 40 mm: 83.1 ± 40.1 vs. 111.8 ± 45.3 min, p = 0.04), tumor location (right side: 64.7 ± 33.3 vs. 81.0 ± 29.7 min, p = 0.03; left side: 50.5 ± 28.0 vs. 82.3 ± 36.9 min, p < 0.01), tumor morphology (polypoid: 39.2 ± 18.6 vs. 74.7 ± 28.6 min, p < 0.01; nonpolypoid: 62.3 ± 32.3 vs. 84.5 ± 35.2 min, p < 0.01), endoscopist (expert: 67.3 ± 41.2 vs. 91.9 ± 40.2 min, p = 0.02; nonexpert: 50.4 ± 18.3 vs. 73.6 ± 24.9 min, p < 0.01), and fibrosis (severe fibrosis: 82.0 ± 20.5 vs. 99.8 ± 40.4 min, p = 0.169; non-severe fibrosis: 52.1 ± 23.8 vs. 75.6 ± 29.0 min, p < 0.01).

CONCLUSIONS

The combination of the PCM and SO using CC achieved a reduction in the colorectal ESD procedure time.

Biological and clinical implications of hsa_circ_0086720 in gastric cancer and its clinical application

Background

Circular RNAs (circRNAs) are thought to be vital participants in carcinogenesis and have the characteristics of being stable, specific, and well conserved. However, their clinical significance and application value in gastric cancer (GC) are still poorly understood. Hsa_circ_0086720 was found to be a dysregulated circRNA in GC by microarray screening and was further explored for its clinical significance and application.

Methods

Hsa_circ_0086720 was detected in GC cell lines, tissues, and plasma, and the clinicopathological correlations were investigated. The existence, stability, origin, and change in the plasma hsa_circ_0086720 level were verified in early GC patients. Moreover, receiver operating characteristic and Kaplan–Meier survival curves were constructed to analyze the diagnostic and prognostic values, and bioinformatics analysis was used to identify the potential functions. Finally, risk factors and nomogram predicting were established.

Results

Hsa_circ_0086720 was found to be downregulated in gastric carcinogenesis, and tissue hsa_circ_0086720 was negatively associated with perineural invasion, Borrmann type, disease‐free survival, and overall survival. Hsa_circ_0086720 was stable in circulating plasma and was actively secreted by cells in gastric carcinogenesis. As a biomarker for early GC screening, plasma hsa_circ_0086720 had good sensitivity and specificity, and its stability met the clinical application requirements. Bioinformatics analysis suggested that dysregulated hsa_circ_0086720 has important functions in gastric carcinogenesis. Univariate Cox regression analysis identified factors associated with overall survival time and disease‐free survival time. The nomograms showed good accuracy of predicting survival time.

Conclusion

Hsa_circ_0086720 is a novel biomarker for screening early GC and predicting the prognosis of advanced‐stage patients.

A novel flexible auxiliary single-arm transluminal endoscopic robot facilitates endoscopic submucosal dissection of gastric lesions (with video)

BACKGROUND

Using conventional endoscope to perform endoscopic submucosal dissection (ESD) is difficult because of the one-handed operation and blind dissection caused by gravity. Poor visualization of the submucosal plane causes ESD to be associated with a high risk of bleeding and perforation. This study aimed to develop a novel ESD-assistive robot system and to evaluate its efficacy.

METHODS

A novel flexible auxiliary single-arm transluminal endoscopic robot (FASTER) was developed. A total of 36 artificial lesions in ex vivo porcine stomachs were removed using the FASTER-assisted ESD method (n = 18) and the conventional ESD method (n = 18). Lesions were 2 cm or 4 cm in diameter, located on the anterior and posterior walls of the antrum. Primary outcome measurements were dissection time and dissection speed.

RESULTS

The dissection time in FASTER-assisted ESD was significantly shorter than that in conventional ESD (7 min vs 13 min, p = 0.012), mainly because of the faster dissection speed (148.6 vs 97.0 mm²/min, p = 0.002). The total procedure time in FASTER-assisted ESD was shorter than that in conventional ESD, but the difference was not significant (16 min vs 24 min, p = 0.252). Complete en bloc resection was achieved in all lesions. No perforations were detected. The FASTER exhibited the ability of regrasp, multidirectional traction, and proper tension control during ESD.

