Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts

Vonoprazan or Proton Pump Inhibitor for Gastric Endoscopic Submucosal Dissection in Patients Taking Antithrombotic Agents

BACKGROUND AND AIM

Delayed bleeding is a major concern after gastric endoscopic submucosal dissection (ESD), especially in patients taking antithrombotic agents. The aim of this study was to evaluate the superiority of vonoprazan (VPZ) over proton pump inhibitor (PPI) in preventing delayed bleeding after gastric ESD in patients taking antithrombotic agents.

METHODS

A multicenter, open-label, randomized controlled trial was conducted in 10 Japanese centers. Gastric neoplasm patients taking antiplatelets or anticoagulants were enrolled and randomly allocated in a 1:1 ratio to either the VPZ (20 mg per day for 8 weeks) or the PPI group (esomeprazole 20 mg per day for 8 weeks). Antithrombotic agents were managed according to Japanese guidelines. The primary outcome was the delayed bleeding rate within 8 weeks after ESD. Secondary outcomes included the incidence of symptoms after ESD, healing status of ulcers at 8 weeks, safety, and factors related to delayed bleeding.

RESULTS

Of 119 patients (59 in VPZ group, 60 in PPI group), the delayed bleeding rates were 13.6% (8/59) in the VPZ group and 8.3% (5/60) in the PPI group, with no significant difference (p = 0.36). Symptoms and adverse events, the healing status of ulcers at 8 weeks, were comparable between the groups. No use of daily antacids and the combination of antiplatelets and anticoagulants were related to delayed bleeding (odds ratio 13.1 and 34.7, p < 0.01).

CONCLUSION

The present study did not demonstrate the superiority of VPZ over PPIs in preventing delayed bleeding after gastric ESD in patients taking antithrombotic agents.

TRIAL REGISTRATION

(UMIN000040641/jRCTs041200045).

Successful perforation management during esophageal endoscopic submucosal dissection using the stent-anchoring method: A case report

Patients with esophageal endoscopic submucosal dissection-associated adverse events can have a severe clinical course. In this report, we describe the case of a 67-year-old male with a history of endoscopic submucosal dissection who had metachronous superficial esophageal cancer. Although endoscopic submucosal dissection was attempted for challenging lesions adjacent to the scar, perforations occurred during the procedure. We placed an esophageal fully covered self-expandable metallic stent at the perforation site to avoid emergency surgery after lesion removal. However, stent migration and displacement concerns remained, as no stenosis was observed in the esophagus. Therefore, a clip with a thread on the upper edge of the stent was placed, and this anchoring clip was useful in preventing stent migration and closing the perforation. The patient improved with conservative treatment. In conclusion, the stent placement and anchoring method with clip and thread could be a treatment option in such cases.

Improved outcomes of endoscopic treatment for delayed perforation following endoscopic submucosal dissection for gastric epithelial neoplasms

Background and study aims

Emergency surgery is usually required for patients with delayed perforation after gastric endoscopic submucosal dissection (ESD); however, cases of successful endoscopic treatment recently have been reported. Here, we elucidated the usefulness of endoscopic intervention for patients with delayed perforation.

Patients and methods

Patients who underwent gastric ESD from 2005 to 2022 were assessed for eligibility. Delayed perforation was defined as no intraprocedural perforation after the ESD but subsequent development of peritoneal irritation and free air on computed tomography scan. Participants were divided into early- and late-period groups based on time (October 2015) of implementation of the polyglycolic acid (PGA) sheet and the over-the-scope clip (OTSC) in clinical practice. We evaluated changes in incidence of required surgery.

Results

Among the 5,048 patients who underwent gastric ESD, delayed perforation occurred in 28 patients (0.6%, 95% confidence interval [CI] 0.4%-0.8%). Incidence of delayed perforation did not differ significantly between the early- and late-period groups (0.5% vs. 0.6%). The proportion of patients who underwent surgery was significantly smaller in the late-period group than in the early-period group (54% vs. 13%, odds ratio [OR] 0.14, 95% CI 0.02-0.83; P = 0.042); this was confirmed by multivariate analysis (adjusted OR 0.04, 95% CI 0.002-0.9; P = 0.043) after adjustment for age, sex, Charlson's comorbidity index, tumor location, and size.

Conclusions

Endoscopic intervention using PGA sheets and OTSC was associated with a low incidence of required surgery for delayed perforation after gastric ESD and is recommended.

Closure methods for large defects after gastrointestinal endoscopic submucosal dissection

Nowadays, endoscopic submucosal dissection (ESD) is commonly performed for the removal of large gastrointestinal lesions. Endoscopic mucosal defect closure after ESD is vital to avoid adverse events. In recent years, many innovative instruments have emerged and proved to be beneficial. In this paper, we conducted a thorough literature review and summarized the closure methods for large-size post-ESD mucosal defects over decades. We separated these methods into five categories based on the operational principle: "side closure" method, "ring closure" method, "layered closure" method, "hand suturing closure" method, and "specially designed device closure" method. Side closure with clips assisted by instruments such as threads or loops is applicable for each segment of the gastrointestinal tract to prevent postoperative bleeding. If the defect tension is too large to close with the traditional side closure methods, zigzag closure and ring closure could be applied to gather the bilateral defect edges together and achieve continuous closure. In the stomach and rectum with a high risk of submucosal dead space between the submucosa and muscular layers, side closure methods with muscle layer grasping clip or layered closure methods could enable the involvement of the deep submucosa and muscle layers. The ring closure method and specially designed devices including over-the-scope clip, Overstitch, and X-tack could resolve perforation effectively. Individual closure method requires endoscope reinsertion or sophisticated operation, which may be limited by the deep location and the narrow lumen, respectively. Although specially designed devices are expected to offer promising prospectives, the cost-effectiveness remains to be a problem.

Emergency esophagectomy for esophageal perforation following balloon dilation due to stenosis post-endoscopic submucosal dissection for esophageal cancer: a case report

Introduction and importance

Esophageal perforation from endoscopic dilation is rare (0.53-0.6% incidence) but serious, with mortality rates of 12.5-20%. Optimal treatment is debated and depends on the medical facility's capabilities, the patient's symptoms, the extent of perforation, and the severity of associated lesions. Treatment options include medical management (fasting, antibiotics), esophageal stenting, surgical closure, or emergency esophagectomy. Early diagnosis and treatment are crucial to reduce mortality and hospital stay.

Case presentation

A 49-year-old male with lower third esophageal cancer (stage cT1aN0M0) underwent endoscopic submucosal dissection (ESD) and developed esophageal stenosis. Dilation attempts led to esophageal perforation, necessitating emergency esophagectomy with gastric conduit reconstruction. The patient improved and was discharged on day 10 post-operation without complications.

