Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm

Painkiller administration after endoscopic submucosal dissection surgery: a retrospective real-world study

OBJECTIVES

This study aimed to investigate the frequency of analgesic administration within 48 h after endoscopic submucosal dissection (ESD) or its derivative techniques across different segments of the digestive tract, as well as the timing of the initial analgesic administration.

MATERIALS AND METHODS

This retrospective observational study was built upon previous research. The primary outcomes assessed were the time to initial analgesic administration postoperatively and the frequency of analgesic use within 48 h after ESD surgery. Additionally, factors influencing painkiller administration in ESD patients were analyzed.

RESULTS

Of the 2162 patients included in the study, 570 (26.36%) required postoperative analgesic medications. Most patients required their initial analgesic within 8 h following ESD, with the highest demand observed within 2 h. Multivariate Cox regression analysis indicated that intraoperative administration of ketorolac reduced the likelihood of analgesic administration within 2 h postoperatively (hazard ratio [HR] = 0.35, 95% confidence interval [CI]: 0.15-0.79, p = 0.012). The time to first analgesic administration did not differ significantly among patients with varying surgical sites (H = 2.043, p = 0.843) or surgical methods (H = 8.647, p = 0.071). Similarly, no significant difference was observed in the frequency of analgesic use within 48 h across different surgical sites (H = 3.817, p = 0.576). However, patients who underwent endoscopic submucosal excavation (ESE) surgery exhibited a lower frequency of analgesic use compared to those who underwent endoscopic full-thickness resection (EFR) surgery (p = 0.038).

CONCLUSIONS

A subset of patients undergoing ESD exhibited a need for analgesics within the initial 48-hour postoperative period. Clinicians should carefully assess patients' pain needs and implement appropriate pain relief measures to improve postoperative outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Registry; ChiCTR2300072854.

Research on the method of mucosal negative pressure electrocoagulation marking under gastrointestinal endoscopy

With the development of medical equipment technology, minimally invasive surgery has become the core advancement direction in surgical treatment. There are still some issues with mucosal marking and injection under gastrointestinal endoscopy. This paper aims to study a novel negative pressure electrocoagulation marking technique. Using a negative pressure pump in conjunction with a radiofrequency energy emission platform, we compared the effects of conventional electrocoagulation marking and negative pressure electrocoagulation marking using porcine stomachs as experimental subjects. The experimental system includes a negative pressure electrocoagulation platform and a radiofrequency energy emission platform. The experimental materials are fresh porcine stomachs. Electrocoagulation marking of porcine stomach under no negative pressure and negative pressure conditions. An infrared thermal imaging camera was used to measure the temperature. The experimental results showed that the highest average temperature in the no negative pressure group was 78.2 ± 7.6°C, while in the negative pressure group it was 78.1 ± 7.9°C, with no significant difference between the two (p = 0.8557). During subsequent injection tests, the average burst pressure in the no negative pressure group was 66.40 ± 16.96 mmHg, while in the negative pressure group it was 83.48 ± 28.56 mmHg. The negative pressure group had a significantly higher burst pressure (p = 0.0135), indicating that the negative pressure electrocoagulation marking technique can significantly enhance mucosal elevation. The results suggest that the negative pressure electrocoagulation marking technique has great potential for application in gastrointestinal endoscopic surgery. It can improve the safety of the surgery without increasing thermal injury, helping to reduce the incidence of intraoperative complications.

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

Background and aims

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

Methods

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

Results

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

Conclusions

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Clinical outcomes and risk factors of post-polypectomy microperforation in patients with colorectal neoplasia: a case-control study

Background

Colonoscopic polypectomy significantly reduces the incidence of colorectal cancer, but it carries potential risks, with colonic perforation being the most common and associated with significant morbidity.

Objectives

This study evaluated the clinical outcomes and risk factors of microperforation during colonoscopic polypectomy.

Design

A retrospective cohort study.

Methods

We retrospectively reviewed the patients' records who underwent colonoscopic polypectomy and subsequent plain radiographic examination to monitor perforation. Patients with pneumoperitoneum detected on plain radiography were enrolled. Patients who underwent adverse event-free colonoscopic polypectomies within 1 week of each case and were matched 2:1 by age and sex to the cases were selected as controls.

Results

Microperforations occurred in 12 patients (8 males; age: median 64.5 years). Polyps with microperforations were more frequent in the right colon (83.3% vs 33.3%). Endoscopic mucosal resection with precutting (EMR-P; 16.7% vs 0.0%) or hot-snare polypectomy (8.3% vs 0.0%) was more frequently performed in the microperforation group. Muscle fibers at the polypectomy site were more frequently visible in the microperforation group (58.3% vs 8.3%). By multivariate analysis, right colon location and visible muscle fibers were independent risk factors for microperforation. All patients with microperforation received intravenous antibiotics and were advised to fast. Patients responded well to these conservative treatments and were discharged after a median of 3 (2-6.75) days of hospital stay.

Conclusion

Our data suggest that conservative treatment is feasible and could be the primary management option for selected patients with microperforations postcolonoscopic polypectomy. Right-sided colonic polyps and visible muscle fibers predispose to microperforations.

High Joule heat as a risk factor for post-endoscopic submucosal dissection electrocoagulation syndrome: A multicenter prospective study

BACKGROUND

Thermal damage may lead to inflammation of the peeled mucosal surface during endoscopic submucosal dissection (ESD).

AIM

To determine the effect of Joule heat on the onset of post-ESD electrocoagulation syndrome (PECS).

METHODS

In this prospective study, PECS was characterized by in-hospital fever (white blood cell count: ≥ 10000 μ/L or body temperature ≥ 37.5 °C) and abdominal pain (visual analog scale score ≥ 30 mm during hospitalization or increased by ≥ 20 mm from baseline at admission). High Joule heat was defined as 15390 J. Between April 2020 and April 2024, 209 patients underwent colorectal ESD; those with intraoperative perforation or penetration were excluded. The remaining 202 patients were divided into the PECS and non-PECS groups.

RESULTS

PECS occurred in 30 (14.9%) patients. Multivariate analysis revealed high Joule heat as an independent factor associated with PECS (odds ratio = 7.96; 95% confidence interval: 2.91-21.8, P < 0.01). The procedure time and presence of lesions in the right colon were not associated with PECS.

CONCLUSION

Accumulated thermal damage on the peeled mucosal surface should be considered during PECS onset. This thermal damage is likely a major component of the mechanism underlying PECS.

Comparing underwater endoscopic submucosal dissection and conventional endoscopic submucosal dissection for large laterally spreading tumor: a randomized controlled trial (with video)

BACKGROUND AND AIMS

Colorectal endoscopic submucosal dissection (ESD) is challenging despite its usefulness. Underwater ESD (UESD) provides better traction and a clearer view of the submucosal layer than conventional ESD (CESD). This study compared the efficiency of UESD and CESD for large (20-50 mm) laterally spreading tumors (LSTs).

METHODS

Preplanned sample size was calculated from our previous experience. As a result, 28 patients were required for the UESD group and CESD group each. The primary outcome was total procedure time; the secondary outcome was dissection speed.