CONCLUSION

FASTER significantly increased the dissection speed by providing proper traction and achieving good submucosal vision. This new device is expected to facilitate ESD in clinical practice.

Validation of the BEST-J score, a prediction model for bleeding after endoscopic submucosal dissection for early gastric cancer: a multicenter retrospective observational study

BACKGROUND

A new scoring system, the BEST-J score, using ten risk factors to assign cases to different post-endoscopic submucosal dissection (ESD) risk groups for bleeding, has been shown to be accurate for risk stratification. We first aimed to validate the BEST-J score at four hospitals not specialized in performing ESD and then aimed to identify other risk factors for post-ESD bleeding.

METHODS

We evaluated the incidence of post-ESD bleeding in 791 cases of early gastric cancer (EGC) between October 2013 and December 2020 as a retrospective, multi-center observational study conducted at four hospitals. Multivariate logistic regression models to examine the effect of independent variables on post-ESD bleeding firstly included ten possible factors raised by the BEST-J score and secondly included statistically significant (p < 0.01) in univariate analysis. The prediction accuracy of the model was evaluated by receiver-operating characteristic analysis and the areas under the curve (AUC).

RESULTS

The incidence of post-ESD bleeding was 4.8% (38/791, 95% confidence interval [CI] 3.4-6.5%). On multivariate analysis, the risk factors were P2Y12 receptor antagonist (odds ratio [OR]: 5.870, 95% CI 1.624-21.219), warfarin (8.382, 1.658-42.322), direct oral anticoagulant (DOAC) (8.980, 1.603-50.322), and tumor location in lower third of stomach (2.151, 1.012-4.571), respectively. When we categorized cases into low-risk by BEST-J score, intermediate-risk, high-risk, and very high-risk groups, the bleeding rates were 2.8%, 7.3%, 12.8%, and 19.0%, respectively. The AUC for our cohort was 0.713 (95% CI 0.625-0.802) for the BEST-J score. In the multivariate analysis in our cohort, the risks were age, body mass index, P2Y12 receptor antagonist, warfarin, DOAC, respectively.

DISCUSSION

The BEST-J score is equally accurate in risk stratification of patients with EGC for post-ESD bleeding at non-specialized facilities for ESD as in specialized hospitals. BMI and age may be helpful additional risk factors at hospitals not specialized.

Gastric endoscopic submucosal dissection in Western countries: Indications, applications, efficacy and training perspective

Endoscopic submucosal dissection was introduced in Japan for the mini-invasive treatment of early gastric cancer, as part of national screening program considering high prevalence of disease in these latitudes. This technique allows en-bloc curative oncological excision and to obtain in a single step R0-resection, characterization, histological staging and potential cure of the tumor with a very high cost-benefit balance. Over the years, Western endoscopists have adopted endoscopic submucosal dissection, achieving good rates of efficacy, long-term improved outcomes and safety, with low risk of local recurrence comparable to those obtained in Asian institutes. However, according to some authors, the excellent outcomes from East country could not be representative of the Western experience. Despite epidemiological differences of early gastric cancer, scant volume data and limitations in training opportunities between Western and Eastern countries, European Society of Gastrointestinal Endoscopy have adopted Japanese guidelines and developed a European core curriculum for endoscopic submucosal dissection training. Endoscopists should be able to estimate the probability of performing a curative resection by considering the benefit/risk relationship case-by-case in order to implement a correct decision-making process.

Comparison of sodium alginate-based and sodium hyaluronate-based submucosal injection materials based on rheological analysis