Clinical discussion

Managing esophageal perforation post-endoscopic dilation is complex. This case highlights the importance of rapid recognition and intervention. Esophageal dilation, while effective for stenosis, carries a perforation risk. Treatment decisions must be tailored to individual patients, considering perforation severity, patient's health, and facility resources. Here, severe perforation and clinical condition warranted emergency esophagectomy. The successful outcome underscores the efficacy of this surgical intervention when performed timely at specialized centers.

Conclusion

Emergency esophagectomy with gastric conduit reconstruction for treating esophageal perforation due to stenosis post-endoscopic submucosal dissection for esophageal cancer is considered a safe procedure and can be performed at an experienced esophageal surgery center.

PRP improves the outcomes of autologous skin graft transplantation on the esophagus by promoting angiogenesis and inhibiting fibrosis and inflammation

BACKGROUND AND OBJECTIVES

Autologous skin graft (ASG) transplantation is a challenging approach but a promising option for patients to prevent postoperative esophageal stricture. Nonetheless, the current strategies require improvement. We aimed to investigate the effectiveness of the injection of platelet-rich plasma (PRP) before skin graft transplantation for extensive esophageal defects after endoscopic resection.

METHODS

Standardized complete circular endoscopic resection (5 cm in length) was performed in 27 pigs allocated into 3 groups. The artificial ulcers were treated with a fully covered esophageal stent (control group), ASG (ASG group), and submucosal injection of PRP with ASG (PRP-ASG group). Macroscopic evaluation and histological analysis of the remolded esophagus were performed 7, 14, and 28 days after surgery.

RESULTS

The macroscopic evaluation indicated that submucosal injection of PRP before transplantation effectively promoted the survival rate of skin grafts and decreased the rate of mucosal contraction compared with those treated with ASG or stent alone. Histological analysis of submucosal tissue showed that this modified strategy significantly promoted wound healing of reconstructed tissues by enhancing angiogenesis, facilitating collagen deposition, and decreasing inflammation and fibrogenesis.

CONCLUSIONS

These findings suggested that PRP might be used as a biological supplement to increase the esophageal skin graft survival rate and improve submucosal tissue remolding in a clinically relevant porcine model. With extremely low mucosal contraction, this novel combination strategy showed the potential to effectively prevent stenosis in extensive esophageal ulcers.

Administration of oral prednisolone to prevent esophageal stricture after balloon-type radiofrequency ablation for ultralong-segment esophageal neoplasia

BACKGROUND AND AIMS

Endoscopic radiofrequency ablation (RFA) has shown good efficacy and safety in eradicating flat-type early esophageal squamous cell neoplasia (ESCN). However, post-RFA stricture is still a major concern, especially when treating ultralong-segment ESCNs. The aim of this study was to investigate the efficacy and safety of oral prednisolone to prevent post-RFA stricture.

METHODS

We prospectively enrolled 48 patients treated with balloon-type RFA who had Lugol-unstained or mosaic-like flat-type ESCNs with an expected treatment area of >10 cm. Oral prednisolone was started at a dose of 30 mg/day on the third day after RFA and continued for 4 weeks. The results were compared with an historical control group of 25 patients who received RFA without oral steroids. The primary endpoint was the frequency of post-RFA stricture. Secondary endpoints were the number of balloon dilation sessions and adverse event rate.

RESULTS

No significant differences were found in the worst pathology grade at baseline and length of unstained lesions between the 2 groups. The complete response rates after 1 session of RFA were 73% and 72%, respectively. Compared with the control group, the oral prednisolone group had a significantly lower stricture rate (4% [2/48 patients] vs 44% [11/25 patients]; P < .0001) and a lower number of balloon dilation sessions (median, 0 [range, 0-4] vs 6 [range, 0-10]). Two cases of asymptomatic candida esophagitis occurred in the study group, but no severe adverse effects.

CONCLUSIONS

Oral prednisolone may offer a useful and safe preventive option for post-RFA stricture in ultralong ESCNs. (Clinical trial registration number: NCT05768282.).

Risk factors for intraoperative and delayed perforation related with gastric endoscopic submucosal dissection

BACKGROUND AND AIM

Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients.

METHODS

This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012.

RESULTS

Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100 min; tumor size >35 mm; body mass index (BMI) < 18.5 kg/m2; and ≥72 years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60 min; BMI < 18.5 kg/m2; ≥75 years; ulceration; and tumor size >20 mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%).

CONCLUSION

This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.

Delayed Perforation After Endoscopic Resection of Upper Gastrointestinal Tumors: CT Findings to Identify Patients Requiring Surgery

PURPOSE

To determine the clinical and imaging factors associated with surgical treatment in patients with delayed perforation after endoscopic resection of upper gastrointestinal tumors.

METHODS

We retrospectively included patients with delayed perforation after endoscopic tumor resection for gastric or duodenal tumors between January 2007 and December 2021 in a tertiary hospital. We compared the clinical, endoscopic, and CT findings of the surgical and conservative treatment groups. Univariable and multivariable analyses were performed to identify significant factors associated with surgery.

RESULTS

Among 10,423 patients who had undergone endoscopic tumor resection, 52 (0.50%) experienced delayed perforation, with 20 patients (35.5%) treated surgically and 32 patients (64.5%) treated conservatively. The CT findings of gross perforation (adjusted odds ratio [OR]=6.75, 95% confidence interval [CI], 1.04-43.89; P=0.045) and presence of peritonitis (OR=34.26, 95% CI, 5.52-212.50; P<0.001) were significantly associated with surgical treatment. Other clinical factors as well as CT-measured amount of pneumoperitoneum were not significant factors.

CONCLUSIONS

CT findings of gross perforation and peritonitis are significant factors associated with surgery in delayed perforation after endoscopic tumor resection. These factors can aid in guiding the patients towards an appropriate treatment plan.

