Efficacy of Current Traction Techniques for Endoscopic Submucosal Dissection

Effectiveness of a novel traction device (TRACMOTION) for endoscopic submucosal dissection using a scissor-type knife: An animal pilot study and clinical experiences

A newly developed articulated through-the-scope traction device, TRACMOTION, has been used clinically for endoscopic submucosal dissection (ESD). However, there are few reports on the characteristics of this device and the lesion types for which it is most effective. Therefore, we evaluated its optimal use, efficacy, and safety clinically in animals. Subsequently, we confirmed the safety and efficacy of ESD using this device in humans. Two live swine were used; one underwent conventional ESD (C-ESD) and the other traction-assisted ESD (T-ESD). To examine the traction effect at each resection site, three ESD ulcers (greater curvature/anterior wall/posterior wall) with a diameter of approximately 40 mm were created in each swine. Based on our preliminary experiments, scissor-type and needle-type knives were used in the T-ESD and C-ESD groups, respectively. The primary endpoint was the resection speed, and the secondary endpoint was the degree of muscle layer damage. T-ESD was faster than C-ESD on the posterior wall, similar to the greater curvature, and T-ESD was slower than C-ESD on the anterior wall. There were no cases of intraoperative perforations. Obvious muscle layer damage was observed in post-C-ESD wounds on the anterior wall. The submucosal layer was retained in all post-T-ESD wounds. Although this study showed that ESD with TRACMOTION may be safe and effective, it is necessary to consider that it may be unsuitable for some lesions. This may be due to device characteristics and requires further validation.

Colitis-Associated Dysplasia in Inflammatory Bowel Disease: Features and Endoscopic Management

Patients with long-standing inflammatory bowel disease (IBD) involving the colon are at higher risk of developing colorectal dysplastic or neoplastic lesions. While from sporadic colorectal cancer follows an "adenoma-carcinoma" sequence, IBD colitis-associated carcinogenesis is mainly related to an "inflammation-dysplasia-carcinoma" sequence. Currently, specific endoscopic surveillance strategies involving dye spray and virtual chromoendoscopy have been standardized, aiming for early CRC diagnosis. When detected, colitis-associated dysplasia should be classified according to standard classification, thus allowing for better treatment. Indeed, most IBD-associated dysplastic lesions can be treated with endoscopic resection, even though available procedures are usually more challenging than those in the general population. The higher frequency of severe submucosal fibrosis and the difficulty in the definition of lesions' margins account for this issue. Current endoscopic resection techniques include polypectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Recent evidence suggests the relevance of en bloc resection, as this may be associated with lower rates of recurrence. Therefore, particularly for larger (>20 mm) lesions, ESD should be preferred, even though it is considered the most difficult technique due to frequent severe submucosal fibrosis. Considering the growing number of new endoscopic resective techniques, including underwater EMR or ESD, which in the general population have been suggested to lower procedure-related risks and may also allow a larger spread of advanced endoscopic resection in IBD. However, additional data are needed to assess the medium- and long-term efficacy of endoscopic resection of visible dysplasia in IBD patients, which are burdened by a high risk of local and, more importantly, metachronous recurrence.

Muscular Injury Is a Risk Factor for Post-Entire Circumferential Esophageal Endoscopic Submucosal Dissection Stricture

INTRODUCTION

Endoscopic submucosal dissection (ESD) has become a widely adopted treatment for early esophageal cancer. However, extensive mucosal defects resulting from ESD pose a significant risk of post-procedural strictures. Despite efforts to prevent strictures through various means, including steroid administration, they remain a challenge, significantly impacting patients' quality of life and healthcare costs. Thus, identifying risk factors for refractory strictures following entire circumferential esophageal ESD (EC-E-ESD) is imperative.

METHODS

Between July 2013 and September 2023, 49 patients who underwent EC-E-ESD were retrospectively analyzed. Patients were classified based on the presence of refractory or non-refractory strictures. A refractory stricture was defined as requiring six or more endoscopic balloon dilation procedures before stricture improvement. Clinicopathological features and outcomes were examined using multivariate logistic regression analysis.

RESULTS

Refractory strictures were observed in 51% of patients. A comparison showed that the refractory group had a significantly higher percentage of muscular injury (52% vs. 8%, p = 0.002) and mucosal defect length ≥50 mm (68% vs. 37%, p = 0.047) than the non-refractory group. Multivariate analysis showed that muscular injury (odds ratio 16.2; 95% confidence interval: 2.04-129.1) was an independent risk factor for refractory strictures after EC-E-ESD.

CONCLUSIONS

Muscular injury during EC-E-ESD is a risk factor for refractory strictures. Strategies to prevent injury, such as meticulous dissection techniques and effective steroid administration, may mitigate this risk. However, current prophylactic measures are inadequate, highlighting the need for further research into preventive strategies.

INTRODUCTION

Endoscopic submucosal dissection (ESD) has become a widely adopted treatment for early esophageal cancer. However, extensive mucosal defects resulting from ESD pose a significant risk of post-procedural strictures. Despite efforts to prevent strictures through various means, including steroid administration, they remain a challenge, significantly impacting patients' quality of life and healthcare costs. Thus, identifying risk factors for refractory strictures following entire circumferential esophageal ESD (EC-E-ESD) is imperative.

METHODS

Between July 2013 and September 2023, 49 patients who underwent EC-E-ESD were retrospectively analyzed. Patients were classified based on the presence of refractory or non-refractory strictures. A refractory stricture was defined as requiring six or more endoscopic balloon dilation procedures before stricture improvement. Clinicopathological features and outcomes were examined using multivariate logistic regression analysis.