As a viscous high-performance submucosal injection material (SIM) used in endoscopic submucosal dissection (ESD), sodium alginate-based SIM (SA-SIM) was recently introduced as high-performance SIM equivalent to sodium hyaluronate-based SIM (HA-SIM) in Japan. However, a comprehensive, detailed comparison of SA and HA is yet to be performed. In this study, we precisely measured the viscoelastic properties, submucosal elevation height (SEH), and injection pressure (IP). Furthermore, we compared the outcomes of ESD using an ex vivo ESD model. There was no significant difference in SEHs between HA-SIM and SA-SIM at all post-injection times, and the IP of the SA-SIM injection was significantly higher than that of the HA-SIM injection in all conditions (P < 0.0001). The viscosity at high shear rates of SA-SIM was higher than that of HA-SIM; this result was consistent with SEH/IP measurement results. No significant difference was observed in ESD procedure time and total volume of injected SIM between HA-SIM and SA-SIM (18.1 ± 6.7 and 17.8 ± 6.0 min, P = 0.8987; 13.3 ± 5.3 and 11.6 ± 5.9 ml, P = 0.4658, respectively). Although SA-SIM was slightly more difficult to inject than HA-SIM, there was no significant difference in performance between the materials. Thus, this basic study demonstrated that SA-SIM can be used for endoscopic treatment as well as HA-SIM, and supported previous clinical research data.

Advances in endoscopic therapy using grasping-type scissors forceps (with video)

Endoscopic submucosal dissection (ESD) is a globally accepted minimally invasive therapy for early-stage gastrointestinal tract tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. The grasping-type scissors forceps [clutch cutter (CC)] is the first forceps-type resection device developed with reference to hemostatic forceps. The aim was to allow easy and safe ESD throughout the gastrointestinal tract, as a biopsy technique, using one device. The CC can grasp the target tissue accurately and pull it away from the underlying muscle layer prior to energizing the tissue, for safe and effective incision and hemostasis during ESD. Reported clinical studies showed that ESD using the CC (ESD-CC) is a safe (perforation rate: 0%-3.6%; delayed bleeding rate: 0%-4.2%), technically efficient (en-bloc resection rate: 88.9%-100%), and single-device method for dissecting early-stage gastrointestinal tract tumors. The ESD-CC technique is simple and easy to learn because it can be completed simply by repeating the grasp, pull, and coagulate and/or incise actions using an electrosurgical current. The reported self-completion rate by non-experts was significantly better with the CC than with conventional knives (61.7% vs 24.5%, respectively; P < 0.001). Furthermore, the CC is used for other endoscopic therapies, such as endoscopic polypectomy for large pedunculated polyps, endoscopic myotomy for Zenker’s diverticulum, endoscopic treatment of buried bumper syndrome, and endoscopic necrosectomy for wall-off pancreatic necrosis. The initial reports using CC for these therapies have shown favorable results. In this review, we describe the structural features of the CC, how to use the instrument, efficacies of ESD-CC, and other unique endoscopic therapies using the CC.

Prediction Model of Lymph Node Metastasis Risk in Elderly Patients with Early Gastric Cancer before Endoscopic Resection: A Retrospective Analysis Based on International Multicenter Data

Background: Patients with early gastric cancer (EGC) must suffer reoperation if diagnosed with a high possibility of lymph node (LN) metastasis. The purpose of the current study was to develop and validate a model to predict the risk of LN metastasis in elderly patients before endoscopic resection.

Methods: A total of 1911 EGC patients who had undergone radical surgery were selected and assigned randomly (2:1) to either the training cohort or the validation cohort. A nomogram was established based on the univariate and multivariate logistic regression models using the training cohort. Cox proportional hazards regression models were applied to identify the prognostic factors in univariate and multivariable analyses.

Results: Three variables—tumor size, grade, and T stage—were derived from the multivariate analyses in the training cohort and incorporated into the nomogram. The AUC of the nomogram was 0.732 in the training cohort and 0.706 in the validation cohort. There were significant differences in survival among patients with different degrees of LN metastasis risk (training cohort: five-year disease-specific survival (DSS): low risk 88.1% vs. moderate risk 80.0% vs. high risk 72.9%, P < 0.001; validation cohort five-year DSS: low risk 89.0% vs. moderate risk 84.3% vs. high risk 72.2%, P < 0.001). The LN metastasis risk assessed from the model was also an independent prognostic factor.

Conclusion: We established a nomogram that accurately predicts LN metastasis risk for elderly patients with EGC before endoscopic resection to avoid further injury from reoperation.

ENDOSCOPIC SUBMUCOSAL DISSECTION WITH CIRCUMFERENTIAL INCISION VERSUS TUNNELING METHOD FOR TREATMENT OF SUPERFICIAL ESOPHAGEAL CANCER

BACKGROUND

Endoscopic submucosal dissection (ESD) of esophageal superficial neoplasm is associated with a high en bloc R0 resection rate and low recurrence.