RESULTS

Fifty-six patients were enrolled, and a total of 28 patients were assigned to each group. The mean LST size was 31.6 mm and 31.3 mm in the UESD and CESD groups, respectively. Fibrosis was observed in 67.9% and 60.7% of patients in the UESD and CESD groups. Total procedure time (mean ± standard deviation) for the UESD group was significantly shorter than that for the CESD group (49.5 ± 20.3 minutes vs 75.7 ± 36.1 minutes; mean difference, -26.2 minutes; 95% confidence interval, -42.0 to -10.5 minutes). Dissection speed of the UESD group was significantly faster than that of the CESD group (21.9 ± 6.9 mm2/min vs 15.2 ± 7.3 mm2/min; mean difference, 6.7 mm2/min; 95% confidence interval, 2.8 to 10.4 mm2/min). There was no difference between groups in the R0 resection rate or en bloc resection rate. No perforations were observed in either group.

CONCLUSIONS

UESD was superior to CESD in total procedure time and dissection speed. UESD can be recommended as the preferred method for the resection of large LSTs.

Clinical utility of a novel anchor pronged clip for mucosal defect closure after colorectal endoscopic submucosal dissection (with video)

Background and study aims The MANTIS Clip (Boston Scientific) is a novel anchor pronged clip designed to enhance tissue grasping and facilitate the closure of defects in the gastrointestinal tract. This study evaluates the feasibility and effectiveness of the MANTIS Clip for closing mucosal defects following colorectal endoscopic submucosal dissection (C-ESD). Patients and methods A retrospective single-center study was conducted on patients who underwent C-ESD with MANTIS Clip closure from May 2023 to April 2024. The primary outcome measured was the complete closure success rate. Secondary outcomes included defect size, sustained closure rate, closure time, number of clips used, adverse events (AEs), and hospital stay duration. Results The MANTIS Clip was used in 52 cases. The complete closure rate was 98.1% (51/52), with a sustained closure rate of 96.1% (49/51). The median closed defect size was 32 mm, with the largest being 62 mm. The median closure time was 8 minutes. Typically, one MANTIS Clip per defect was used, with only one lesion requiring two clips. The median number of additional clips used was seven. AEs included one case of bleeding (1.9%) and one case of post-ESD coagulation syndrome (1.9%), both managed without extending hospital stays. The median C-reactive protein level on the first day post-ESD was 0.35 mg/dL and the median hospital stay was 5 days. Conclusions The MANTIS Clip is effective and practical for mucosal defect closure post-C-ESD, demonstrating high success and sustained closure rates with minimal complications. Future multicenter randomized trials are needed to further assess its efficacy and safety.

A Case of Colonic Intussusception with Post-polypectomy Electrocoagulation Syndrome and Review of Literature: How to Manage Intussusception Following Colonoscopy?

Colonic intussusception is often reported to be related to malignancy in adults. Colonoscopy itself with or without polypectomy is known to be a rare cause of colonic intussusception. We encountered a case in which an individual was diagnosed with intussusception following colonoscopy. The patient was a 44-year-old female who, on the same day, had undergone a colonoscopy including endoscopic mucosal resection for a polyp in the ascending colon. She visited the emergency room with complaints of right-sided abdominal pain. Abdominal examination revealed peritoneal irritation in the right upper quadrant. Abdominal CT revealed colocolic intussusception near the hepatic flexure. This was suspected to have been induced by post-polypectomy electrocoagulation syndrome. A laparoscopic right hemicolectomy was performed because conducting a reduction trial through colonoscopy involves a high risk of peritonitis, in addition to a low likelihood of spontaneous reduction of intussusception due to the additional edema and ischemia resulting from the polypectomy. The patient was discharged without complications six days after the surgery. Though some cases have been reported, there is no treatment strategy for intussusception following colonoscopy. Therefore, we report this case of colonic intussusception following colonoscopy, which was found to be caused by Post-polypectomy Electrocoagulation Syndrome, with a literature review.

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

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

Establishment and Validation of Risk Prediction Models for Postoperative Pain After Endoscopic Submucosal Dissection: A Retrospective Clinical Study

Objective

Postoperative pain is a common complication in endoscopic submucosal dissection (ESD) patients. This study aimed to develop and validate predictive models for postoperative pain associated ESD.

Methods

We retrospectively constructed a development cohort comprising 2162 patients who underwent ESD at our hospital between January 2015 and April 2022. The dataset was randomly divided into a training set (n = 1541) and a validation set (n = 621) in a 7:3 ratio. The bidirectional stepwise regression with Akaike's information criterion (AIC) and multivariate logistic regression analysis were used to screen the predictors of post-ESD pain and construct three nomograms. We evaluated the model's discrimination, precision and clinical benefit through receiver operating characteristic (ROC) curves, calibration plots, Hosmer-Lemeshow (HL) goodness-of-fit test and decision curve analysis (DCA) in internal validation.

Results

The proportion of patients developing postoperative pain in the training and testing data set was 25.6% and 28.5%, respectively. Three nomograms were constructed according to the final logistic regression models. The clinical prediction models for preoperative risks, preoperative and intraoperative risks, and perioperative risks consisted of seven, nine and six independent predictors, respectively, after bidirectional stepwise elimination. The models demonstrated the AUC of 0.794 (95% CI 0.768-0.820), 0.823 (95% CI 0.799-0.847) and 0.817 (95% CI 0.792-0.842) in the training cohort and 0.702 (95% CI 0.655-0.748), 0.705 (95% CI 0.659-0.752) and 0.747 (95% CI 0.703-0.790) in the validation cohort. The calibration plot, HL and DCA demonstrated the model's favorable clinical applicability.

Conclusion

We developed and validated three robust nomogram models, which might identify patients at risk of post-ESD pain and promising for clinical applications.

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

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

Prospective cross-organ analysis for the causes of fever and increased inflammatory response after endoscopic resection

OBJECTIVES

Fever and increased inflammatory responses sometimes occur following endoscopic resection (ER). However, the differences in causes according to the organ are scarcely understood, and several modified ER techniques have been proposed. Therefore, we conducted a comprehensive prospective study to investigate the cause of fever and increased inflammatory response across multiple organs after ER.

METHODS

We included patients who underwent gastrointestinal endoscopic submucosal dissection (ESD) and duodenal endoscopic mucosal resection at our hospital between January 2020 and April 2022. Primary endpoints were fever and increased C-reactive protein (CRP) levels following ER. The secondary endpoints were risk factors for aspiration pneumonia. Blood tests and radiography were performed on the day after ER, and computed tomography was performed if the cause was unknown.

RESULTS

Among the 822 patients included, aspiration pneumonia was the most common cause of fever and increased CRP levels after ER of the upper gastrointestinal tract (esophagus, 53%; stomach, 48%; and duodenum, 71%). Post-ER coagulation syndrome was most common after colorectal ESD (38%). On multivariate logistic regression analysis, lesions located in the esophagus (odds ratio [OR] 3.57; P < 0.001) and an amount of irrigation liquid of ≥1 L (OR 3.71; P = 0.003) were independent risk factors for aspiration pneumonia.

CONCLUSIONS

Aspiration pneumonia was the most common cause of fever after upper gastrointestinal ER and post-ER coagulation syndrome following colorectal ESD. Lesions in the esophagus and an amount of irrigation liquid of ≥1 L were independent risk factors for aspiration pneumonia.

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

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

Association of local steroid injection as a risk factor for electrocoagulation syndrome after esophageal endoscopic submucosal dissection

BACKGROUND

Postendoscopic submucosal dissection electrocoagulation syndrome (PEECS) is commonly observed after performing endoscopic submucosal dissection (ESD) for esophageal neoplasia. However, data on the incidence and risk factors for PEECS in the esophagus are lacking due to an unclear definition of PEECS and varied clinical settings. Therefore, we aimed to determine the risk factors for PEECS in patients undergoing ESD for esophageal neoplasia.