The white ring sign is useful for differentiating between fundic gland polyps and gastric adenocarcinoma of the fundic gland type

Background and study aims Gastric adenocarcinoma of the fundic gland type (GA-FG) is characterized by an elevated lesion with vessel dilation exhibiting branching architecture (DVBA). However, this feature is also found in fundic gland polyps (FGPs), posing a challenge in their differentiation. In this study, we aimed to investigate the clinicopathological features of gastric elevated lesions with DVBA and assess the efficacy of the white ring sign (WRS) as a novel marker for distinguishing between FGPs and GA-FGs. Methods We analyzed 159 gastric elevated lesions without DVBA and 51 gastric elevated lesions with DVBA, further dividing the latter into 39 in the WRS-positive group and 12 in the WRS-negative group. The clinicopathological features, diagnostic accuracy, and inter-rater reliability were analyzed. Results Univariate and multivariate analyses for gastric elevated lesions with DVBA identified the histological type consistent with FGPs and GA-FGs, along with the presence of round pits in the background gastric mucosa, as independent predictors. FGPs were present in 92.3% (36/39) of the WRS-positive group and GA-FGs were observed in 50.0% (6/12) of the WRS-negative group. WRS positivity and negativity exhibited high diagnostic accuracy, with 100% sensitivity, 80.0% specificity, and 94.1% accuracy for FGPs, and 100% sensitivity, 86.7% specificity, and 88.2% accuracy for GA-FGs. Kappa values for WRS between experts and nonexperts were 0.891 and 0.841, respectively, indicating excellent agreement. Conclusions WRS positivity and negativity demonstrate high diagnostic accuracy and inter-rater reliability for FGPs and GA-FGs, respectively, suggesting that WRS is a useful novel marker for distinguishing between FGPs and GA-FGs.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Self-expandable metallic stents may be more efficient than balloon dilatation alone for esophageal stricture after circumferential endoscopic submucosal dissection: a retrospective cohort study in China

INTRODUCTION

Self-expandable metallic stents (SEMSs) can be used to treat esophageal stricture after circumferential endoscopic submucosal dissection (ESD), but its efficacy and placement timing remain to be determined. In this study, the treatment time and number of dilatations were compared between the SEMS placement group and the balloon dilatation (BD) group to clarify the efficacy and placement time of SEMSs in the treatment of esophageal stricture after circumferential esophageal ESD.

METHODS

This was a retrospective cohort study. Patients with esophageal stricture after circumferential ESD between January 2015 and January 2020 were included. Data on the patients' demographic characteristics, esophageal lesion-related factors, esophageal stricture occurrence, and measures taken to treat the stricture were collected. The primary outcome was the treatment time, and the secondary outcome was the number of dilatations.

RESULTS

The total number of dilatations was 30 in the SEMS group and 106 in the BD group. The average number of dilatations in the SEMS group (1.76 ± 1.64) was significantly lower than that in the BD group (4.42 ± 5.32) (P = 0.016). Among the patients who underwent SEMS placement first had a shorter treatment time (average 119 days) than those who underwent BD first (average 245 days) (P = 0.041), and the average number of dilatations inpatients who underwent SEMS placement first (0.71 ± 1.07) was significantly lower than that in the patients who underwent BD first (2.5 ± 1.54).

CONCLUSION

SEMSs were more efficient in the treatment of esophageal stricture in a cohort of patients after circumferential esophageal ESD.

Characteristics and Risk Factors of Delayed Perforation in Endoscopic Submucosal Dissection for Early Gastric Cancer

(1) Background: Delayed perforation after gastric endoscopic submucosal dissection (ESD) for early gastric cancer is a relatively uncommon and serious complication that sometimes requires emergency surgery. This study aimed to determine the clinicopathological features, risk factors, and appropriate management strategies for delayed perforation. (2) Methods: This study included 735 patients with 791 lesions who underwent ESD for early gastric cancer at a single institution between July 2009 and June 2019. We retrospectively compared the clinical features of patients with and without delayed perforations. (3) Results: The incidence of delayed perforations was 0.91%. The identified risk factors included a postoperative stomach condition and histopathological ulceration. A comparison between delayed and intraoperative perforations revealed a postoperative stomach condition as a characteristic risk factor for delayed perforation. Patients with delayed perforation who avoided emergency surgery tended to exhibit an earlier onset of symptoms such as abdominal pain and fever. No peritoneal seeding following delayed perforation was observed for any patient. (4) Conclusions: A postoperative stomach condition and histopathological ulceration were risk factors for delayed perforation. Delayed perforation is a significant complication that requires careful monitoring after gastric ESD for early gastric cancer, particularly in patients with postoperative gastric conditions.

Red Dichromatic Imaging Improves the Recognition of Bleeding Points During Endoscopic Submucosal Dissection

BACKGROUND

Previous studies have indicated that red dichromatic imaging (RDI) improved the visibility of gastrointestinal bleeding.

AIMS

To investigate the recognition of bleeding points during endoscopic submucosal dissection (ESD) under RDI compared with that under white light imaging (WLI).

METHODS

Consecutive patients scheduled to undergo esophageal or gastric ESD at a single center were enrolled. Paired videos of active bleeding during ESD under WLI and RDI were created. Six endoscopists identified the virtual hemostasis point on still images after random video viewing. The distance between virtual hemostasis and actual bleeding points was scored in four levels (0-3 points), and the association with the color value was analyzed in both WLI and RDI.

RESULTS

We evaluated 116 videos for 58 bleeding points. The median visibility score and recognition rate were significantly higher for RDI than for WLI (2.17 vs. 1.42, p < 0.001 and 62.1% vs 27.6%, p < 0.001). Additionally, the recognition rate of trainees in RDI was higher than that of experts in WLI (60.3% vs. 43.1%, p = 0.067). The median color difference of RDI was significantly higher than that of WLI (8.97 vs. 3.69, p < 0.001). Furthermore, the correlation coefficient between the visibility score and color difference was 0.712 (strong correlation).

CONCLUSION

RDI can provide better recognition of bleeding points than WLI during ESD. Therefore, further studies are warranted to investigate whether RDI improves ESD outcomes.

Safety and Efficacy of Endoscopic Full Thickness Resection of Upper Gastrointestinal Lesions Using a Full Thickness Resection Device: A Systematic Review and Meta-analysis

INTRODUCTION

Endoscopic full-thickness resection (EFTR) is a promising technique that allows for a minimally invasive resection of mucosal and submucosal lesions in the gastrointestinal (GI) tract. The data regarding the efficacy and safety of performing EFTR of upper GI lesions using a full-thickness resection device (FTRD) is limited. Hence, we performed a systematic review and meta-analysis of the studies that evaluated this technique.

METHODS

We performed a comprehensive systematic search of multiple electronic databases and conference proceedings that reported outcomes of EFTR using the FTRD system. The weighted pooled rates of technical success, complete (R0) resection, adverse events (AE), and residual or recurrent lesions were analyzed with 95% CI using the random effects model.

RESULTS

Eight studies with a total of 139 patients who underwent EFTR of upper GI lesions were included in the study. The pooled, weighted rate of technical success was 88.2% (95% CI: 81.4-92.7%, I2 : 0). The R0 resection rate was 70.7% (95% CI: 62.5-77.8%, I2 : 0). Overall AE rates were 22.1% (95% CI: 15.8-30.1%, I2 : 0), however, most of the AEs were minor. Of the patients who had follow-up endoscopies, the residual and/or recurrent lesion rate was 6.1% (95% CI: 2.4-14.4%, I2 : 0). Heterogeneity in the analysis was low.