RESULTS

Refractory strictures were observed in 51% of patients. A comparison showed that the refractory group had a significantly higher percentage of muscular injury (52% vs. 8%, p = 0.002) and mucosal defect length ≥50 mm (68% vs. 37%, p = 0.047) than the non-refractory group. Multivariate analysis showed that muscular injury (odds ratio 16.2; 95% confidence interval: 2.04-129.1) was an independent risk factor for refractory strictures after EC-E-ESD.

CONCLUSIONS

Muscular injury during EC-E-ESD is a risk factor for refractory strictures. Strategies to prevent injury, such as meticulous dissection techniques and effective steroid administration, may mitigate this risk. However, current prophylactic measures are inadequate, highlighting the need for further research into preventive strategies.

Prospective, randomized controlled study evaluating a double-balloon interventional endoscopic platform for colorectal endoscopic submucosal dissection (with video)

BACKGROUNDS AND AIMS

Endoscopic submucosal dissection (ESD) can be challenging and time-consuming. A double-balloon interventional platform (DBIP) was designed to assist with navigation, stabilization, traction, and device delivery during complex colorectal polypectomy. We compared traditional ESD (T-ESD) with DBIP-assisted ESD (DBIP-ESD) in a prospective, randomized trial.

METHODS

Patients with colorectal polyps ≥2 cm were randomly assigned (1:1) to DBIP-ESD or T-ESD. The primary study endpoint was the mean total procedure time difference between groups. Secondary endpoints were intraprocedural time points, en bloc resection rate, procedure cost, adverse events, and 3-month assessment. A sample size of 200 subjects for ≥80% power was calculated. Interim analysis for early study termination was planned at 70% enrollment if the primary endpoint was met (P ≤ .05).

RESULTS

One hundred forty-seven patients were enrolled between February 2019 and February 2020. Seven patients dropped out, and the interim analysis was performed on 140 patients (71 DBIP-ESD, 69 T-ESD). Demographics, comorbidities, and lesion size, location, and classification were similar between groups. The mean procedure time decreased with DBIP-ESD (88.6 ± 42.7 minutes) versus T-ESD (139.5 ± 83.2 minutes; difference of ∼51 minutes [36.5%]; P < .001], with procedural savings of $610.16 (11.4%) per patient after DBIP cost. The DBIP increased dissection speed by 49.0% (15.1 ± 8.0 vs 7.7 ± 6.6 cm2/h, P < .001). En bloc resection was superior with the addition of DBIP (97.2% vs 87.0%, P = .030). The mean navigation time with DBIP-ESD for sutured defect closure decreased by 7.7 minutes (P < .001). There were no adverse events in the DBIP-ESD group.

CONCLUSIONS

DBIP-ESD decreased the total procedure time, improved the en bloc resection rate, and facilitated sutured defect closure, making DBIP a promising and cost-effective tool to improve colorectal ESD adoption. (Clinical trial registration number: NCT03846609.).

Giant gastric leiomyoma excision using endoscopic submucosal dissection with dental floss clip traction technique: a case report

For gastric leiomyomas measuring ≥5 cm, endoscopic resection is necessary. The larger size of these tumors significantly impairs the resection field of view, increasing the risk of intraoperative bleeding and perforation and potentially leading to incomplete tumor removal. The combination of dental floss and tissue clip traction techniques is commonly used for resecting mucosal lesions but is rarely reported for submucosal tumors. We recently completed a case of endoscopic resection of a giant gastric leiomyoma in the body of the stomach, approximately 7 cm in length, using endoscopic submucosal dissection with dental floss clip traction. The dissection was carefully controlled within the muscularis propria layer, avoiding damage to the serosa. No bleeding or perforation occurred. A special technique was employed to avoid damage to the muscle layer. By combining this technique with tissue forceps, better traction stability may have been achieved. During the traction process, slight tension was consistently maintained between the swelling and the muscle layer, preventing perforation due to traction. The resection field remained clear throughout the procedure, which lasted 50 minutes in total. The final outcome was satisfactory. This method may be worthy of clinical application.

A novel entire traction method with clip-anchored nylon ring facilitating endoscopic submucosal dissection of early gastric cancer

A 48-year-old woman with a high-grade intraepithelial neoplasia of the gastric antrum was referred for ESD treatment.The difficulty of ESD is to expose the submucosa,especially in difficult sites and lesions with severe fibrosis.Adequate submucosal exposure is the most critical technology to reduce complications and improving efficiency.Here we report a novel entire traction method to facilitate safe and efficient ESD.

Conventional versus rubber band traction-assisted endoscopic submucosal dissection for rectal neuroendocrine tumors: a single-center retrospective study (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is a safe and effective technique for the treatment of gastrointestinal tumors, including rectal neuroendocrine tumors (r-NETs). However, the relative advantages of traction-assisted ESD for the treatment of small rectal lesions are still debated.

AIMS

We conducted a study to compare the efficacy and safety of rubber band traction-assisted ESD (RBT-ESD) to conventional ESD (C-ESD).

METHODS

This study retrospectively analyzed consecutive patients with r-NET treated with ESD between October 2021 and October 2023. Our study assessed differences between the groups in the complete resection rate of lesions, muscular layer injury, surgical complications, operation time, resection speed, time to liquid diet, postoperative hospital stay, hospital cost, and recurrence rate.