METHODS

We retrospectively reviewed data of relevant clinical and endoscopy-specific parameters from 202 consecutive patients with esophageal neoplasias (139 carcinomas and 63 dysplasias) who underwent ESD under general anesthesia. Esophageal PEECS was defined by satisfying at least two of the following criteria: fever ≥ 37.8 °C, leukocytosis ≥ 10,800/mm3, and localized chest pain ≥ 5/10 points as assessed on a numeric rating scale within 24 h after ESD. Significant factors associated with PEECS were determined by regression analysis.

RESULTS

PEECS was recorded in 98 of 202 (48.5%) patients. Patients with PEECS exhibited a larger tumor size (25.0 vs. 17.0 mm, P = 0.002), longer procedure (40.0 vs. 29.5 min, P = 0.021) and hemostasis times (5.0 vs. 3.5 min, P = 0.004), required greater submucosal injection volume (60.0 mL vs. 50.0 mL, P = 0.030), and had a lower rate of local steroid injection (4.1% vs. 12.5%, P = 0.029) than those without PEECS. Multivariate regression analysis revealed tumor size ≥ 17 mm (P = 0.047), procedure time ≥ 33 min (P = 0.027), and hemostasis time ≥ 5 min (P = 0.007) as risk factors for PEECS. In addition, local steroid injection was a significant negatively associated factor (P = 0.001).

CONCLUSIONS

Patients with a large tumor, prolonged procedure and hemostasis times are at a high risk of PEECS occurrence. Further, local steroid injection is a negatively associated factor.

Risk factors and a nomogram for prediction of post-endoscopic submucosal dissection electrocoagulation syndrome for superficial colorectal lesions

BACKGROUND

Post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) is an uncommon complication after colorectal endoscopic submucosal dissection (ESD). This study aimed to explore the risk factors of PEECS for superficial colorectal lesions based on the latest and consistent diagnostic criteria and to establish a predictive nomogram model.

METHODS

This retrospective analysis included patients with superficial colorectal lesions who underwent endoscopic submucosal dissection (ESD) between June 2008 and December 2021 in our center. The independent risk factors of PEECS for superficial colorectal lesions were identified using least absolute shrinkage and selection operator (LASSO) logistic regression analysis, as well as univariate analysis and multivariate logistic regression, and derived predictive nomogram model was constructed.

RESULTS

Among the 555 patients with superficial colorectal lesions enrolled, PEECS occurred in 45 (8.1%) patients. Multivariate logistic regression revealed that female sex (OR 3.94, P < 0.001), age > 50 years (OR 4.28, P = 0.02), injury to muscle layer (OR 10.38, P < 0.001), non-lifting sign (OR 2.20, P = 0.04) and inadequate bowel preparation (OR 5.61, P < 0.001) were independent risk factors of PEECS for superficial colorectal lesions. A predictive nomogram model was constructed based on the above five predictors. For this model, the area under the receiver operating characteristic (ROC) curve was 0.855, the calibration curve exhibited good consistency between the prediction and the actual observation, and the C-index was confirmed as 0.843 by bootstrap method.

CONCLUSION

Female sex, age > 50 years, injury to muscle layer, non-lifting sign and inadequate bowel preparation were independent risk factors of PEECS for superficial colorectal lesions. The proposed nomogram could accurately predict the risk of PEECS for superficial colorectal lesions.

Risk Prediction of Post-Endoscopic Submucosal Dissection Coagulation Syndrome

INTRODUCTION

Endoscopic submucosal dissection (ESD) has been popular worldwide to treat laterally spreading tumors and large polyps. Post-ESD coagulation syndrome (PECS) is more common than the two major ESD-related complications, perforation, and bleeding. The aim of this study was to assess the prevalence of PECS, identify the risk factors for PECS, and create a risk prediction model for PECS.

METHODS

Retrospective cross-sectional study analyzed a total of 986 patients who underwent colorectal ESD. Logistic regression models were used to assess risk factors with PECS. Each risk factor was scored, and the 3-step risk stratification index of prediction model was assessed.

RESULTS

The prevalence of PECS was 21.4% (95% confidence interval [CI] = 18.9-24.1%). The risk factors of PECS in the multivariate logistic regression were tumor size (+1 cm: odds ratio [OR], 1.29; 95% CI, 1.16-7.09), cecal lesion (OR, 1.96; 95% CI, 1.09-1.53), procedure time (+30 min: OR, 1.19; 95% CI, 1.02-1.39), and ESD with snaring (OR, 0.64; 95% CI, 0.43-0.95). Applying a simplified weighted scoring system based on adjusted OR increments of 1, the risk of PECS was 12.3% (95% CI, 0.3-16.0%) for the low-risk group (score ≤4) and was 36.0% (95% CI = 29.4-43.2%) for the high-risk group (score ≥8). Overall discrimination (C-statistic = 0.629; 95% CI = 0.585-0.672) and calibration (p = 0.993) of the model were moderate to good.

CONCLUSION

PECS occurs frequently, and the prediction model can be helpful for effective treatment and prevention of PECS.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A prospective cohort study of a new electrosurgical unit for preventing colorectal post-endoscopic submucosal dissection coagulation syndrome

BACKGROUND AND AIM

Post-endoscopic submucosal dissection coagulation syndrome (PECS) is a recognized complication of colorectal endoscopic submucosal dissection (ESD); however, there is a lack of interventions for preventing PECS. We therefore conducted a prospective study to evaluate the utility of maXium, a novel electrosurgical unit, for preventing PECS.

METHODS

This single-center, prospective cohort study prospectively enrolled patients undergoing colorectal ESD. The voltage and power of the electrosurgical units were measured. PECS was defined as a visual analog scale (VAS) ≥ 30 mm, an increase of VAS ≥ 20 mm from baseline, body temperature ≥ 37.5°C, or white blood cell count ≥ 10 000/μL after ESD. PECS was classified into type I (without extra-luminal air) and type II (with peri-luminal air). The primary endpoint was the incidence of PECS. A sample size of 92 patients was required to ensure the upper limit of the 90% CI for the incidence of PECS was less than 15%.

RESULTS

At resistances greater than 400 Ω, the maXium unit allowed submucosal dissection with lower power than with the VIO300D unit. Ninety-one patients meeting the inclusion criteria were included in the final study analysis. The incidence of PECS was 16% (90% CI, 10-23%), comprising type I (11%) and type II (5%) PECS. Simple extra-luminal air without PECS was observed in 7% of patients.

CONCLUSION

Use of the maXium electrosurgical unit did not reduce the incidence of PECS after colorectal ESD; however, the maXium unit had equivalent performance to a conventional electrosurgical unit used for colorectal ESD.

Analysis of Predictors and Risk Factors of Postpolypectomy Syndrome

BACKGROUND AND AIMS

Postpolypectomy syndrome (PPS) is a relevant adverse event that can appear after polypectomy. Several publications mention postpolypectomy syndrome using different criteria to define it. The aim of this study is to detect potential risk factors and predictors for developing PPS and to define the main criteria of PPS.

METHODS

In this retrospective monocentric study, 475 out of 966 patients who underwent colonoscopy with polypectomy from October 2015 to June 2020 were included. The main criterion of PPS is defined as the development of postinterventional abdominal pain lasting more than six hours.