CONCLUSIONS

EFTR using the FTRD seems to be effective and safe with acceptable R0 resection rates and low recurrence rates. Further prospective studies are required to validate our results and to compare various modalities of endoscopic resection with this single-step EFTR device.

The efficacy of newly proposed gastric open peroral endoscopic myotomy (GO-POEM) in preventing post-endoscopic submucosal dissection stenosis: A comparison with non-GO-POEM group

Extensive endoscopic submucosal dissection (ESD) for gastric adenoma or early cancer can lead to post-ESD stenosis. This may cause a decrease in quality of life and an increase in medical issues. Therefore, this study examined the safety and effectiveness of gastric open peroral endoscopic myotomy (GO-POEM) in preventing stenosis following ESD. A retrospective investigation was carried out on 31 patients who underwent gastric ESD for > 75% of the lumen in the antrum or pylorus at the Presbyterian Medical Center in Korea between December 2004 and October 2022. The patients were divided into GO-POEM (n = 11) and non-GO-POEM groups (n = 20). The average age of the 31 patients was 73.23 years, and 18 were male. There were no differences in age, sex, location, gross findings, or procedure time between the 2 groups. In the GO-POEM group, only 1 patient (9 %) developed stenosis, compared to 11 patients (55 %) in the control group (P = .02). Multivariate analysis showed that the GO-POEM group had a significantly lower risk of post-ESD stenosis (P < .05). Stenosis symptoms resolved with a single endoscopic balloon dilatation (EBD) in 1 patient in the GO-POEM group. In contrast, 5 of 11 patients with stenosis in the non-GO-POEM group required a median of 2 EBD sessions (range, 1-8). GO-POEM may be an effective and reliable method for preventing stenosis post extensive gastric ESD. Further investigations are necessary to establish its efficacy and safety.

Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics

Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.

Twin-grasper assisted mucosal inverted closure achieves complete healing of large perforations after gastric endoscopic full-thickness resection

OBJECTIVES

This study aimed to demonstrate the feasibility and safety of a novel twin-grasper assisted mucosal inverted closure (TAMIC) technique for large perforations after gastric endoscopic full-thickness resection (EFTR) in a porcine model.

METHODS

Iatrogenic large perforations of the stomach were created and closed by an experienced endoscopist using the TAMIC technique in 12 pigs. Repeat gastroscopy was performed in 4 weeks after surgery to examine the wound sites and then the animals were killed. The primary outcomes were the successful TAMIC closure rate and the complete healing rate. Secondary end points included procedure time of TAMIC, complete inverted healing rate, delayed bleeding rate, and postsurgery perforation. Histologies of the wounds were analyzed by hematoxylin-eosin, Masson trichrome, and immunohistochemistry staining.

RESULTS

The median size of the defects was 3.5 (range 2.5-4.5) cm. TAMIC was successfully performed in all the 12 pigs. Complete healing was achieved in 11 pigs 4 weeks after operation as one pig died postsurgery due to severe pneumonia. The median procedure time for TAMIC was 39 (range 23-81) min. The complete inverted healing rate was 45.5% (5/11). No delayed bleeding or postsurgery perforation was observed. Histologic analyses showed that both the epithelium and muscularis mucosae layers were appropriately connected under inverted healing.

CONCLUSIONS

Twin-grasper assisted mucosal inverted closure is feasible and safe for closure of large perforations after gastric EFTR and could be a propagable and promising technique for clinical practice.

Complications after endoscopic submucosal dissection for early colorectal cancer (Review)

Colorectal cancer (CRC) is a gastrointestinal malignancy that seriously threatens human life and health, resulting in a heavy disease burden. Endoscopic submucosal dissection (ESD) is widely used in clinical practice and is an effective treatment for early CRC (ECC). Colorectal ESD is a challenging operation, and the incidence of postoperative complications is relatively high because of the thin intestinal wall and limited space for endoscopic operations. Systematic reports on the postoperative complications of colorectal ESD, such as fever, bleeding and perforation, from both China and elsewhere are lacking. In the present review, progress in research on postoperative complications after ESD for ECC is summarized.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and Tmax) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.

A new protective gel to facilitate ulcer healing in artificial ulcers following oesophageal endoscopic submucosal dissection: a multicentre, randomized trial

There are significant risks of adverse events following oesophageal endoscopic submucosal dissection (ESD), such as stricture, delayed bleeding and perforation. Therefore, it is necessary to protect artificial ulcers and promote the healing process. The current study was performed to investigate the protective role of a novel gel against oesophageal ESD-associated wounds. This was a multicentre, randomized, single-blind, controlled trial that recruited participants who underwent oesophageal ESD in four hospitals in China. Participants were randomly assigned to the control or experimental group in a 1:1 ratio and the gel was used after ESD in the latter. Masking of the study group allocations was only attempted for participants. The participants were instructed to report any adverse events on post-ESD days 1, 14, and 30. Moreover, repeat endoscopy was performed at the 2-week follow-up to confirm wound healing. Among the 92 recruited patients, 81 completed the study. In the experimental group, the healing rates were significantly higher than those in the control group (83.89 ± 9.51% vs. 73.28 ± 17.81%, P = 0.0013). Participants reported no severe adverse events during the follow-up period. In conclusion, this novel gel could safely, effectively, and conveniently accelerate wound healing following oesophageal ESD. Therefore, we recommend applying this gel in daily clinical practice.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

A nomogram and risk classification system predicting esophageal stricture after endoscopic submucosal dissection of a large area for early esophageal cancer

BACKGROUND AND OBJECTIVES

Esophageal stricture is a troublesome adverse effect of endoscopic submucosal dissection (ESD) for early esophageal cancer. However, risk factors of post-ESD esophageal stricture formation are incomprehensive. This study aimed to conduct a comprehensive analysis of independent risk factors and provide predictive tools.

METHODS

Patients who underwent ESD for early esophageal cancer between 2014 and 2021 at the Beijing Friendship Hospital, Capital Medical University, were recruited. A nomogram and risk classification system was established based on Cox proportional hazards analyses and validated using the concordance index (C-index), calibration curves, decision curve analysis (DCA), and Kaplan-Meier (K-M) curves.