RESULTS

A total of 119 patients with r-NETs participated in this study (RBT-ESD group, n = 27; C-ESD group, n = 92). The operation time in RBT-ESD group was shorter than in C-ESD group, but the difference was not statistically significant (16.0 min [9.0-22.0 min] vs. 18.0 min [13.3-27.0 min], P = 0.056). However, the resection speed was significantly faster in the RBT-ESD group (6.7 vs. 4.1 mm2/min, P = 0.005). Furthermore, the RBT-ESD group showed significantly less muscular layer injury (P = 0.047) and faster diet recovery (P = 0.035). No significant differences were observed in the complete resection rate, surgical complications, postoperative hospital stay, hospital cost, or recurrence rate between the two groups.

CONCLUSION

For r-NETs of < 2 cm in size, the RBT method did not significantly shorten the operation time but resulted in faster resection speed, less muscular layer injury, and earlier postoperative recovery to a liquid diet.

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Compared with conventional endoscopic submucosal dissection (C-ESD) for colorectal lesions, the traction method (T-ESD) allows the lesion to be stabilized with easier dissection. However, randomized controlled trials (RCTs) have reported conflicting results on the clinical outcomes of T-ESD as compared with C-ESD. We conducted a meta-analysis to compile the data.

METHODS

Multiple databases were searched for RCTs evaluating C-ESD versus T-ESD for colorectal tumors. The end points of interest were procedure time (min), resection speed (mm²/min), R0 resection, en bloc resection, delayed bleeding, and perforation. Standard meta-analysis methods were employed using the random-effects model.

RESULTS

Six RCTs with a total of 566 patients (C-ESD n=284, T-ESD n=282) were included. The mean age was 67±10 y and 60% were men. As compared with the T-ESD technique, the C-ESD group was associated with longer procedure time (SMD 0.91, 95% CI 0.58 to 1.23, P <0.00001) and lesser resection speed (SMD -1.03, 95% CI -2.01 to -0.06, P =0.04). No significant difference was found in the 2 groups with respect to R0 resection rate (RR 1.00, 95% CI 0.94 to 1.06, P =0.87), en bloc resection (RR 0.99, 95% CI 0.97 to 1.01, P =0.35), delayed bleeding (RR 0.66, 95% CI 0.17 to 2.59, P =0.55) and perforation (RR 2.16, 95% CI 0.75 to 6.27, P =0.16).

DISCUSSION

On meta-analysis, pooled procedure time was significantly faster with T-ESD compared with C-ESD. The clinical outcomes, however, were comparable.

Entire traction using clip-and-nylon ring to facilitate endoscopic submucosal dissection of a laterally spreading tumor with fibrosis in the rectum

A 78-year-old woman with hematochezia underwent a colonoscopy and found a 2 × 2-cm laterally spreading tumor (LST) in the rectum, 3 cm from the anus. Because of the risk related to anus preservation and the potential operative trauma, the patient refused surgery and was referred for ESD treatment. Here, we applied a novel entire traction method to deal with this subset of tumors.

Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Up to 15% of colorectal polyps are amenable for conventional polypectomy. Advanced endoscopic resection techniques are introduced for the treatment of those polyps. They provide higher en bloc resection rates compared with conventional techniques, while helping patients to avoid the complications of surgery. Note that 20 mm is considered as the largest size of a polyp that can be resected by polypectomy or endoscopic mucosal resection (EMR) in an en bloc fashion. Endoscopic submucosal dissection (ESD) is recommended for polyps larger than 20 mm. Intramucosal carcinomas and carcinomas with limited submucosal invasion can also be resected with ESD. EMR is snare resection of a polyp following submucosal injection and elevation. ESD involves several steps such as marking, submucosal injection, incision, and dissection. Bleeding and perforation are the most common complications following advanced endoscopic procedures, which can be treated with coagulation and endoscopic clipping. En bloc resection rates range from 44.5 to 63% for EMR and from 87.9 to 96% for ESD. Recurrence rates following EMR and ESD are 7.4 to 17% and 0.9 to 2%, respectively. ESD is considered enough for the treatment of invasive carcinomas in the presence of submucosal invasion less than 1000 μm, absence of lymphovascular invasion, well-moderate histological differentiation, low-grade tumor budding, and negative resection margins.

A Novel Retractable Robotic Device for Colorectal Endoscopic Submucosal Dissection

Background/Aims

: Appropriate tissue tension and clear visibility of the dissection area using traction are essential for effective and safe endoscopic submucosal dissection (ESD). In this study, we developed a retractable robot-assisted traction device and evaluated its performance in colorectal ESD.

Methods

: An experienced endoscopist performed ESD 18 times on an ex vivo porcine colon using the robot and 18 times using the conventional method. The outcome measures were procedure time, dissection speed, procedure-related adverse events, and blind dissection rate.

Results

: Thirty-six colonic lesions were resected from ex vivo porcine colon samples. The total procedure time was significantly shorter in robot-assisted ESD (RESD) than in conventional ESD (CESD) (20.1±4.1 minutes vs 34.3±8.3 minutes, p<0.05). The submucosal dissection speed was significantly faster in the RESD group than in the CESD group (36.8±9.2 mm2/min vs 18.1±4.7 mm2/min, p<0.05). The blind dissection rate was also significantly lower in the RESD group (12.8%±3.4% vs 35.1%±3.9%, p<0.05). In an in vivo porcine feasibility study, the robotic device was attached to a colonoscope and successfully inserted into the proximal colon without damaging the colonic wall, and ESD was successfully performed.