OBJECTIVE

We aim to compare the performance and clinical outcomes of ESD via ESD after circumferential incision (ESD-C) versus submucosal tunneling (ESD-T).

METHODS

Single-center retrospective analysis of all consecutive patients who underwent ESD for superficial esophageal cancer, between 2009 and 2018. ESD-T was defined as the technique of making the mucosal incisions followed by submucosal tunneling in the oral to anal direction. ESD-C consisted of completing a circumferential incision followed by ESD. Main study outcomes included en bloc and R0 resection rates. Secondary outcomes included procedural characteristics, curative resection rate, local recurrence and adverse events.

RESULTS

A total of 65 procedures (23 ESD-T and 42 ESD-C) were performed for ESCC (40; 61.5%) and BE-neoplasia (25; 38.5%). There were no statistically significant differences between patients who underwent ESD-T versus ESD-C in en bloc (91.3% vs 100%, P=0.12), R0 (65.2% vs 78.6%, P=0.24), curative resection rates (65.2% vs 73.8%, P=0.47) and mean procedure time (118.7 min with vs 102.4 min, P=0.35). Adverse events for ESD-T and ESD-C were as follows: bleeding (0 versus 2.4%; P=0.53), perforation (4.3% vs 0; P=0.61), esophageal stricture (8.7% versus 9.5%; P=0.31). Local recurrence was encountered in 8.7% after ESD-T and 2.4% after ESD-C (P=0.28) at a mean follow-up of 8 and 2.75 years, respectively (P=0.001).

CONCLUSION

ESD-T and ESD-C appear to be equally effective with similar safety profiles for the management of superficial esophageal neoplasms.

Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video)

BACKGROUND AND AIMS

Colonic endoscopic submucosal dissection (ESD) is particularly challenging and limited to a few expert centers. We recently conducted a pilot study on improvement of colonic ESD with systematic use of a countertraction device (double-clip traction with rubber band [DCT-ESD]).

METHODS

A French prospective multicenter study was conducted between March 2017 and September 2019, including all consecutive cases of naive colonic ESD. Since the first case of DCT-ESD in March 2017, all cases of colonic ESD have been performed using the DCT-ESD strategy in the 3 centers involved in the study.

RESULTS

Five hundred ninety-nine lesions with a mean size of 53 mm were included in this study, resected by 5 operators in 3 centers. The en bloc, R0, and curative resection rates were 95.7%, 83.5%, and 81.1%, respectively. The adverse event rates were 4.9% for perforation and 4.2% for postprocedure bleeding. Between 2017 and 2019, the rates of R0 and curative resections increased significantly from 74.7% in 2017 to 88.4% in 2019 (P = .003) and from 72.6% in 2017 to 86.3% in 2019 (P = .004), respectively. Procedure duration and speed of resection were 62.4 minutes and 39.4 mm²/minute, respectively. No differences were noted between operators.

CONCLUSION

DCT-ESD is a safe and reproducible technique, with results comparable with those of the large Japanese teams with speed of resection twice as high as previously reported studies. The DCT strategy is promising, cheap, and seems to be reproducible. Physicians performing colonic ESD should be aware of this promising tool to improve their results in ESD.

Outcomes of 601 Colorectal Endoscopic Submucosal Dissections in a Single Western Center: Is Right Colon Location Still a Major Concern?

BACKGROUND

Endoscopic submucosal dissection (ESD), as a minimally invasive procedure for removal of early gastrointestinal neoplasms, is a standard approach in Asian countries. Outcomes of ESD in Western European countries significantly differ, which makes it more difficult to apply this procedure to daily-basis clinical routine. The aim of this study is to analyze the safety and efficiency of colorectal ESD based on a large series of cases performed by a single operator after finishing the learning curve period in a western referral center.

MATERIALS AND METHODS

We retrospectively studied 601 patients who underwent ESD procedure for colorectal neoplasm from January 2016 to December 2019 in a tertiary colorectal ESD center in Poland.