RESULTS

Stricture formed in 36 patients, while stricture was not observed in the remaining 112 patients. Operative time (odds ratio [OR]: 1.01; 95% confidence interval [CI]: 1.00-1.01; p < 0.01); lesions >3/4 circumferential range of esophagus (OR: 3.82; 95% CI: 1.90-7.66; p < 0.01), and tumor infiltration to the mucosal lamina propria (m2) or deeper (OR: 2.40; 95% CI: 1.24-4.66; p = 0.01) were independent predictive factors for post-ESD esophageal stricture. The nomogram and risk classification system was developed and validated with 0.79 C-index, good calibration curves, good DCA results, and good K-M curves.

CONCLUSIONS

We developed a nomogram and risk stratification system to predict post-ESD esophageal stricture using three independent risk factors.

Gelatin/alginate-based microspheres with sphere-in-capsule structure for spatiotemporal manipulative drug release in gastrointestinal tract

Microsphere with sphere-in-capsule structure is a multi-drugs delivery system to achieve the purpose of combination therapy. In this paper, we have prepared gelatin/alginate-based microspheres with sphere-in-capsule structure by a relatively fast, simple, and easily large-scale industrialized emulsification method for spatiotemporal manipulative drug release in gastrointestinal tract. Calcium alginate microspheres encapsulated with bovine serum albumin (BSA) were first prepared as inner microspheres, and then inner microspheres and ranitidine hydrochloride (RH) were co-encapsulated by gelatin microspheres to form double-layer microspheres with sphere-in-capsule structure. The size and distribution of microspheres can be easily controlled by emulsifying conditions. The microspheres with sphere-in-capsule structure displayed desirable encapsulation efficiency of BSA (61.52 %) and RH (56.07 %). The in vitro simulated drug release showed the spatiotemporal release feature of microspheres with sphere-in-capsule structure. In the specific simulated fluid, the release behavior and cumulative release of RH (sustainedly released 95 % in simulated gastric fluid) and BSA (rapidly released 73 % in simulated intestinal fluid) were different. The drug release mechanisms were analyzed to determine RH and BSA's release behavior. Overall, the microspheres with sphere-in-capsule structure have the potential application of spatiotemporal manipulative drug delivery in the gastrointestinal tract.

Circulating exosomal microRNAs as potential prognostic biomarkers in gastrointestinal cancers: a systematic review and meta-analysis

BACKGROUND

Recent reports suggested that circulating exosomal microRNAs (exomiRs) may serve as non-invasive prediction biomarkers in gastrointestinal (GI) cancers, yet their clinicopathological and prognostic values need to be more clarified. Hence, the present meta-analysis was aimed to quantitatively assess the evidence regarding the association between circulating exomiRs and prognosis in GI cancer patients.

METHODS

A comprehensive search was carried out in prominent literature databases, including PubMed, ISI Web of Science, Scopus, and Embase. Odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs) were gathered to evaluate the strength of the association. The quality assessment was investigated through the Newcastle-Ottawa Scale (NOS) and publication bias via Eggers' test and funnel plots.

RESULTS

A total of 47 studies, comprising of 4881 patients, were considered eligible for this meta-analysis. Both up-regulated and down-regulated circulating exomiRs are significantly associated with differentiation (HR = 1.353, P = 0.015; HR = 1.504, P = 0.016), TNM stage (HR = 2.058, P < 0.001; HR = 2.745, P < 0.001), lymph node metastasis (HR = 1.527, P = 0.004; HR = 2.009, P = 0.002), distant metastasis (HR = 2.006, P < 0.001; HR = 2.799, P = 0.002), worse overall survival (OS) (HR = 2.053, P < 0.001; HR = 1.789, P = 0.001) and poorer disease/relapse/progression-free survival (DFS/RFS/PFS) (HR = 2.086, P < 0.001; HR = 1.607, P = 0.001) in GI cancer patients, respectively. In addition, subgroup analyses based on seven subcategories indicated the robustness of the association. The majority of findings were lack of publication bias except for the association between up-regulated exomiRs and OS or DFS/RFS/PFS and for the down-regulated exomiRs and TNM stage.

CONCLUSION

This study supports that up- and down-regulated circulating exomiRs are associated with poorer survival outcomes and could be served as potential prognostic biomarkers in GI cancers. Given the limitations of the current findings, such as significant heterogeneity, more investigations are needed to fully clarify the exomiRs prognostic role.

Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade

Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.

Research trends in endoscopic applications in early gastric cancer: A bibliometric analysis of studies published from 2012 to 2022

Background

Endoscopy is the optimal method of diagnosing and treating early gastric cancer (EGC), and it is therefore important to keep up with the rapid development of endoscopic applications in EGC. This study utilized bibliometric analysis to describe the development, current research progress, hotspots, and emerging trends in this field.

Methods

We retrieved publications about endoscopic applications in EGC from 2012 to 2022 from Web of Science™ (Clarivate™, Philadelphia, PA, USA) Core Collection (WoSCC). We mainly used CiteSpace (version 6.1.R3) and VOSviewer (version 1.6.18) to perform the collaboration network analysis, co-cited analysis, co-occurrence analysis, cluster analysis, and burst detection.

Results

A total of 1,333 publications were included. Overall, both the number of publications and the average number of citations per document per year increased annually. Among the 52 countries/regions that were included, Japan contributed the most in terms of publications, citations, and H-index, followed by the Republic of Korea and China. The National Cancer Center, based in both Japan and the Republic of Korea, ranked first among institutions in terms of number of publications, citation impact, and the average number of citations. Yong Chan Lee was the most productive author, and Ichiro Oda had the highest citation impact. In terms of cited authors, Gotoda Takuji had both the highest citation impact and the highest centrality. Among journals, Surgical Endoscopy and Other Interventional Techniques had the most publications, and Gastric Cancer had the highest citation impact and H-index. Among all publications and cited references, a paper by Smyth E C et al., followed by one by Gotoda T et al., had the highest citation impact. Using keywords co-occurrence and cluster analysis, 1,652 author keywords were categorized into 26 clusters, and we then divided the clusters into six groups. The largest and newest clusters were endoscopic submucosal dissection and artificial intelligence (AI), respectively.

Conclusions

Over the last decade, research into endoscopic applications in EGC has gradually increased. Japan and the Republic of Korea have contributed the most, but research in this field in China, from an initially low base, is developing at a striking speed. However, a lack of collaboration among countries, institutions, and authors, is common, and this should be addressed in future. The main focus of research in this field (i.e., the largest cluster) is endoscopic submucosal dissection, and the topic at the frontier (i.e., the newest cluster) is AI. Future research should focus on the application of AI in endoscopy, and its implications for the clinical diagnosis and treatment of EGC.

Endoscopic resection for gastric submucosal tumors: Japanese multicenter retrospective study

OBJECTIVES

Limited information is available on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMTs) in Japanese endoscopic practice where ER for gastric tumors is extremely popular.