Conclusions

: The dissection speed and safety profile improved significantly with the retractable RESD. Thus, our robotic device has the potential to provide simple, effective, and safe multidirectional traction during colonic ESD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic Resection of Malignancies in the Upper GI Tract: A Clinical Algorithm

Background

Malignancies in the upper gastrointestinal tract are amenable to endoscopic resection at an early stage. Achieving a curative resection is the most stringent quality criterion, but post-resection risk assessment and aftercare are also part of a comprehensive quality program.

Summary

Various factors influence the achievement of curative resection. These include endoscopic assessment prior to resection using chromoendoscopy and HD technology. If resectability is possible, it is particularly important to delineate the lateral resection margins as precisely as possible before resection. Furthermore, the correct choice of resection technique depending on the lesion must be taken into account. Endoscopic submucosal dissection is the standard for esophageal squamous cell carcinoma and gastric carcinoma. In Western countries, it is becoming increasingly popular to treat Barrett's neoplasia over 2 cm in size and/or with suspected submucosal infiltration with en bloc resection instead of piece meal resection. After resection, risk assessment based on the histopathological resection determines the patient's individual risk of lymph node metastases, particularly in the case of high-risk lesions. This is categorized according to the current literature.

Key Messages

This review presents clinical algorithms for endoscopic resection of esophageal SCC, Barrett's neoplasia, and gastric neoplasia. The algorithms include the pre-resection assessment of the lesion and the resection margins, the adequate resection technique for the respective lesion, as well as the post-resection risk assessment with an evidence-based recommendation for follow-up therapy and surveillance.

The efficacy and safety of snare traction-assisted endoscopic submucosal dissection for circumferential superficial esophageal cancer

OBJECTIVE

This study aims to investigate the efficacy and safety of snare traction-assisted endoscopic submucosal dissection (ESD) for the management of circumferential superficial esophageal cancer.

METHODS

A total of 68 patients who underwent ESD for circumferential superficial esophageal cancer were included in this study. All the patients were divided into two groups based on whether the snare traction was used or not; the snare traction group (S-ESD, group n = 35) and the control group (C-ESD, group n = 33).

RESULTS

There was no significant difference in the size of the resected area between the groups [21.98 (18.30, 27.00) cm2 vs 24.00 (15.28, 30.72) cm2, P = 0.976]. The snare traction group had a shorter dissection time [92.00 (74.00, 121.00) min vs 110.00 (92.50, 137.00) min, P = 0.017] and a faster resection speed [0.28 ± 0.13 cm2/min vs 0.22 ± 0.11cm2/min, P = 0.040] compared to the control group. There were no statistically significant differences between the two groups in terms of hospital stay, cost, en bloc resection rate, R0 resection rate, curative resection rate, bleeding rate, perforation rate, stricture rate, and recurrence rate (P > 0.05).

CONCLUSION

Snare traction-assisted ESD is a safe and efficient approach for the treatment of circumferential superficial esophageal cancer. Its advantages includes shorter procedure so the anesthesia requirement, clear operative filed view, improved mucosal dissection efficiency, simple, and easily accessible equipment.

Clip-and-snare method with a pre-looping technique versus conventional method in the treatment of precancerous lesion and early gastric cancer: a retrospective study

BACKGROUND

Low grade intraepithelial neoplasia (LGIN) and high grade intraepithelial neoplasia (HGIN) are potential precancerous lesion of gastric neoplasms. Endoscopic submucosal dissection (ESD) is the first option for the treatment of precancerous lesion and early gastric cancer (EGC). Traction is an effective method to improve efficiency, and reduce complications during ESD. In this study, we shared a useful traction method using the clip-and-snare method with a pre-looping technique (CSM-PLT) for precancerous lesion and EGC.

METHODS

We retrospectively analyzed patients received ESD combined with CSM-PLT or conventional ESD from June 2018 to December 2021 in Shenzhen People's hospital. The primary outcome was resection speed.

RESULTS

Forty-two patients were enrolled in ESD combined with CSM-PLT group and sixty-five patients in conventional ESD group respectively. Baseline characteristics were comparable among two groups (P>0.05). There were no significant differences in terms of R0 resection rate, en bloc resection rate (97.6% vs. 98.5%, P = 1.000 and 97.6% vs. 96.9%, P = 1.000, respectively), operation costs (933.7 (644.1-1102.4) dollars vs. 814.7 (614.6-988.3) dollars, P = 0.107), and hospital stays (8.0 ± 3.1 days vs. 7.3 ± 3.2 days, P = 0.236). In addition, no significant difference was observed with respect to complications (P>0.05). However, the resection speed of ESD combined with CSM-PLT was faster than that of conventional ESD (11.3 (9.4-14.9) mm2/min vs. 8.0 (5.8-10.9) mm2/min, P < 0.001), particularly lesions located in anterior wall and lesser curvature. In addition, the association between ESD combined with CSM-PLT and resection speed was still supported after propensity matching scores (PMS).

CONCLUSIONS

CSM-PLT can help to improve ESD efficiency without reducing the en bloc resection rate or increasing the incidence of complications.

Novel devices for third-space endoscopy procedures

Third-space endoscopy (TSE) is a subspecialty in interventional endoscopy that exploits the submucosa as a working space for the management of various gastrointestinal diseases. Over recent years, TSE has emerged as a viable alternative to surgery for the treatment of various conditions. The rapid dissemination and adoption of TSE has been largely supported by the advent of novel devices aimed to improve the efficacy and safety of these procedures. In this article, we review some of the recent developments in TSE devices and provide our initial experience with these instruments in clinical practice.