RESULTS

The overall en bloc resection was achieved in 88.02%. Complete histologic resection rate (R0) was reported at a level of 86.36%. Lesions located in the right colon were characterized by statistically lower en bloc, R0 resection, and success rate (73.95%, 71.43%, 69.75%, respectively). In 9.82% (n=59) of cases, the ESD procedure-related complications have been observed. Post-ESD bleeding occurred in 23 patients (3.83%) and perforation in 32 patients (5.32%). Twenty-seven patients were treated endoscopically (4.49%) and 5 required surgery (0.83%). Analysis of complications showed that tumors located within the right colon were characterized by the highest perforation rate at 10.92%. Within the rectum there were minimal number of perforations (2.69%), whereas the bleeding rate was 4.48%.

CONCLUSIONS

Our results represent the largest material concerning ESD of colorectal lesions in the West and show that ESD is characterized by a high rate of successful resections with a low risk of complications. Thus, confirming that it is possible to obtain results similar to Asian centers and that colorectal ESD procedures can be implemented in clinical routine in western countries. Nevertheless, ESD in the right colon is still related with high rate of complications, so qualification for the ESD procedure should be very careful and discussed with the patient and should be performed by an experienced endoscopist after the learning curve.

Traction-assisted endoscopic submucosal dissection reduces procedure time and risk of serious adverse events: a systematic review and meta-analysis

BACKGROUND AND AIMS

Conventional endoscopic submucosal dissection (C-ESD) is a technically demanding procedure with prolonged procedure times and higher risk of adverse events. To overcome the procedural difficulty of ESD, several traction-assisted techniques (T-ESD) have been developed to improve visualization of the submucosa in hopes to facilitate safe and effective dissection. The aim of this study was to conduct a meta-analysis that compares short-term outcomes (30-day) of T-ESD to C-ESD.

METHODS

Clinical studies published up to April 2020 comparing the efficacy and safety of T-ESD and C-ESD were identified using electronic bibliographic searches. Both randomized controlled trials and observational studies were included. Outcomes of interests were procedure time, rates of en bloc and R0 resection, and rates of adverse events. Fixed effect and random effect model were used to calculate pooled mean difference for continuous variables and risk differences (RDs) for categorical variables.

RESULTS

Twenty-three studies with 2574 patients were included in this meta-analysis, with a total of 2582 lesions (1292 T-ESD and 1290 C-ESD). Pooled estimates of T-ESD showed shorter procedure times (weighted mean difference = -20.35 min, 95% CI -27.51 to -13.19, p < 0.001), higher R0 resection rates (RD 0.04, 95% CI 0.01-0.06, p = 0.004) and lower perforation rates (RD -0.03, 95% CI -0.04 to -0.01, p =  < 0.0001). No significant differences were seen in en bloc rates and bleeding risk between the two groups.

CONCLUSIONS

Traction-assisted ESD results in shorter procedure time, improved R0 resection rates and lower risk of perforation as compared to conventional ESD.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis

BACKGROUND

Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective.

AIM

To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms.

METHODS

A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed.

RESULTS

This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01).

CONCLUSION

Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.

Submucosal tunneling endoscopic resection for large symptomatic submucosal tumors of the esophagus: A clinical analysis of 24 cases

BACKGROUND/AIMS

Studies evaluating submucosal tunneling endoscopic resection (STER) for the treatment of upper gastrointestinal submucosal tumors (SMTs) have recently increased. However, the efficacy and safety of STER for the treatment of large symptomatic SMTs in the esophagus have not been well investigated. The aim of the present study was to evaluate the efficacy and safety of STER for the treatment of large symptomatic SMTs in the esophagus.

METHODS

A total of 24 patients with large symptomatic SMTs in the esophagus who underwent STER in our hospitals between January 2015 and May 2018 were included in the study. The tumors were confirmed to be of muscularis propria layer origin. Treatment outcomes, complications, and follow-up results were retrospectively analyzed.

RESULTS

All 24 lesions were resected en bloc with STER. The mean maximum transverse diameter of the lesions was 4.7 (3.5-6.5) cm. The mean maximum longitudinal diameter of the lesions was 2.1 (1.5-3.0) cm. The mean duration from mucosal incision to complete mucosal closure was 65 (50-115) min. Postoperative pathological diagnosis confirmed 18 cases with leiomyomas, 4 cases with stromal tumors, and 2 cases with schwannomas. There were no major complications. There were no residual lesions or disease recurrence during follow-up.