METHODS

We conducted this study to elucidate the current scenario of ER for gastric SMTs in Japanese endoscopic practice. Patients (from 12 institutions) with gastric SMTs who underwent ER were enrolled from the first case until August 2020.

RESULTS

We enrolled 117 patients with 118 lesions. The number of patients who underwent ER increased over the years. The mean endoscopic tumor size was 20 ± 7.2 (8-40) mm. The growth type was primarily intraluminal (90%). The mean resection and wound closure times were 58 ± 38 (range, 12-254) min and 31 ± 41 (range, 3-330) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full-thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for decompression. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Gastrointestinal stromal tumors were the most common pathology (74%). No recurrence was observed during the mean follow-up period of 4.3 ± 2.9 years. The 5-year overall survival rate was 98.9% (95% confidence interval 97.8-100%).

CONCLUSION

Performance of ER for gastric SMTs is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study.

Safety of early oral intake after endoscopic ultrasound-guided hepaticoenterostomy

BACKGROUND

Techniques and devices for endoscopic ultrasound (EUS)-guided hepaticoenterostomy (EUS-HES) procedures, including EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided hepaticojejunostomy (EUS-HJS), have been developed; however, the optimal timing to begin oral intake after EUS-HES remains unknown. This study aimed to evaluate the safety of early oral intake after EUS-HES.

METHODS

We retrospectively investigated patients who underwent EUS-HES (EUS-HGS or EUS-HJS) between March 2015 and March 2022. Patients who had no problems with the results of blood tests and computed tomography examinations on the morning of day 1 after EUS-HES were classified as either the early intake group (started oral intake on day 1 after EUS-HES) or the late intake group (started oral intake on day 2 or later after EUS-HES). Patients' characteristics, procedure characteristics, and early postprocedural adverse events (within 14 days after the procedure) were compared between groups.

RESULTS

Fifty patients were enrolled in this study. Forty-three patients had no problems with the results of examinations performed on the morning of day 1 after EUS-HES. Twenty-one patients comprised the early intake group and 22 comprised the late intake group. Adverse events that developed within 14 days after EUS-HES were not significantly different between groups (early 4.7% vs. late 9.0%; odds ratio, 0.50; 95% confidence interval, 0.0080-10.49; P = 1.00).

CONCLUSIONS

Starting oral intake on day 1 after EUS-HES did not increase postprocedural adverse events compared with starting oral intake on day 2 or later after EUS-HES.

Efficacy of endoscopic ligation with O-ring closure for prevention of bleeding after gastric endoscopic submucosal dissection under antithrombotic therapy: a prospective observational study

BACKGROUND

We examined the efficacy of a novel endoscopic ligation technique with O-ring closure (E-LOC) to prevent bleeding after gastric endoscopic submucosal dissection (ESD) under antithrombotic therapy.

METHODS

This single-center prospective study involved consecutive patients who were taking antithrombotic agents and underwent gastric ESD. E-LOC was performed by anchoring the nylon loop with hemoclips on both defect edges and/or the exposed muscle layer, and using O-ring band ligation around these deployed clips. The primary outcome was post-ESD bleeding rate. Secondary outcomes were complete closure rate, procedure time, sustained closure rate, and complications.

RESULTS

48 patients were finally analyzed. The post-ESD bleeding rate was 0 %, the complete closure rate was 97.9 %, and the mean closure time was 29.9 minutes. The sustained closure rate was 95.8 % at postoperative day 2-3 and 33.3 % at postoperative day 10-11. No complications occurred.

CONCLUSION

E-LOC may be an effective option for closing mucosal defects after gastric ESD under antithrombotic therapy. However, the preventive effect on post-ESD bleeding should be further investigated in high risk groups.

The Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project: Development of Criteria for Reporting Adverse Events During Surgical Procedures and Evaluating Their Impact on the Postoperative Course

BACKGROUND

Intraoperative adverse events (iAEs) are surgical and anesthesiologic complications. Despite the availability of grading criteria, iAEs are infrequently reported in the surgical literature and in cases for which iAEs are reported, these events are described with significant heterogeneity.

OBJECTIVE

To develop Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration criteria to standardize the assessment, reporting, and grading of iAEs. The ultimate aim is to improve our understanding of the nature and frequency of iAEs and our ability to counsel patients regarding surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

The present study involved the following steps: (1) collecting criteria for assessing, reporting, and grading of iAEs via a comprehensive umbrella review; (2) collecting additional criteria via a survey of a panel of experienced surgeons (first round of a modified Delphi survey); (3) creating a comprehensive list of reporting criteria; (4) combining criteria acquired in the first two steps; and (5) establishing a consensus on clinical and quality assessment utility as determined in the second round of the Delphi survey.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Panel inter-rater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α.

RESULTS AND LIMITATIONS

The umbrella review led to nine common criteria for assessing, grading, and reporting iAEs, and review of iAE grading systems led to two additional criteria. In the first Delphi round, 35 surgeons responded and two criteria were added. In the second Delphi round, 13 common criteria met the threshold for final guideline inclusion. All 13 criteria achieved the consensus minimum of 70%, with agreement on the usefulness of the criteria for clinical and quality improvement ranging from 74% to 100%. The mean inter-rater agreement was 89.0% for clinical improvement and 88.6% for quality improvement.

CONCLUSIONS

The ICARUS Global Collaboration criteria might aid in identifying important criteria when reporting iAEs, which will support all those involved in patient care and scientific publishing.

PATIENT SUMMARY

We consulted a panel of experienced surgeons to develop a set of guidelines for academic surgeons to follow when publishing surgical studies. The surgeon panel proposed a list of 13 criteria that may improve global understanding of complications during specific procedures and thus improve the ability to counsel patients on surgical risk.

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.

Comparison of 180° anti-reflux mucosectomy versus 270° anti-reflux mucosectomy for treatment of refractory gastroesophageal reflux disease: a retrospective study

BACKGROUND

Anti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD.

METHODS

This study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed.

RESULTS

Among 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups (p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups.

CONCLUSION

Although 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia.

Antithrombotics increase bleeding after endoscopic submucosal dissection for gastric cancer: Nationwide propensity score analysis

OBJECTIVES

Post-operative bleeding is the most common adverse event in endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Patients taking antithrombotic agents has increased. We evaluated the influence of antithrombotic agents on delayed bleeding in ESD for EGC.

METHODS

This was a post hoc analysis of nationwide, multicenter, retrospective cohort study in Japan. Altogether, 11,452 patients who underwent ESD for EGC in 33 institutions between November 2013 and October 2016 were enrolled. The primary outcome was the incidence of delayed bleeding in patients with or without antithrombotic agents. The secondary outcome was the incidence of delayed bleeding in those who took each antithrombotic agent and the cessation status of its use compared with each matched pair of patients. We used propensity matching and inverse probability of treatment weighting (IPTW) analyses.