Assessment of predictive factors associated with the technical difficulty of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: Japanese multicenter retrospective study

OBJECTIVES

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) is performed for the treatment of lesions with varied backgrounds and factors. However, the predictive factors associated with the technical difficulty of ESD remain unknown in patients with varied lesions. Therefore, this study aimed to identify the predictive factors associated with the technical difficulty of ESD for ESCC using a retrospective cohort.

METHODS

This multicenter, retrospective study was conducted in 10 hospitals in Japan. Consecutive patients who underwent esophageal ESD between January 2013 and December 2019 were enrolled. Lesions of subepithelial tumors, adenocarcinoma, and adenoma were excluded. Difficult lesions were defined as ESD requiring a long procedure time (≥120 min), perforation development, piecemeal resection, or discontinued ESD. In the present study, the clinical factors were assessed to identify the technical difficulty of ESD using univariate and multivariate analyses.

RESULTS

Among 1708 lesions treated with esophageal ESD, eight subepithelial tumors, 44 adenocarcinomas, and two adenomas were excluded. Finally, 1505 patients with 1654 lesions were analyzed, and 217 patients with 217 lesions (13.1%) were classified as patients with difficult lesions. In multivariate analysis, the predictive factors associated with the technical difficulty of ESD were as follows: tumors with varices, tumors with diverticulum, antiplatelet use (discontinued), circumference of tumor (≥1/2), preoperative tumor size ≥30 mm, trainee, and nonhigh-volume center.

CONCLUSION

This multicenter retrospective study identified the predictive factors associated with the technical difficulty of ESD for ESCC with varied backgrounds and factors.

Traction Devices May Not Affect the Vertical Margin Distance in the Endoscopic Submucosal Dissection of Rectal Neuroendocrine Tumors

Introduction The usefulness of traction devices (TDs) in endoscopic submucosal dissection (ESD) for rectal neuroendocrine tumors (NETs) has not been reported. The aim of this study was to investigate the impact of using a TD on the vertical margin (VM) distance in the ESD of rectal NETs. Methods In this single-center, retrospective study, we included patients with rectal NETs who were treated with ESD during 2013-2023. They were divided into TD and non-TD groups. One pathologist remeasured the VM distance (primary outcome) and the depth of submucosal invasion (SM depth). Secondary outcomes were margins, resection time, delayed bleeding, and perforation. First, we performed propensity score matching (PSM) to assess the usefulness of TD for VM distance. Then, we used multiple regression analysis to identify factors affecting the VM distance. Results The TD and non-TD groups comprised 24 and 117 lesions, respectively. Patients in the TD group were significantly younger than those in the non-TD group (P = 0.003). In the TD and non-TD groups, the VM distance was 150 μm and 100 μm, respectively (P = 0.70). Only resection time significantly differed between groups, shorter in the TD group (P = 0.005). Twenty-two cases in each group were matched after PSM, yielding no significant differences in VM distance. The use of a TD was not an independent predictor of VM distance (P = 0.65), but age (P < 0.001) and SM depth (P = 0.003) were. Conclusion Using a TD does not seem to affect the VM distance in ESD for rectal NETs.

Endoscopic submucosal dissection assisted by adaptive traction: results of the first 54 procedures

BACKGROUND : Good submucosal exposure is key to successful endoscopic submucosal dissection (ESD) and can be achieved with various traction devices. Nevertheless, these devices have a fixed traction force that tends to decrease as the dissection progresses. In contrast, the ATRACT adaptive traction device increases traction during the procedure. METHODS : In this retrospective analysis of prospectively collected data (from a French database), we analyzed ESD procedures performed with the ATRACT device between April 2022 and October 2022. The device was used consecutively whenever possible. We collected details of lesion characteristics, procedural data, histologic outcomes, and clinical consequences for the patient. RESULTS : 54 resections performed in 52 patients by two experienced operators (46 procedures) and six novices (eight procedures) were analyzed. The ATRACT devices used were the ATRACT-2 (n = 21), the ATRACT 2 + 2 (n = 30), and the ATRACT-4 (n = 3). Four adverse events were observed: one perforation (1.9 %), which was closed endoscopically, and three delayed bleeding events (5.5 %). The R0 rate was 93 %, resulting in curative resection in 91 % of cases. CONCLUSION:  ESD using the ATRACT device is safe and effective in the colon and rectum, but can also be used to assist with procedures in the upper gastrointestinal tract. It may be particularly useful in difficult locations.

The Impact of Traction Methods on Endoscopic Submucosal Dissection Efficacy for Gastric Neoplasia: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic submucosal dissection (ESD) for gastric neoplasms can be challenging due to limited traction and visualization. The efficacy of traction-assisted endoscopic submucosal dissection (TA-ESD) continues to require additional validation. This study aims to explore the safety and efficiency of TA-ESD for early gastric neoplasms located at varying sites, in comparison with conventional endoscopic submucosal dissection (C-ESD).

METHODS

We conducted a comprehensive literature search using databases up until August 2022. The outcome measures procedure time, en bloc resection rate, complete resection rate, procedure time, and procedure-related adverse event rate. We calculated pooled mean differences (MDs) and odds ratios (ORs) for these outcomes.

RESULTS

The mean procedure time was significantly shorter in the TA-ESD group compared to the C-ESD group (MD - 14.9, 95% CI - 21.78 to - 8.03, I2 = 83%, p < 0.0001). Subgroup analysis revealed that mean procedure times for lesions on the greater curvature and upper/middle of the stomach were significantly shorter in the TA-ESD group - 19.2 min (95% CI - 27.75 to - 10.65, I2 = 12%, p < 0.0001) and - 7.35 min (95% CI - 35.4 to - 1.15, p = 0.04), respectively. The en bloc resection and complete resection rates were comparable between the two groups. The rate of perforation was significantly lower in the TA-ESD group than in the C-ESD group (OR 0.36, 95% CI 0.15-0.85, p = 0.02, I2 = 0%).