RESULTS

A total of 9.7% of the patients developed PPS, which was defined as local abdominal pain around the polypectomy area after six hours. A total of 8.6% of the study population had abdominal pain within six hours postintervention. A total of 3.7% had an isolated triad of fever, leukocytosis, and increased CRP in the absence of abdominal pain. Increased CRP combined with an elevated temperature over 37.5 °C seems to be a positive predictor for developing PPS. Four independent risk factors could be detected: serrated polyp morphology, polypoid configurated adenomas, polyp localization in the cecum, and the absence of intraepithelial neoplasia.

CONCLUSIONS

Four independent risk factors for developing PPS were detected. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology. As expected, the increasing use of cold snare polypectomies will reduce the incidence of this syndrome. Key summary: Our monocentric study on 966 patients detected four independent risk factors for developing PPS: pedunculated polyp, resected polyps in the cecum, absence of IEN, and serrated polyp morphology. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology.

Novel quantitative assessment indicators for efficiency and precision of endoscopic submucosal dissection in animal training models by analyzing an electrical surgical unit

OBJECTIVES

Although endoscopic submucosal dissection (ESD) training is important, quantitative assessments have not been established. This study aimed to explore a novel quantitative assessment system by analyzing an electrical surgical unit (ESU).

METHODS

This was an ex vivo study. Step one: to identify the novel efficiency indicators, 20 endoscopists performed one ESD each, and we analyzed correlations between their resection speed and electrical status. Step two: to identify the novel precision indicators, three experts and three novices performed one ESD each, and we compared the stability of the electrical status. Step three: three novices in step two performed 19 additional ESDs, and we analyzed the learning curve using novel indicators.

RESULTS

Step one: the percentage of total activation time (AT) of ESU in the procedure time (β coefficient, 0.80; P < 0.01) and AT required for submucosal dissection (β coefficient, -0.57; P < 0.01) were significantly correlated with the resection speed. Step two: coefficient of variation of the AT per one pulse (0.16 [range, 0.13-0.17] vs. 0.26 [range, 0.20-0.41], P = 0.049) and coefficient of variation of the peak electric power per pulse during mucosal incision (0.14 [range, 0.080-0.15] vs. 0.25 [range, 0.24-0.28], P = 0.049) were significantly lower in the experts than in the novices. Regarding the learning curve, the percentage of total AT of ESU in the procedure time and AT required for submucosal dissection had a trend of improvement.

CONCLUSION

Novel indicators identified by analyzing ESU enable quantitative assessment for endoscopist's skill.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Underwater endoscopic submucosal dissection for colorectal tumors decreases the incidence of post-electrocoagulation syndrome

BACKGROUND AND AIMS

Underwater endoscopic submucosal dissection (U-ESD) is a recently developed procedure that has the potential to prevent post-ESD coagulation syndrome (PECS) owing to its heat-sink effect. We aimed to clarify whether U-ESD decreases the incidence of PECS compared with conventional ESD (C-ESD).

METHODS

A total of 205 patients who underwent colorectal ESD (C-ESD: 125; U-ESD: 80) were analyzed. Propensity score matching analysis was performed to adjust for patient backgrounds. Ten C-ESD and two U-ESD patients with muscle damage or perforation during ESD were excluded when comparing PECS. The primary outcome was to compare the incidence of PECS between the U-ESD and C-ESD groups (54 matched pairs). Secondary outcomes were to compare procedural outcomes between the C-ESD and U-ESD groups (62 matched pairs).

RESULTS

Among the 78 patients who underwent U-ESD, PECS occurred in only one patient (1.3%). Adjusted comparisons between the U-ESD and C-ESD groups demonstrated a significantly lower incidence of PECS in the U-ESD group (0% vs 11.1%; P = 0.027). Median dissection speed was significantly faster in the U-ESD than in the C-ESD group (10.9 mm2 /min vs 6.9 mm2 /min; P < 0.001). En bloc and complete resection rates were 100% in the U-ESD group. Although perforation and delayed bleeding occurred in one patient each (1.6%) as adverse events in the U-ESD group, there were no differences compared with the C-ESD group.

CONCLUSIONS

Our study demonstrates that U-ESD effectively decreases the incidence of PECS and is a faster and safer method for colorectal ESD.

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.

Modified double-layered suturing for a mucosal defect after colorectal endoscopic submucosal dissection (Origami method) (with video)

BACKGROUND AND AIMS

Through-the-scope clips (TTSCs) are among the most common devices used to close colorectal post-endoscopic submucosal dissection (ESD) defects. Although TTSCs are easy to deliver, even to the proximal colon, simple clipping of large defects results in mucosa-mucosa closure, which could be unreliable. We developed a novel endoscopic closure technique using a modified double-layered suturing called the origami method (OGM). This method closes not only the mucosal layer but also the muscle layer with only TTSCs, which can obtain robust closure even for large defects. This study aimed to evaluate the feasibility of this new closure method for colorectal post-ESD defects.

METHODS

This retrospective observational study was conducted at a tertiary care hospital. We reviewed the cases of the OGM attempted after colorectal ESD at our institute between October 2021 and October 2022 and measured the clinical characteristics and outcomes of enrolled cases.

RESULTS

The OGM was attempted in 47 cases after colorectal ESD. Thirty-one cases (66%) were in the proximal colon, 5 (11%) in the distal colon, 6 (13%) in the upper rectum, and 5 (10%) in the lower rectum. The median defect size was 38 mm, with the largest being 85 mm. Complete closure was achieved in 44 cases (94%), including all lower rectum cases. No perforations were caused by clips during closure, and delayed perforation and bleeding were not observed.

CONCLUSIONS

This new closure method is feasible and recommended. The OGM could achieve reliable closure of large defects in any location, including the proximal colon and thick-walled lower rectum, using only TTSCs.

Short‐term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions

Objectives

Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients.

Methods

Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events.

Results

A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors.

Conclusions

No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.

Dexmedetomidine is safe and effective for reducing intraprocedural pain in colorectal endoscopic submucosal dissection

Objectives

Endoscopic submucosal dissection (ESD) is effective for the resection of colorectal intramucosal lesions. This study was performed to examine the safety and effectiveness of using dexmedetomidine (DEX) in the anesthesia regimen of patients with colorectal lesions undergoing ESD.

Methods

We retrospectively examined 287 consecutive patients who underwent ESD for colorectal lesions in our institution from January 2015 to December 2021. Outcomes including the frequency of intraprocedural pain and adverse events were compared between the DEX and no DEX groups. Moreover, univariate and multivariate analyses were conducted for each clinical factor of intraprocedural pain. Intraprocedural pain was defined as patient-reported abdominal pain or body movement during the procedure.

Results

The incidence of intraprocedural pain was significantly lower in the DEX than in the no DEX group (7% vs. 17%, p = 0.02). The incidence of hypotension was also significantly higher in the DEX group (7% vs. 0%, p = 0.01), but no cerebrovascular or cardiac ischemic events occurred. In the univariate analyses, the diameter of the resected specimen, procedure time, no use of DEX, and total midazolam dose was associated with intraprocedural pain. The midazolam dose and DEX administration were significantly negatively correlated and the diameter of resected specimen and procedure time were significantly positively correlated. Multivariate logistic regression showed that no use of DEX was independently associated with intraprocedural pain (p = 0.02).