CONCLUSION

STER is safe and effective for the treatment of large symptomatic SMTs of muscularis propria layer origin in the esophagus.

A Pilot Study of Endoscopic Submucosal Dissection Using an Endoscopic Assistive Robot in a Porcine Stomach Model

Background/Aims

Endoscopic assistive devices have been developed to reduce the complexity and improve the safety of surgeries involving the use of endoscopes. We developed an assistive robotic arm for endoscopic submucosal dissection (ESD) and evaluated its efficiency and safety in this in vitro pilot study.

Methods

ESD was performed using an auxiliary transluminal endoscopic robot. An in vitro test bed replicating the intra-abdominal environment and pig stomachs were used for the experiment. Participants were divided into skilled operators and unskilled operators. Each group performed ESD 10 times by using both conventional and robot-assisted methods. The perforation incidence, operation time, and resected mucous membrane size were measured.

Results

For the conventional method, significant differences were noted between skilled and unskilled operators regarding operation time (11.3 minutes vs 26.7 minutes) and perforation incidence (0/10 vs 6/10). Unskilled operators showed a large decrease in the perforation incidence with the robot-assisted method (conventional method vs robot-assisted method, 6/10 vs 1/10). However, the operation time did not differ between the conventional and robot-assisted methods. On the other hand, skilled operators did not show differences in the operation time and perforation incidence between the conventional and robot-assisted methods. Among both skilled and unskilled operators, the operation time decreased with the robot-assisted method as the experiment proceeded.

Conclusions

The surgical safety of unskilled operators greatly improved with robotic assistance. Thus, our assistive robotic arm was beneficial for ESD. Our findings suggest that endoscopic assistive robots have positive effects on surgical safety.

A Single-Center Early Experience of Endoscopic Submucosal Dissection for Gastric Lesions in Thailand

Endoscopic submucosal dissection (ESD) was also considered a "high risk" at the starting point with skillful endoscopic techniques and terrible complications. Still, it remains challenging yet has become widespread among institutes in many parts of the world. This study is aimed at further investigating the feasibility, efficacy, and safety of ESD of gastric lesions and at evaluating clinical outcomes in early experience. The patient characteristics, postoperative outcomes, and results of histopathological examinations were reviewed retrospectively between January 2017 and May 2019. Thirteen patients' gastric ESD were included with all of en bloc resections without recurrence. The long duration was related to the large lesion, the upper part of the stomach, and previous treatment. In this study, the ESD procedure of the stomach is a feasible and safe minimally invasive treatment option with organ preservation. It requires training and experience with a learning approach where skill may be improved to prevent unwanted complications.

History and future perspectives in Japanese guidelines for endoscopic resection of early gastric cancer

Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the therapeutic approach among institutions, and so on. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk-scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C-2 in the latest guidelines, additional gastrectomy with lymphadenectomy may be excessive for many patients, even those at high risk for LNM. Less-invasive function-preserving surgery, such as non-exposed endoscopic wall-inversion surgery with laparoscopic sentinel node sampling, may overcome this problem. In addition, further less-invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy.

Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) for superficial gastrointestinal neoplasms has become widespread. However, certain aspects of the procedure remain difficult to manage, such as intraoperative bleeding and perforation. There are two kinds of scissor-type knife: the Clutch Cutter (Fujifilm Co., Tokyo, Japan) and the SB knife (Sumitomo Bakelite Co., Tokyo, Japan). These knives have different features from other types of ESD knives and enable the performance of all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis. The standard approach with scissor-type knives involves first grabbing the tissue and then incising or dissecting it. Theoretically, perforation as a result of unintentional movement should never happen with scissor-type knives compared to needle- or blade-type knives, which may induce perforation through unintentional movement. Moreover, the rates of severe bleeding and self-completion of ESD with scissor-type knives by non-experts were reported to be significantly better than for other knives. Thus, scissor-type knives can resolve these problems and help to further standardize ESD globally. In this review, we summarize reports on the efficacy of such scissor-type knives for ESD of gastrointestinal tumors. We also present the pocket-creation method and the application of traction devices, such as dental floss and S-O clips (Zeon Medical Co., Tokyo, Japan) for improving the performance of ESD with a Clutch Cutter.