CONCLUSIONS

This study demonstrates the potential benefits of TA-ESD over C-ESD in treating patients with early-stage gastric tumors, highlighting its safety and efficacy. The findings indicate a significant reduction in procedure times at challenging stomach sites with TA-ESD in comparison to C-ESD.

Curative criteria for endoscopic treatment of oesophageal squamous cell cancer

Endoscopic treatment of early oesophageal squamous cell carcinoma is widely accepted. ESD (Endoscopic Submucosal Dissection), which allows en bloc resection regardless of size, provides resected specimens that facilitate histological evaluation of curability. In the histological investigation, the determination of tumor depth, lymphovascular involvement, and lateral and vertical margins play a great role in the assessment of curability. The diagnosis of lymphovascular invasion, in particular, is enhanced by the addition of immunostaining. The long-term outcome of ESD is comparable to that of oesophagectomy, and ESD may be the first-line treatment for early-stage oesophageal cancer due to its fewer complications. Surveillance after curative resection is also imperative because oesophageal cancer is often characterized by the concept of field cancerization, which results in metachronous multiple primary lesions.

Curative Resection of T1a Inlet Patch Adenocarcinoma With Traction-Assisted Endoscopic Submucosal Dissection

Esophageal inlet patch (EIP) adenocarcinoma is extremely rare. We present a case of a 58-year-old man who underwent a diagnostic esophagogastroduodenoscopy for dysphagia and found to have a 2 cm polypoid mass arising from an EIP. Biopsies and staging were consistent with T1aN0M0 EIP adenocarcinoma. While surgical resection was the main method of treatment of these lesions, very few case reports have shown that endoscopic resection can successfully remove these lesions. After multidisciplinary discussion, the patient underwent curative traction-assisted endoscopic submucosal dissection-which is the first known case report to highlight the success of this technique.

Curative endoscopic full-thickness resection of a fundic gland-type gastric adenocarcinoma

Video 1Summary of the presented case. Macroscopic images of the lesion in a white-light endoscopy and narrow-band imaging and in an underwater view followed by scenes from the resection with circular marking, submucosal injection, circumferential incision, and submucosal dissection using a multi-bend double-channel endoscope, as well as clip traction, controlled full-thickness dissection, and inspection of the defect plus closure of the defect with the clip-and-loop technique.

Endoscopic submucosal dissection of recurrent, circumferential, distal rectal tumor with severe submucosal fibrosis using multiple clip-line tractions

Video 1Endoscopic submucosal dissection for a recurrent, circumferential, distal rectal tumor.

ESD with elastic ring traction is more effective and safer than conventional ESD in large proximal colon neoplastic lesions: a retrospective cohort study (with video)

BACKGROUND AND AIMS

Colorectal endoscopic submucosal resection (ESD), especially ESD in proximal colon, has always been challenging. We invented a novel elastic ring as a traction method to facilitate ESD. Our study aims to compare the safety and effectiveness of ESD with in vivo traction and conventional ESD without traction in the treatment of large proximal colon neoplastic lesions.

METHODS

This retrospective cohort study included consecutive patients with large (≥ 20 mm in their maximal diameter) proximal colon neoplastic lesions who underwent ESD with in vivo elastic ring traction or conventional ESD without traction in our endoscopy center between June 2018 and April 2022 by one experienced endoscopist.

RESULTS

The ESD with traction group has lower overall complication rate and lower perforation rate than those in the conventional ESD group (0% vs 14.71%, P = 0.021; 0% vs 11.76%, P = 0.048, respectively), and the differences are statistically significant. Although there are no significant differences in the rates of en bloc resection and R0 resection and bleeding rate, ESD with traction group still had higher en bloc resection and R0 resection rates and lower bleeding rate than conventional ESD group without traction (100% vs 94.12%, P = 0.226; 94.59% vs 85.29%, P = 0.189, 8.82% vs 2.70%, P = 0.276, respectively).

CONCLUSION

ESD with elastic ring traction is potentially more effective and safer than conventional ESD in the treatment of large proximal colon neoplastic lesions. Further large, prospective controlled studies are needed to fully evaluate this novel method.

Endoscopic submucosal dissection for a large cecal lesion using the circumferential-inversion method

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The value of single-channel endoscopic traction and kiss suture technique in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumors

BACKGROUND

To investigate the value of single forceps endoscopic traction stapling suture technique (SFETSST) in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumor (GMPT).

METHODS

Consecutive patients who underwent submucosal tumor excavation (ESE) and endoscopic full-thickness resection (EFR) for GMPT in the Second Affiliated Hospital of Xiamen Medical College from January 2015 to January 2022 were retrospectively collected. They were divided into the SFETSST group and the standard group (patients who receive single forceps traction-free endoscopic suture technique). The healing effects were compared between the two groups.