RESULTS

There were 1353 matched pairs of patients. The incidence of delayed bleeding was 2.8% and 10.7% in those without and with antithrombotic agents, respectively (odds ratio [OR] 4.15, 95% confidence interval [CI] 2.88-5.99; P < 0.001). The IPTW analysis showed similar results (OR 4.21, 95% CI 3.48-5.08; P < 0.001). Antiplatelets, anticoagulants, and their combination increased such incidence. Heparin bridging therapy had high OR (8.80), and the continuation (OR 3.46) and cessation (OR 2.95) of antithrombotic agent use had similar risk.

CONCLUSIONS

Antithrombotic agents increased the incidence of delayed bleeding in patients who underwent ESD for EGC. Continuing antithrombotics may be more appropriate than heparin bridging therapy.

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.

Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

Deep Learning-Based Ultrasound Combined with Gastroscope for the Diagnosis and Nursing of Upper Gastrointestinal Submucous Lesions

The study focused on the diagnostic value of deep learning-based ultrasound combined with gastroscope examination for upper gastrointestinal submucous lesions and nursing. A total of 104 patients with upper gastrointestinal submucous lesions diagnosed in hospital were selected as the research subjects. In this study, the feed forward denoising convulsive neural network (DnCNN) was improved, and the n-DnCNN model was designed and applied to ultrasonic image processing. The peak signal-to-noise ratio (PSNR) and structural similarity (SSIM) of Gaussian filtering, NL-means, and DnCNN were then compared with n-DnCNN. Subsequently, the distribution and types of submucosal lesions in different parts of the upper digestive tract were analyzed by ultrasound combined with gastroscope and gastroscope examination alone, and the diagnostic performance of this method was evaluated. The results showed that the average PSNR and SSIM of the n-DnCNN model were 33.01 dB and 0.87, respectively, which were significantly higher than GF, NL-means, and DnCNN algorithms, and the difference was statistically significant ( $P<0.05$ ). Of the 116 lesions detected, 49 were located in the esophagus (42.24%), 52 in the stomach (44.83%), and 15 in the duodenum (12.93%). Of the 49 esophageal submucosal lesions, 6.12% were located in the upper esophagus, 55.1% in the middle esophagus, and 38.79% in the lower esophagus, and the difference was statistically significant ( $P<0.05$ ). Of the gastric submucosal lesions, the lesions in the gastric cardia were significantly less than in other parts, and the difference was statistically significant ( $P<0.05$ ). The accuracy of ultrasound combined with gastroscope in the diagnosis of upper gastrointestinal submucous episodes was 82.32%, higher than that of gastroscope examination, and the difference was statistically significant ( $P<0.05$ ). In conclusion, the n-DnCNN model has a good noise reduction effect, and the obtained image is of high quality. Ultrasound combined with gastroscope examination can effectively improve the accuracy of diagnosis of upper gastrointestinal submucous lesions.

Safety and efficacy of prophylactic gastric open peroral endoscopic myotomy for prevention of post-ESD stenosis: A case series (with video)

OBJECTIVE

Endoscopic resection of over 3/4 of the lumen of the antrum or pylorus is a known risk factor for post-endoscopic submucosal dissection (ESD) stenosis. Local or systemic steroids may reduce the risk of stenosis, but their overall role in stenosis prevention remains controversial. We aimed to evaluate the efficacy and safety of prophylactic gastric open peroral endoscopic myotomy (GO-POEM) in preventing post-ESD stenosis.

METHODS

Ten patients who underwent GO-POEM during or immediately after ESD in the Presbyterian Medical Center between June 2017 and November 2020 were included. All patients underwent excision of over 3/4 of the lumen of the antrum or pylorus. GO-POEM was performed without submucosal tunneling.

RESULTS

Well-differentiated tubular adenocarcinoma, tubulovillous adenoma with high-grade dysplasia, and tubular adenoma with low-grade dysplasia were diagnosed in three, one, and six patients, respectively. GO-POEM was performed successfully in all the 10 patients. Stenosis could not be evaluated in one patient, whereas one of the remaining nine patients developed post-ESD stenosis. GO-POEM decreased the risk of post-ESD stenosis in the other eight patients. Two patients presented with intraprocedural bleeding, both of whom were managed endoscopically successfully.

CONCLUSIONS

Prophylactic GO-POEM may be a novel, effective and safe treatment modality for preventing post-ESD stenosis in the stomach. Well-designed, multicenter studies with large sample sizes are needed to confirm our results.

Long-term outcomes of refractory esophageal strictures after endoscopic submucosal dissection of superficial esophageal neoplasms

Background

Many studies have focused on prophylactic therapy for post-endoscopic submucosal dissection (ESD) of esophageal strictures. However, various strategies cannot prevent the occurrence of postoperative strictures after extensive ESD. Postoperative strictures often inevitably occur, and endoscopic dilation is still a temporarily effective therapy.

Methods

This study included patients with post-ESD refractory esophageal strictures (RESs) from January 2014 to November 2019. Clinical effectiveness was assessed using univariate analysis and multivariate logistic regression. Hierarchical linear models were used to identify factors that predicted the dysphagia-free period.

Results

A total of 50 patients fulfilled the inclusion criteria and entered the study. Twenty-seven (54%) patients had a history of prophylactic oral steroid therapy. Forty-six patients (92%) underwent ≥ 75% circumferential resection, including 32 (64%) cases involving entire circumferential ESD. The mean dysphagia-free period of 50 patients was 2.9 months (95% CI 2.3–3.5). The dysphagia-free period had a linear growth trend over time, increasing by 6.9 days per endoscopic therapy, and the estimated last dysphagia-free period was 85.9 days. Old and female patients had shorter dysphagia-free periods compared with young and male patients. Endoscopic therapy success was achieved in 30 (60%) patients. Multivariate analysis revealed that circumferential lesions (OR 6.106, 95% CI 1.013–36.785, P = 0.048) were significant predictive factors for poor clinical outcome.

Conclusion

Endoscopic dilation seemed effective in patients with post-ESD RESs by increasing the dysphagia-free period. After approximately 10 continuous dilations, 60% of patients achieved endoscopic success, and the remission rate of obstruction was increased. Prophylactic oral steroid therapy could reduce the occurrence of RESs. However, once a RES had occurred, prophylactic steroid therapy could not reduce the frequency of dilations or change the long-term outcomes.

Trial registration: This study was prospectively registered and approved by the Ethics Committee of West China Hospital of Sichuan University (IRB number: ChiCTR-ONN-17012382) on 2015.