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgery-sparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen-confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort.

METHODS

Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months.

RESULTS

Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence.

CONCLUSIONS

ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only. (Clinical trial registration number: NCT02306707.).

Efficacy and safety of 0.6% sodium alginate solution in endoscopic submucosal dissection for esophageal and gastric neoplastic lesion: A randomized controlled study

OBJECTIVES

Sodium alginate (SA) solution has characteristic viscoelasticity. We aimed to determine efficacy and safety of 0.6% SA for submucosal injection during endoscopic submucosal dissection (ESD) in patients with localized neoplastic lesion in the esophageal and gastric mucosa.

METHODS

We conducted a randomized controlled study at six major hospitals in Japan including 130 patients with endoscopically localized neoplastic lesion in the esophageal and gastric mucosa and eligible for ESD. Patients were randomly assigned to SA or 0.4% sodium hyaluronate (SH) group (control); ESD was performed using a submucosal injection of SA/SH. As a primary outcome measure, non-inferiority of SA against SH was investigated using en bloc complete resection in ESD and formation and maintenance of mucosal elevation upon injection as an efficacy index. Adverse events during the study were evaluated as safety outcome measures. This study was registered with Pharmaceuticals and Medical Devices Agency (clinical trial no. 28-277/2016-18; clinical trial identification no. KP2013-009_C001).

RESULTS

Efficacy rate of submucosal injection during ESD was 91.7% (55/60) and 88.7% (55/62) in the SA and SH groups, respectively, demonstrating non-inferiority of SA against SH. Adverse events for which a causal relationship with submucosal injection solution could not be eliminated were noted in 8.2% (5/61) and 4.7% (3/64) in the SA and SH groups, respectively, but symptoms disappeared without treatment/after drug administration in both groups.

CONCLUSIONS

In Japan, 0.4% SH is the only commercially approved formulation for submucosal injection during ESD. The study results may expand submucosal injection solution options in clinical practice.

Endoscopic submucosal tunnel dissection for superficial esophageal neoplastic lesions: a meta-analysis

BACKGROUND AND AIMS

The emerging endoscopic submucosal tunnel dissection (ESTD) is becoming an alternative method for superficial esophageal neoplastic lesions. This study aimed to evaluate the effectiveness and feasibility of ESTD for superficial esophageal neoplastic lesions.

METHODS

A comprehensive literature review was conducted to search relevant studies through PubMed, EMBASE, Cochrane Library, and Web of Science before 1 December 2018. Studies relating to ESTD for superficial esophageal neoplastic lesions were included. Rates of effectiveness (en bloc resection rate, R0 resection rate, and curative resection rate), rates of feasibility (muscular damage rate, perforation rate, postprocedural bleeding rate, and emphysema rate), and rates of follow-up (recurrence rate and stricture rate) were pooled and analyzed. Forest plots were constructed based on the random-effects model. Sensitivity analyses were also performed if significant heterogeneity existed.

RESULTS

Six studies including 414 patients and 436 superficial esophageal neoplastic lesions that underwent ESTD were available for analysis. The pooled estimates of en bloc resection rate, R0 resection rate, and curative resection rate were 98% (95% CI 95.8-99.0%), 87.0% (95% CI 78.2-92.5%), and 87.6% (95% CI 67.4-96.0%), respectively. The pooled outcomes of muscular damage rate, perforation rate, postprocedural bleeding rate and emphysema rate were 19.1% (95% CI 9.8-33.8%), 2.2% (95% CI 1.1-4.1%), 1.6% (95% CI 0.7-3.5%), and 12.2% (95% CI 4.3-29.9%), respectively. Finally, the pooled results of recurrence and stricture were 4.7% (0.9-20.5%) and 20.9% (11.3-35.2%), respectively.

CONCLUSIONS

ESTD appears to be an effective and feasible approach for treating superficial esophageal neoplastic lesions. However, future research is needed for new and comprehensive methods to decrease the stricture rate after ESTD.