Conclusions

Adding DEX to the anesthesia regimen in patients undergoing colorectal ESD appears to be safe and effective for reducing intraprocedural pain.

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.

Injury to the muscle layer, increasing the risk of post-colorectal endoscopic submucosal dissection electrocoagulation syndrome

BACKGROUND AND AIM

In colorectal endoscopic submucosal dissection (ESD), post-ESD electrocoagulation syndrome (PECS) has been recognized as one of the major complications. There are no reports on the relationships between ESD findings and PECS. This study aims to evaluate the risk factors for PECS, including ESD findings such as muscularis propria exposure.

METHODS

We performed a retrospective cohort study of patients who underwent colorectal ESD between January 2017 and December 2021 in Japan. The grade of injury to the muscle layer caused by ESD was categorized as follows: Grade 0, no exposure of muscularis propria; Grade 1, muscularis propria exposure; Grade 2, torn muscularis propria; and Grade 3, colon perforation. The risk factors for PECS, including injury to the muscle layer, were analyzed by univariate and multivariate analyses.

RESULTS

Out of 314 patients who underwent colorectal ESD, PECS occurred in 28 patients (8.9%). The multivariate analysis showed that female sex (odds ratio [OR] 3.233; 95% confidence interval [95% CI]: 1.264-8.265, P = 0.014), large specimen size (≥ 40 mm) (OR 6.138; 95% CI: 1.317-28.596, P = 0.021), long procedure time (≥ 90 min) (OR 2.664; 95% CI: 1.053-6.742, P = 0.039), and Grade 1 or 2 injury to the muscle layer (OR 3.850; 95% CI: 1.090-13.61, P = 0.036) were independent risk factors for PECS.

CONCLUSIONS

Injury to the muscle layer, such as exposure or tear, was identified as a novel independent risk factor for PECS. We should perform colorectal ESD carefully to avoid injuring the muscle layers.

Tip-in EMR as an alternative to endoscopic submucosal dissection for 20- to 30-mm nonpedunculated colorectal neoplasms

BACKGROUND AND AIMS

Tip-in EMR, which includes anchoring the snare tip, has recently shown a favorable en-bloc and R0 resection rate for colorectal neoplasms. Thus, Tip-in EMR may be an alternative to endoscopic submucosal dissection (ESD). We aimed to compare clinical outcomes between Tip-in EMR and ESD for large colorectal neoplasms.

METHODS

This retrospective study evaluated consecutive patients who underwent Tip-in EMR or ESD for 20- to 30-mm nonpedunculated colorectal neoplasms at a Japanese tertiary cancer center between January 2014 and December 2019. Baseline characteristics, treatment results, and long-term outcomes were analyzed using 1:1 propensity score matching.

RESULTS

Seven hundred nine lesions were evaluated. The Tip-in EMR group included 1 lesion with a nonlifting sign but no lesions with fold convergence. After propensity score matching, each group included 140 lesions. The ESD group showed significantly higher en-bloc resection rates (99.3% vs 85.0%) and R0 resection rates (90.7% vs 62.9%). Procedure time was significantly shorter in the Tip-in EMR group (8 minutes vs 60 minutes). The Tip-in EMR and ESD groups did not differ significantly with respect to local recurrence rate (2.1% vs 0%).

CONCLUSIONS

Tip-in EMR is comparable with ESD with respect to the local recurrence rate but has a shorter procedure time, despite the lower en-bloc and R0 resection rates for 20- to 30-mm nonpedunculated colorectal neoplasms without fold convergence or nonlifting sign. Thus, Tip-in EMR could be a feasible alternative to ESD in these lesions.

Post-endoscopic submucosal dissection electrocoagulation syndrome: a clinical overview

INTRODUCTION

Post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) is a rare complication following endoscopic submucosal dissection (ESD). However, many aspects of PEECS are still controversial and there is a lack of up-to-date review. The aim of this article is to provide a comprehensive review on PEECS.

AREAS COVERED

The English-language literature was searched for articles on PEECS, with a focus on its pathogenesis, definition, and diagnosis, incidence rate, risk factors, prevention, management, and prognosis.

EXPERT OPINION

Many aspects of PEECS are still controversial such as etiology, diagnostic criteria, prevention and management. The recent studies tend to agree on the diagnostic criteria for PEECS, defined as localized abdominal tenderness and fever or inflammatory response without delayed perforation. Most patients with PEECS have a favorable prognosis with conservative treatment and more high-quality studies are needed in the controversial aspects mentioned above.

Efficacy of endoscopic clip closure for nonperforated muscle layer exposure during esophageal endoscopic submucosal dissection

Exposure of the muscle layer during endoscopic submucosal dissection (ESD) in the esophagus can lead to complications such as fever and pain. Although closure with endoscopic clips is widely used when perforation is a major complication, its value when the exposed muscle layer is not perforated is unclear. Data for 104 lesions in 104 patients who underwent esophageal ESD between 2008 and 2020 were retrospectively analyzed. Patients with multiple tumors, those who experienced procedure-related adverse events such as aspiration pneumonitis, perforation during ESD, or delayed bleeding, and those in whom the muscle layer was not exposed were excluded. The clinical course of inflammation after ESD in patients in whom the muscle layer was exposed was examined according to whether endoscopic clips were used for closure. A significantly greater number of patients had a temperature ≤ 37.5°C in the clip closure group than in the nonclip closure group (≤37.5°C/≥37.6°C, 47/14 vs. 25/18, respectively, P = 0.040). Furthermore, significantly more patients in the clip closure group had a white blood cell count ≤10,000/μL (≤10,000/μL/>10,000/μL, 51/10 vs. 21/22, P < 0.001) and a C-reactive protein level < 1.0 mg/dL (<1.0 mg/dL/≥1.0 mg/dL, 40/21 vs. 36/7, P = 0.040) in the 24 hour post-ESD. The results were not changed after propensity score matching. Closure with endoscopic clips reduces inflammation after esophageal ESD with nonperforated muscle layer exposure. Even if there is no obvious perforation during ESD, closure of the exposed muscle layer with endoscopic clips may contribute to the clinical course post-ESD.

Post-polypectomy syndrome—a rare complication in colonoscopy procedures: a case report

Post-polypectomy syndrome (PPS) is a complication that may arise after some colonoscopy procedures that require electrocoagulation, due to a transmural burn, which irritates the serous membrane. Its clinical presentation is similar to the one of intestinal perforation, but it has a favorable prognosis, and does not require surgical treatment. We report the case of a 55-year-old woman diagnosed with a polyp in the ascending colon, who was admitted for an endoscopic resection. After the procedure, she complained of nausea, emesis and abdominal pain in the right iliac fossa. She was transferred to the emergency department. An abdominal tomography showed cecal wall thickening without pneumoperitoneum. Therefore, the diagnosis of PPS was made and was managed with bowel rest, parenteral fluids and antibiotics, with full recovery. Despite of its low incidence, it is important to suspect this syndrome to avoid unnecessary surgical treatment and initiate medical management right away.

Endoscopic submucosal dissection for removal of large colorectal neoplasias in an outpatient setting: a single-center series of 660 procedures in Sweden

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the removal of large lesions in the GI tract. Because of the complexity of the technique, implementation in Western health care has been slow. An ESD procedure is usually followed by hospital admission. Our aim was to investigate if ESD of colorectal lesions can be performed in an outpatient setting.