RESULTS

Seventy-seven patients were included in our study with 50 patients included in SFETSST group. The baseline characteristics had no significant difference between the two groups. The technical success rate of wound suture in SFETSST cluster was significantly upper than that within standard cluster (100% vs. 88.89%, P = 0.04). The wound suture time in SFETSST cluster was significantly lower than that within standard cluster (33.19 ± 10.64 min, P < 0.001). Moreover, the incidence rates of intra-operative and postoperative complications in SFETSST cluster were lower than standard cluster (0 vs. 7.41%, P = 0.051 and 0 vs. 11.11%, P = 0.016). Interestingly, the SFETSST cluster had lower cost of consumables (2485.40 ± 591.78 vs. 4098.52 ± 1903.06 Yuan, P = 0.01) and shorter hospital stay (4.96 ± 0.90 vs. 7.19 ± 2.45, P < 0.001) than standard cluster.

CONCLUSION

Our study showed that to fully closure the full-thickness defects of digestive tract, SFETSST was effective, safe, and economical, which was worth popularizing.

Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience

BACKGROUND AND AIMS

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

METHODS

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

RESULTS

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

CONCLUSIONS

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

Factors associated with increased duration of endoscopic submucosal dissection for rectal tumors: a 22-year retrospective analysis

BACKGROUND AND AIMS

Colorectal endoscopic submucosal dissection (ESD) is widely used in several countries. However, it is associated with technical difficulties. Rectal ESD is considered an intermediate step in colorectal ESD training. Nevertheless, some rectal lesions require a longer procedure time than usual, and the reason for the prolonged time taken for these specific lesions remains unclear. Therefore, this study aimed to clarify the factors associated with prolonged rectal ESD.

METHODS

In total, 483 rectal lesions resected using ESD from February 1998 to June 2021 were investigated. Prolonged ESD procedure time was defined as the time from the first submucosal injection to lesion removal exceeding 120 minutes, whereas other procedures were defined as average ESD procedure time. Clinicopathologic and endoscopic findings were compared between the 2 groups using univariate and multivariate analyses.

RESULTS

One hundred forty-four lesions were resected using a prolonged ESD procedure time of 202.9 ± 92.3 minutes, whereas 339 lesions were resected using an average ESD procedure time of 77.8 ± 29.4 minutes. Multivariate analysis revealed that tumors involving the dentate line (P = .026), resection size ≥50 mm (P < .001), invasion depth ≥T1b (P = .006), and circumferential range ≥2/3 (P = .001) were independent risk factors for prolonged-duration ESDs, regardless of whether the procedure was performed by an expert or not.

CONCLUSIONS

The results of the present study suggest that the location of a lesion involving the dentate line, resection size ≥50 mm, circumferential range ≥2/3, and invasion depth ≥T1b are the independent risk factors for prolonged ESD procedure time.

American Society for Gastrointestinal Endoscopy guideline on endoscopic submucosal dissection for the management of early esophageal and gastric cancers: methodology and review of evidence

This document from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used in the review of the evidence used to inform the final guidance outlined in the accompanying Summary and Recommendations document regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. This guideline used the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, the ASGE suggests surgical evaluation over endosic approaches.

Initial multicenter experience using a novel articulating through-the-scope traction device for endoscopic submucosal dissection

Background and study aims A single-operator, articulating, through-the-scope (TTS) traction device was recently developed to facilitate endoscopic submucosal dissection (ESD). Clinical data on the performance of this device are limited. We report an initial multicenter experience with ESD using this articulating TTS traction device. Patients and methods Retrospective analysis on all consecutive patients who underwent ESD using this traction device (T-ESD) at five centers between August 2021 and December 2022. Endpoints included: rates of en-bloc resection, R0 resection, curative resection, and adverse events. Results Thirty-six patients (median age 64.8 years; 47.2% women) underwent ESD (median lesion size 40 mm; interquartile range [IRQ]: 27.5-67.5) for lesions in the esophagus (n=2), stomach (n=8), sigmoid colon (n=6), and rectum (n=20). Submucosal fibrosis was encountered in one-third of the lesions (33.3%). Median ESD time was 104.6 minutes (IQR: 65-122). En-bloc, R0 and curative resection were achieved in 94.4%, 91.6%, and 97.2%, respectively. The single patient with non-curative resection of an invasive rectal adenocarcinoma underwent surgery. There were no cases of delayed bleeding or perforation. There was no recurrence on surveillance endoscopy (n=20) at a median of 6 months (IQR: 3.75-6). Conclusions This initial multicenter experience demonstrates high resection rates and excellent safety profile when performing ESD with this novel articulating TTS device. Dynamic real-time traction may lower the technical difficulty of ESD. Additional studies are needed to assess its cost-effectiveness and compare its usefulness with other traction devices and techniques during ESD.

Multitraction with rubber bands and surgical silk as a method to facilitate endoscopic submucosal dissection

We propose this variant of the clip technique as a method that assist traction during endoscopic submucosal dissection (ESD): traction on the mucosa plane using an hemoclip carrying a surgical silk and three rubber bands, before the incision, to allow easier access to the submucosa space. We propose this variant with the intention of facilitating access to ESD quickly and safely for beginners.

Management of complications related to colorectal endoscopic submucosal dissection

Compared to endoscopic mucosal resection (EMR), colonoscopic endoscopic submucosal dissection (C-ESD) has the advantages of higher en bloc resection rates and lower recurrence rates of colorectal neoplasms. Therefore, C-ESD is considered an effective treatment method for laterally spread tumors and early colorectal cancer. However, C-ESD is technically more difficult and requires a longer procedure time than EMR. In addition to therapeutic efficacy and procedural difficulty, safety concerns should always be considered when performing C-ESD in clinical practice. Bleeding and perforation are the main adverse events associated with C-ESD and can occur during C-ESD or after the completion of the procedure. Most bleeding associated with C-ESD can be managed endoscopically, even if it occurs during or after the procedure. More recently, most perforations identified during C-ESD can also be managed endoscopically, unless the mural defect is too large to be sutured with endoscopic devices or the patient is hemodynamically unstable. Delayed perforations are quite rare, but they require surgical treatment more frequently than endoscopically identified intraprocedural perforations or radiologically identified immediate postprocedural perforations. Post-ESD coagulation syndrome is a relatively underestimated adverse event, which can mimic localized peritonitis from perforation. Here, we classify and characterize the complications associated with C-ESD and recommend management options for them.