How I do it: Flexible 3-D endoscope for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is technically challenging as a result of a lack of depth perception. The present article investigated the 3-D endoscope for carrying out ESD and translated the technique from bench to clinical use. In a preclinical porcine experiment, ESD using a 3-D endoscope was compared between an experienced and a novice endoscopist. All ESD were completed without perforation. Median operative time per surface area was significantly lower for the experienced endoscopist than for the novice (197.9 s/cm² vs 434.7 s/cm² ; P = 0.05). The second part was a prospective clinical experience to evaluate use of the 3-D endoscope for carrying out ESD. Ten patients received ESD using the 3-D endoscope. Four patients had gastric ESD, two had duodenal ESD and four had sigmoid and rectal ESD. There were no complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Mean operative time was 99.4 min, and operative time per surface area resection was 391 s/cm² . The operating endoscopist did not complain of motion sickness, whereas the assistants had some dizziness upon prolonged ESD procedure. This study showed that carrying out ESD was safe and effective using a 3-D endoscope with an excellent 3-D view enhancing depth perception. Future study should be conducted to compare 3-D against 2-D endoscopes for ESD.

Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe

Background and study aims  Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods  Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results  Median size was 4 cm (range 1 - 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 - 588) and median proficiency was 7.2 cm ² /h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 - 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm ² /h) and the last study period (10.8 cm ² /h). Conclusions  This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.

Implementation of mentor-assisted colorectal endoscopic submucosal dissection in Sweden; learning curve and clinical outcomes

OBJECTIVE

It's still challenging to introduce colorectal (CR) ESD in Western countries. We assessed the feasibility of introducing and implementing CR-ESD in Sweden with hiring Japanese expert as a supervisor.

METHODS

We analyzed 71 consecutive CR-ESD cases performed by two endoscopists who had no (endoscopist A (E-A)) or 20 cases (endoscopist B (E-B)) of experience in ESD. E-A performed rectal lesions while E-B performed lesions in any locations. Factors associated with failure in en bloc resection and in self-accomplishment were analyzed.

RESULTS

Overall en bloc and R0 resection rates were 80.3% and 70.4%. Adverse event occurred in 7.0% including two perforations, two post-operative hemorrhage and one delayed perforation. Only case with delayed perforation underwent surgical treatment. Total self-accomplishment rate was 50% (10/20) for E-A, and 37.3% (19/51) for E-B. Dividing each performer's cases into three learning phases, self-accomplishment rates increased from 42.9% to 83.3% for E-A, and from 29.4% to 70.6% for E-B, as well as en bloc resection rates from 71.4% to 100% for E-A, and from 52.9% to 94.1% for E-B. Multivariate analysis revealed that location upper than rectum, lesions with formerly taken biopsy and lesions larger than 30mm were significantly associated with en bloc resection failure.

CONCLUSIONS

Implementation of CR-ESD with hiring Japanese supervisor for certain period was safe for patients and effective for good learning curve.

Screening for gastric cancer with magnetically controlled capsule gastroscopy in asymptomatic individuals

BACKGROUND AND AIMS

Gastric cancer (GC) is the fourth most common cancer and the fourth leading cause of cancer death worldwide. In some Asian countries, screening EGD has greatly improved the survival rate. However, patients' discomfort and the need for sedation may limit adherence to screening programs. Previous studies have shown good tolerance and good agreement of magnetically controlled capsule gastroscopy (MCCG) with EGD. This study was designed to assess the application of MCCG in GC detection in an asymptomatic population.

METHODS

In this observational cohort study, 3182 asymptomatic individuals undergoing MCCG in 99 participating medical examination centers from April to December 2016 were enrolled. Patients with ulcers and suspected malignancies were referred for gastroscopy and biopsy. The detection rate of GC and focal lesions were used to explore the application of MCCG in asymptomatic individuals.

RESULTS

Seven patients (0.22%) were diagnosed with GC among the enrolled 3182 individuals, accounting for 0.74% (7/948) in patients over 50 years. No gender disparity was observed. EGD and biopsy confirmed adenocarcinoma in all cases of suspected malignancy. Benign polyps, gastric ulcers, and submucosal tumors were found in 10.4%, 4.9%, and 3.6% of patients, respectively. There was a trend for the prevalence of focal lesions to increase with age. MCCG examination proved to be safe.

CONCLUSIONS

MCCG can detect cancer and benign lesions and is safe and clinically feasible in a large population. Studies of its role in a screening program should be considered.