METHODS

Six hundred sixty colorectal ESD procedures between 2014 and 2020 were evaluated retrospectively. All patients referred to the unit with an early colorectal neoplasm >20 mm without signs of deep invasion were considered eligible for an ESD procedure.

RESULTS

Of 660 lesions, 323 (48.9%) were localized in the proximal colon, 102 (15.5%) in the distal colon, and 235 (35.6%) in the rectum. Median lesion size was 38 mm (interquartile range, 30-50) and median procedure duration 70 minutes (interquartile range, 45-115). En-bloc resection was achieved in 620 cases (93.9%). R0 resection was achieved in 492 en-bloc resections (79.4%), whereas the number of Rx and R1 resections was 124 (20.0%) and 4 (.6%), respectively. Low-grade dysplasia was found in 473 cases (71.7%), high-grade dysplasia in 144 (21.8%), and adenocarcinoma in 34 (5.1%). Six hundred twelve procedures (92.7%) were scheduled as outpatient, and 33 of these underwent unplanned admission. Forty-eight cases (7.3%) were planned as inpatient procedures. The rate of full wall perforation was 38 (5.8%), in which 35 (92.1%) were managed endoscopically and 3 patients (7.9%) required emergency surgery. Forty-six patients (7.0%) sought medical attention within 30 days because of bleeding (21 [3.2%]), abdominal tenderness (16 [2.4%]), and other reasons (9 [1.4%]). Twenty-four of these patients were admitted for observation for a median of 2 days (range, 1-7). Ten of these patients were treated with antibiotics, and 6 patients required blood transfusion. None required additional surgery.

CONCLUSIONS

ESD of colorectal lesions can be safely performed in an outpatient setting in a well-selected patient.

Fever and electrocoagulation syndrome after colorectal endoscopic submucosal dissection for patients with immunosuppressants and steroids

OBJECTIVES

Transient fever and electrocoagulation syndrome after colorectal endoscopic submucosal dissection (ESD) remain a challenge. The aim of this study was to assess the risk factors of post-ESD fever and post-ESD coagulation syndrome (PECS), focusing on the involvement of immunosuppressive drugs and steroids (IM).

METHODS

This retrospective analysis included 510 patients who underwent colorectal ESD at Okayama University Hospital from 2015 to 2020. The incidence rate, clinical outcome, and factors associated with post-ESD fever and PECS were investigated.

RESULTS

Post-ESD fever and PECS occurred in 63 patients (12.4%) and 43 patients (8.4%), respectively. In multivariate analysis, the American Society of Anesthesiologists Physical Status ≥3, the use of immunosuppressants or prednisolone ≥5mg (IM group), and injury to muscle layer/perforation were significantly associated with post-ESD fever. In PECS, IM group, tumors located on the right side, treatment time ≥60 min, injury to the muscle layer, and multiple lesions were independent risk factors. Both post-ESD fever and PECS improved conservatively in the IM group, and no serious complication was observed.

CONCLUSIONS

The use of IM was a risk factor for both post-ESD fever and PECS. However, there were no serious complications in colorectal ESD for patients taking IM.

Risk Factors for Fever After Esophageal Endoscopic Submucosal Dissection and Its Derived Technique

BACKGROUND

Fever is one of the postoperative adverse events of endoscopic submucosal dissection and its derived technique, but the probability and risk factors of postoperative fever are still unclear. The aim of the current study was to investigate the incidence and risk factors of postoperative fever after esophageal lesion removal.

METHODS

We conducted a retrospective study of 446 patients who underwent esophageal endoscopic submucosal dissection and its derived technique between January 2014 and January 2020. Cases included in this study were divided into fever and non-fever groups.

RESULTS

Postoperative fever developed in 135 patients (30.3%). The median (range) highest fever temperature was 38 (37.8-38.4)°C, the median (range) duration of fever was 1 (1-2) day, and 127 (94.1%) patients developed fever within 24 h after operation. Through logistic regression analysis, factors associated with postoperative fever were age (OR: 1.740, 95% CI: 1.005-3.013, p = 0.048), lesion size (OR: 2.007, 95% CI: 1.198-3.362, p = 0.008), operation time (OR: 3.007, 95% CI: 1.756-5.147, p < 0.001) and nasogastric tube placement (OR: 1.881, 95% CI: 1.165-3.037, p = 0.010), while prophylactic antibiotics (OR: 0.181, 95% CI: 0.082-0.401, p < 0.001) were negatively associated with fever.

CONCLUSIONS

Age ≥52 years old, lesion size ≥19 mm, operation time ≥37 min, and nasogastric tube placement are risk factors for postoperative fever after esophageal endoscopic submucosal dissection and its derived technique, prophylactic antibiotic use after operation may help reduce fever rate. Attention should be paid to such patients to minimize the risk of postoperative fever.

Prognosis and risk factors of electrocoagulation syndrome after endoscopic submucosal dissection in the colon and rectum. Large cohort study

BACKGROUND

There are few studies on electrocoagulation syndrome after colorectal endoscopic submucosal dissection (ESD). This study aimed to investigate the various risk factors associated with thermal injury and to determine the prognosis of post-colorectal ESD electrocoagulation syndrome (PECS).

METHODS

We conducted a retrospective analysis of the medical records of 395 colorectal neoplasms of 508 patients who were treated with colorectal ESD between January 2013 and December 2019. The incidence, risk factors, and clinical outcomes of colorectal PECS were evaluated and analyzed.

RESULTS

Colorectal PECS occurred in 25 patients (6.3%). The PECS group had a larger lesion size (≥ 40 mm), lesions with fibrosis, longer procedure time, older age, and a larger amount of submucosal injection per square meter than the non-PECS group. In multivariate analysis, lesion with size ≥ 40 mm (odds ratio [OR] 16.941, 95% confidence interval [CI] 3.869-74.178), lesions with fibrosis (OR 7.127, 95% CI 2.541-19.984), old age (OR 1.068, 95% CI 1.010-1.130), and amount of submucosal injection per square meter (OR 1.067, 95% CI 1.015-1.121) were independent risk factors. The PECS group had more fasting days (3.08 vs 1.56 days, P < 0.001), longer hospital stays (7.04 vs 4.09 days, P < 0.001), and higher medical costs (2367 vs 2046, US$, P = 0.004) than the non-PECS group.

CONCLUSION

Lesions with size ≥ 40 mm, lesions with fibrosis, old age, and amount of submucosal injection per square meter were independent risk factors. Therefore, caution should be exercised when performing colorectal ESD in patients with these risk factors.

Performance of perioperative antibiotics against post-endoscopic submucosal dissection coagulation syndrome: a multicenter randomized controlled trial

BACKGROUND AND AIMS

This study aimed to evaluate the efficacy of perioperative antibiotics against post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) in patients undergoing colorectal ESD.

METHODS

A prospective, multicenter, randomized controlled, parallel, superiority trial was conducted at 21 Japanese tertiary institutions. Patients with superficial colorectal lesions ≥20 mm and those undergoing ESD management for a single lesion were eligible. Patients with perforation during and after ESD were withdrawn. Before the ESD procedure, participants were randomly assigned (1:1) to either undergo conventional treatment (nonantibiotic group) or investigational treatment (antibiotic group). In the antibiotic group, 3 g of ampicillin-sulbactam was administered just before, 8 hours after, and the morning after ESD. The primary endpoint was the incidence of PECS. The onset of PECS was defined as localized abdominal pain (both spontaneous pain and tenderness) and fever (≥37.6°C) or inflammatory response (leukocytosis [≥10,000 cells/μL] or elevated C-reactive protein level [≥.5 mg/dL]).