Randomized study of two endo-knives for the traction-assisted endoscopic submucosal dissection of early esophageal squamous cell carcinoma

Needle-type devices, such as the DualKnife (Olympus, Tokyo, Japan), are widely used for traction-assisted esophageal endoscopic submucosal dissection (ESD) but require a prolonged operation time. An improved model of the ITknife (Olympus), the ITknife nano, may allow faster and easier ESD than the DualKnife. We conducted a randomized study to compare the performances of the DualKnife and the ITknife nano for traction-assisted esophageal ESD. Patients with early esophageal squamous cell carcinoma were eligible for this study. The primary outcome was the total procedure time. The secondary outcomes were submucosal dissection time, en bloc, and complete resection rates, perforation rate, and adverse events. Results Fifty patients were equally divided into two groups: the DualKnife group (D-group) and the ITknife nano group (I-group), and all underwent the assigned treatment. The I-group had significantly shorter total procedure time (36.8 vs. 60.7 min; P < 0.01) and submucosal dissection time (17.2 vs. 35.8 min; P < 0.01) than the D-group. The en bloc and complete resection rates were sufficiently high in both groups (100% and 100% in the D-group and 100% and 96% in the I-group, respectively). Significantly fewer hemostatic procedures due to intraoperative bleeding were performed in the I-group than in the D-group (0.2 vs. 1.4; P < 0.01). Delayed bleeding, perforation, or esophageal stricture did not occur in either group. The ITknife nano exhibited lower procedure time for traction-assisted esophageal ESD than the DualKnife, without increasing adverse events.

Propensity score matching analysis to evaluate efficacy of polyethylene oxide adhesive on preventing delayed bleeding after gastric endoscopic submucosal dissection

Regardless of technical advancements, delayed bleeding is still a common adverse event after gastric endoscopic submucosal dissection (ESD), often occurring in the early postoperative phase. This study aimed to evaluate the efficacy of a newly designed polyethylene oxide (PEO) adhesive for preventing delayed gastric bleeding. Patients who underwent gastric ESD between December 2017 and December 2020 at three Chinese institutions were retrospectively reviewed. Patients receiving PEO application on gastric post-ESD ulcers were included in the PEO group, and patients without this procedure were included in the control group. To minimize potential bias, propensity score matching was performed, and sex, age, lesion size, lesion morphology, ulceration, localization, procedure time, frequency of major intraoperative bleeding, resected specimen size, lesion histopathology, submucosal invasion and the taking of antithrombotic drugs were included as matching factors. The incidence of delayed bleeding and time to bleeding were compared between both groups. After propensity score matching, 270 patients (135 per group) were included in the analysis. The delayed bleeding rate in the PEO group was significantly lower than that in the control group (1.5%, 2/135 vs. 8.9%, 12/135, P = 0.006). The median time (range) to bleeding was 4.5 (4–5) days in the PEO group and 2 (1–15) days in the control group, with no significant difference (P = 0. 198). PEO demonstrated a significant effect in reducing the rate of delayed bleeding. Further study is warranted to confirm the efficacy of PEO for bleeding that occurs in the early phase after gastric ESD.

Simultaneous endoscopic submucosal dissection for synchronous multiple early esophageal squamous cell carcinoma: a propensity score-matched analysis

BACKGROUND

The clinical effect of endoscopic submucosal dissection (ESD) in the treatment of early esophageal squamous cell carcinoma (EESCC) is widely recognized. However, the long-term treatment outcome of simultaneous ESD for multiple EESCC currently remained unknown. Hence, this study was aimed at further evaluating the long-term outcome of simultaneous ESD for synchronous multiple EESCC by comparing with ESD for single EESCC.

METHODS

Consecutive patients who underwent ESD for EESCC from June 2008 to June 2018 were included. Propensity score-matched analysis was used to compensate for the differences in age, sex, tumor location, tumor size, and tumor invasion depth between simultaneous and single ESD groups. Treatment outcomes including en bloc resection rate, curative resection rate, complication rate, and long-term outcomes including overall survival (OS), recurrence-free survival (RFS), metachronous recurrence were compared between the 2 groups after matching.

RESULTS

The propensity score-matched analysis included 332 lesions (166 patients) and 332 lesions (332 patients) in simultaneous and single ESD groups, respectively. Among all the outcomes, en bloc resection, curative resection, 5-year OS, and 5-year RFS rates were comparable. Complications were more common in the simultaneous ESD group (15.06% vs. 9.64%, P = 0.073). The 5-year metachronous recurrence rates were significantly high in the simultaneous ESD groups (24.28% vs. 6.99%).

CONCLUSIONS

Simultaneous ESD is an effective and safe methodology for synchronous multiple EESCC; it also reduces hospital stay and medical expenses. The risk of metachronous recurrence is higher for patients with synchronous multiple EESCC; thus, more intensive strategies are required.

Risk factors of postoperative stricture after endoscopic submucosal dissection for superficial esophageal neoplasms: A meta-analysis

BACKGROUND

As larger-sized superficial esophageal neoplasms became candidates for endoscopic submucosal dissection (ESD), post-ESD esophageal stricture has inevitably developed into a significant complication during long-term follow-up.

METHOD

The PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, as well as China National Knowledge Infrastructure, the Wanfang Database, and the Chinese Biomedical Literature Database, were searched to identify all the appropriate studies published from January 2000 through October 2019. For risk factor assessment between postoperative stricture and control groups, pooled odds ratios (OR) and weighted mean differences (WMD) estimation was done. All meta-analytical procedures were conducted by using Stata version 15.1 software.

RESULTS

The results showed that 11 studies with 2248 patients (284 structure cases and 1964 controls) were eligible for this meta-analysis. Statistical results indicated 6 substantial risk factors: lesion characteristics involving the upper third of the esophagus (OR 1.51, [1.02-2.25]), macroscopic type of IIa/IIc (OR 2.76, [1.55-4.92]), tumor depth of invasion above m1 (OR 7.47, [3.31-16.86]), and m2 (OR 12.67, [4.00-40.10]), longitudinal length (WMD 13.75 mm, [7.76-19.74]), circumferential diameter (WMD 10.87 mm, [8.13-13.60]), and circumferential range >3/4 (OR 38.17, [9.94-146.52]). Each additional 10% of the circumferential range increased the risk of stricture by 149% (OR 9282.46, [978.14-88089.35]).

CONCLUSIONS

Six risk factors were assessed to have a key role in the elevated risk levels of post-ESD esophageal stricture. The results can help doctors identify patients with increased risk and thus can guide management of the adequate period of surveillance after ESD and take available approaches of stricture prevention.

Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.