RESULTS

From February 5, 2019 to September 7, 2020, 432 patients were enrolled and assigned to the antibiotic group (n = 216) or nonantibiotic group (n = 216). After withdrawal of 52 patients, 192 in the antibiotic group and 188 in the nonantibiotic group were analyzed. PECS occurred in 9 of 192 patients (4.7%) in the antibiotic group and 14 of 188 patients (7.5%) in the nonantibiotic group, with an odds ratio of .61 (95% confidence interval, .23-1.56; P = .29).

CONCLUSIONS

Perioperative use of antibiotics was not effective in reducing the incidence of PECS in patients undergoing colorectal ESD. (Clinical trial registration number: UMIN000035178.).

Temperature profile and residual heat of monopolar laparoscopic and endoscopic dissection instruments

BACKGROUND

Endoscopic and laparoscopic electrosurgical devices (ED) are of great importance in modern medicine but can cause adverse events such as tissue injuries and burns from residual heat. While laparoscopic tools are well investigated, detailed insights about the temperature profile of endoscopic knives are lacking. Our aim is to investigate the temperature and the residual heat of laparoscopic and endoscopic monopolar instruments to increase the safety in handling ED.

METHODS

An infrared camera was used to measure the temperature of laparoscopic and endoscopic instruments during energy application and to determine the cooling time to below 50 °C at a porcine stomach. Different power levels and cutting intervals were studied to investigate their impact on the temperature profile.

RESULTS

During activation, the laparoscopic hook exceeded 120 °C regularly for an up to 10 mm shaft length. With regards to endoknives, only the Dual Tip Knife showed a shaft temperature of above 50 °C. The residual heat of the laparoscopic hook remained above 50 °C for at least 15 s after activation. Endoknives cooled to below 50 °C in 4 s. A higher power level and longer cutting duration significantly increased the shaft temperature and prolonged the cooling time (p < 0.001).

CONCLUSION

Residual heat and maximum temperature during energy application depend strongly on the chosen effect and cutting duration. To avoid potential injuries, the user should not touch any tissue with the laparoscopic hook for at least 15 s and with the endoknives for at least 4 s after energy application. As the shaft also heats up to over 120 °C, the user should be careful to avoid tissue contact during activation with the shaft. These results should be strongly considered for safety reasons when handling monopolar ED.

Effects of colorectal endoscopic submucosal dissection on postoperative abdominal symptoms: a prospective observational study

BACKGROUND

Endoscopic submucosal dissection (ESD) is an effective procedure to resect large superficial gastrointestinal neoplasms. In gastric ESD, several studies showed the relationship between postoperative abdominal symptoms and endoscopic treatment. However, the influence of colorectal ESD on abdominal symptoms after treatment is still unknown. To the best of our knowledge, this is the first prospective multicenter study performed to investigate the impact of colorectal ESD on postoperative abdominal symptoms. This study aimed to clarify the association between change of abdominal symptoms and ESD.

METHODS

This study was a prospective multicenter observational trial that enrolled 141 out of 171 patients who underwent colorectal ESD and answered the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire from March 2015 to August 2019. We evaluated abdominal symptoms in the patients using the GSRS questionnaire before ESD and a few weeks after ESD.

RESULTS

Comparing the GSRS before and after ESD, overall scores changed from 1.58 ± 0.58 to 1.48 ± 0.48, and the five subscales (reflux syndrome, abdominal pain, indigestion syndrome, diarrhea syndrome, and constipation syndrome) were slightly improved. Overall scores, indigestion syndrome, and constipation syndrome were statistically significantly different before and after ESD (P < 0.05).

CONCLUSIONS

In GSRS, a score of ≥ 3 is often treated as a clinically significant symptom. Therefore, our findings indicated that there was no clinically significant difference. For this reason, colorectal ESD does not affect postoperative abdominal symptoms and is considered a minimally invasive treatment. The analysis of the impact of colon ESD on gastrointestinal symptoms UMIN000016914.

Risk factors for delayed bleeding after endoscopic submucosal dissection of colorectal tumors

AIM

To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) for colorectal neoplasms.

METHODS

We retrospectively reviewed the medical records of 991 consecutive patients who underwent ESD for colorectal neoplasms at our hospital from January 2007 to November 2016. Delayed post-ESD bleeding was defined as bleeding within 6 h to 30 days after ESD that resulted in either of the three situations: overt hematochezia, bleeding spots confirmed by repeat colonoscopy, or the requirement of a blood transfusion. Delayed bleeding was furtherly separated into early and late delayed bleeding by the end of post-ESD day 2. We analyzed the relationship between delayed bleeding and candidate factors including patient-, lesion-, and treatment-related details.

RESULTS

Delayed post-ESD bleeding was found in 47 patients (4.7%), of which 18 cases were late delayed bleeding. Among all patients, 14 patients required a second colonoscopy, and 2 other patients were transferred to surgery. Univariate analysis revealed that patients with hypertension (p = 0.017) and using hot biopsy forceps for wound management (p = 0.028) were significantly associated with late delayed bleeding. Both risk factors remained significant after multivariate analysis: hypertension (OR 2.829, 95% CI 1.101-7.265, p = 0.031), hot biopsy forceps (OR 2.873, 95% CI 1.013-8.147, p = 0.047). Using hot biopsy forceps was also the significant risk factor for late delayed bleeding compared with early delayed bleeding.

CONCLUSION

Patient with hypertension and using hot biopsy forceps for wound management during procedure call for attention on high risk of delayed post-ESD bleeding. Therefore, additional perioperative treatment is recommended in patients with these risk factors.

Features of post-endoscopic submucosal dissection electrocoagulation syndrome for early gastric neoplasm

BACKGROUND AND AIM

Post-endoscopic submucosal dissection electrocoagulation syndrome (PECS) has become a common adverse event after colorectal endoscopic submucosal dissection (ESD) and esophageal ESD. However, little is known about PECS after gastric ESD. Therefore, this study aimed to investigate the clinical features of PECS after gastric ESD.

METHODS

Patients who underwent ESD for gastric cancer or adenoma between January 2016 and December 2017 were retrospectively investigated. PECS was clinically diagnosed based on the presence of upper abdominal pain and localized abdominal tenderness with a temperature of >37.5°C, without perforation. We analyzed the clinical features of PECS.

RESULTS

A total of 637 ESD cases were enrolled; PECS occurred in 32 patients (5.0%), all of whom were diagnosed on postoperative Day 1. Among PECS cases, unplanned prolongation of hospitalization or fasting period was observed in 15 patients (47%). As a result, the median durations of hospitalization and fasting period were significantly longer in PECS cases (P = 0.008 and P < 0.001, respectively); however, the mean differences were less than a day. Additionally, all PECS cases recovered with conservative treatment.

CONCLUSIONS

PECS is considered a common adverse event after gastric ESD. More than half of patients with PECS could start diets and be discharged as well as those without PECS.

High total Joule heat increases the risk of post-endoscopic submucosal dissection electrocoagulation syndrome after colorectal endoscopic submucosal dissection

BACKGROUND

We hypothesized that thermal damage accumulation during endoscopic submucosal dissection (ESD) causes the pathogenesis of post-ESD electrocoagulation syndrome (PECS).

AIM

To determine the association between Joule heat and the onset of PECS.

METHODS

We performed a retrospective cohort study in patients who underwent colorectal ESD from May 2013 to March 2021 in Japan. We developed a novel device that measures swift coagulation time with a sensor adjacent to the electrosurgical coagulation unit foot switch, which enabled us to calculate total Joule heat. PECS was defined as localized abdominal pain (visual analogue scale ≥ 30 mm during hospitalization or increased by ≥ 20 mm from the baseline) and fever (temperature ≥ 37.5 degrees or white blood cell count ≥ 10000 µ/L). Patients exposed to more or less than the median Joule heat value were assigned to the high and low Joule heat groups, respectively. Statistical analyses included Mann-Whitney U and chi-square tests and logistic regression and receiver operating characteristic curve (ROC) analyses.

RESULTS

We evaluated 151 patients. The PECS incidence was 10.6% (16/151 cases), and all patients were followed conservatively and discharged without severe complications. In multivariate analysis, high Joule heat was an independent PECS risk factor. The area under the ROC curve showing the correlation between PECS and total Joule heat was high [0.788 (95% confidence interval: 0.666-0.909)].

CONCLUSION

Joule heat accumulation in the gastrointestinal wall is involved in the onset of PECS. ESD-related thermal damage to the peeled mucosal surface is probably a major component of the mechanism underlying PECS.

Factors influencing development of non-cardiac chest pain after endoscopic submucosal dissection for esophageal neoplasms: a retrospective case-control study of 309 patients from a single center

Endoscopic submucosal dissection (ESD) is widely used for early stage esophageal cancer and precancerous lesions. Non-cardiac chest pain (NCCP) is a frequent complication of ESD. However, little is known about its incidence and associated factors. This study investigated the pain incidence and predictive factors for pain development after ESD for esophageal neoplasms. We enrolled a total of 309 patients with esophageal neoplasms, who underwent ESD in our center from January 2018 to June 2019. Sociodemographic and clinicopathological information for all patients was collected, and patients were divided into either a pain-free group (n = 156) or a pain group (n = 153) according to whether there was onset of NCCP 24-48 hours after surgery. We made comparisons between groups using Student's t test or the χ2 test. Logistic-regression analysis was used to screen for risk factors. There were statistically significant differences in histories of previous surgery (P = 0.039), lesion size (P = 0.026), operation time (P = 0.009), and postoperative fever (P = 0.001). History of previous surgery (P = 0.043) and postoperative fever (P = 0.007) were independent risk factors for chest pain after esophageal ESD treatment. Chest pain and fever prolonged postoperative hospitalization time (P = 0.005, P = 0.001) and increased hospitalization cost (P = 0.034, P < 0.001). A history of previous surgery and postoperative fever was associated with the occurrence of NCCP after ESD in patients with esophageal neoplasms. NCCP and fever after esophageal ESD increased both hospitalization time and cost.

Impact of Procedure Time of Preceding Endoscopic Submucosal Dissection on the Difficulty of Laparoscopic Rectal Surgery

Objetive: 

In this study, we addressed which factors, including endoscopic submucosal dissection (ESD)–related parameters, affect the difficulty of laparoscopic rectal surgery.

Summary of background data: 

Endoscopic treatment for gastrointestinal cancer can cause inflammation, edema, and fibrosis formation in the surrounding tissue. Recently, we reported that preceding endoscopic treatment increased the volume of intraoperative blood loss and slightly prolonged the operative time of laparoscopic surgery for rectal cancer.

Methods: 

We retrospectively reviewed 24 consecutive patients who underwent ESD followed by laparoscopic surgery for rectal cancer in our hospital. Short-term surgical outcomes were evaluated by intraoperative blood loss and operative time for laparoscopic surgery. The correlations between the surgical outcomes and preoperative parameter were analyzed by multiple linear regression analyses.

Results: 

The patient cohort comprised 12 men and 12 women. The median distance between primary cancer and anal verge was 7 cm. The median procedure time of ESD was 120 minutes (21 available cases). Based on multiple linear regression analyses, the ESD procedure time (P = 0.007) and tumor location from the anal verge (P = 0.046) were independently predictive of intraoperative blood loss. On the other hand, only tumor location was found to be an independent predictor of surgical time (P = 0.014).

Conclusions: 

A long session of ESD for rectal cancer may make subsequent laparoscopic surgery difficult based on intraoperative blood loss.

A retrospective cohort study of factors influencing long procedure times in colorectal endoscopic submucosal dissection

OBJECTIVE

To evaluate the outcomes and factors influencing colorectal endoscopic submucosal dissection (ESD) with a long procedure time.

MATERIALS AND METHODS

In this single-center, retrospective study, we included 1,100 patients with 1,199 lesions who underwent colorectal ESD between April 2016 and December 2020. ESD was performed using an advanced system knife for lesions >20 mm. An S-O clip was used as the traction device. The long-time group (LP; procedure time >120 min) and normal-time group (NP; procedure time <120 min) were compared.

RESULTS

The procedure times were 166.86 and 44.72 min in the LP and NP groups, respectively. The completion rate was higher in the NP group (96.5% vs. 83.5%, p = .001); the completed lesions were resected en bloc. Multivariate analysis revealed 18.8% and 7.8% of submucosal fibrosis in the LP and NP groups, respectively (odds ratio [OR] = 2.410, p = .026). Compared to the NP group, the LP group presented larger maximum lesion sizes and higher rates of R1 resection, and traction device use. Time to introduction of traction device use was longer in the LP than in the NP group (126.05 vs. 21.72 min; p < .001). Fibrosis tends to occur cecal lesions (OR 2.436, p = .011) and laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) (OR 2.6181, p = .001).

CONCLUSIONS

Lesion size and fibrosis were factors associated with a long procedure time in colonic ESD. For fibrotic lesions (LST-NG-PD and cecal lesions), it is necessary to consider early use of traction devices and advisable to plan a strategy for the use of traction devices.

Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20-30 mm colorectal polyps

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) for large polyps provides a high en bloc resection rate, accurate pathological diagnosis, and low recurrence rate. However, ESD requires advanced techniques, and underwater endoscopic mucosal resection (UEMR) is an alternative. We investigated the efficacy and safety of UEMR for 20-30 mm colorectal lesions compared with ESD.

METHODS

We retrospectively evaluated systematically collected data of patients who underwent UEMR or ESD for 20-30 mm sessile colorectal lesions. Outcome measures were the incidence of local recurrence, procedure time, en bloc resection rate, and incidence of adverse events. We performed propensity score matching and inverse probability weighting adjustment to control for possible confounders.

RESULTS

We evaluated 125 patients undergoing UEMR and 306 patients undergoing ESD. Using propensity score matching, we analyzed 74 lesions in each group. UEMR had a shorter procedure time than ESD [6.7 min (95% confidence interval (CI), 5.3-8.1 min) vs 64.8 min (95% CI, 57.4-72.2 min), respectively]. Although the en bloc resection rate with UEMR was inferior to ESD [61% (95% CI, 49-72%) vs 99% (95% CI, 93-100%), respectively], there was no significant difference in the local recurrence rate between the procedures [0% (95% CI, 0-4.0%) in each group]. Inverse probability weighting adjustment revealed that neither ESD nor UEMR had a significant association with local recurrence.

CONCLUSIONS

Underwater endoscopic mucosal resection for 20-30  mm colorectal lesions was comparable with ESD regarding long-term outcomes, with a shorter procedure time, despite the lower en bloc resection rate.