Difficult colorectal polypectomy: Technical tips and recent advances

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

Endoscopic full‑thickness resection with clip‑ and snare‑assisted traction for gastric submucosal tumours in the fundus: A single‑centre case series

Exposed endoscopic full-thickness resection (Eo-EFTR) has been recognized as a feasible therapy for gastrointestinal submucosal tumours (SMTs) originating deep in the muscularis propria layer; however, Eo-EFTR is difficult to perform in a retroflexed fashion in the gastric fundus. As a supportive technique, clip- and snare-assisted traction may help expose the surgical field and shorten the operation time in endoscopic resection of difficult regions. However, the application of clip- and snare-assisted traction in Eo-EFTR of SMTs in the gastric fundus is limited. Between April 2018 and December 2021, Eo-EFTR with clip- and snare-assisted traction was performed in 20 patients with SMTs in the gastric fundus at The First Affiliated Hospital of Soochow University. The relevant clinical data were collected retrospectively for all of the patients and analysed. All 20 patients underwent Eo-EFTR successfully without conversion to open surgery or severe adverse events. The en bloc resection rate and R0 resection rate were both 100%. Two patients had abdominal pain and fever after the operation, and five patients had fever, which recovered with medical therapy. No complications, such as delayed bleeding or delayed perforation, were observed. The postoperative pathology indicated that 19 cases were gastrointestinal stromal tumours and one case was leiomyoma. During the follow-up, no residual tumour, local recurrence or distant metastasis was detected by endoscopy or abdominal computed tomography. In conclusion, Eo-EFTR with clip- and snare-assisted traction appears to be a relatively safe and effective treatment for gastric SMTs in the fundus. However, prospective studies on a larger sample size are required to verify the effect of the clip- and snare-assisted traction in Eo-EFTR.

Endoscopic submucosal tunnel dissection vs conventional endoscopic submucosal dissection for large colorectal neoplasms: a single-centre retrospective study

BACKGROUND

Colorectal endoscopic submucosal dissection (ESD) is still not widely used due to its technical difficulty and the risk of complications. Several techniques, such as traction techniques, pocket techniques and others, have been proposed to facilitate it. One modified pocket technique especially suitable for large lesions is endoscopic submucosal tunnel dissection (ESTD). The aim of this study was to evaluate the safety and efficacy of ESTD and compare ESTD to the conventional ESD (CESD) for treating large colorectal lesions.

METHODS

The charts of consecutive patients referred to the Arcispedale Santa Maria Nuova (Reggio Emilia, Italy) for colorectal ESD between January 2014 and February 2021 for colorectal neoplasms > 40 mm were retrospectively analysed. The primary outcome of the study was the en bloc resection rate. Secondary outcomes were complete and curative resection rates, procedure speed, the adverse events rate and the recurrence rate.

RESULTS

There were 59 patients (M:F ratio 29:30, median age 70 years [range 50-93 years]). Of 59 colorectal lesions > 40 mm, 25 were removed by ESTD and 34 by CESD. The en bloc resection rate was 100% in both groups and the complete resection rate was similar (ESTD 92% vs CESD 97.1%, p = 0.569), while the curative resection rate was higher in the CESD group, but not significantly (94.1% vs 76%, p = 0.061). Procedure speed was significantly faster with ESTD (22 vs 17 mm²/min, p = 0.045), and the overall incidence of adverse events was low (6.8%). Eight patients were referred to surgery due to non-curative resection. During follow-up, no recurrence was observed in either treatment group.

CONCLUSION

ESTD achieves a very high en bloc resection rate and is faster than CESD.

Efficacy and safety of pocket-creation method for early gastric cancers

BACKGROUND

Endoscopic submucosal dissection (ESD) is the standard endoscopic treatment for early gastric cancers (EGCs). However, obscured view and difficulty in submucosal lifting during ESD have been demonstrated. Additionally, ESD is time-consuming and poses a high risk of perforation and bleeding when performed in challenging locations. The pocket-creation method (PCM) is a newly developed strategy for colorectal tumors, while the outcomes of application in the treatment of EGCs are rarely reported. In the present study, we aimed to compare the technical efficacy and safety of PCM-ESD and the conventional ESD (c-ESD) technique for the treatment of EGCs.

METHODS

This was a single-center retrospective study consisting of 162 patients with EGCs who underwent ESD between February 2019 and February 2021. One-to-one propensity score matching (PSM) was performed. In addition, clinicopathological characteristics and treatment outcomes were also compared.

RESULTS

PCM-ESD was more likely to be used in patients with larger lesions than c-ESD with/without traction. In addition, the resection speed for lesions of the PCM-ESD was faster compared with c-ESD without traction (median dissection speed: 19.6 mm²/min vs. 15 mm²/min; p < 0.001) and c-ESD with traction (median dissection speed after PSM: 19.9 mm²/min vs. 15 mm²/min; p = 0.001). In multiple linear regression analysis, significant factors related to a higher dissection speed were the treatment method of PCM-ESD (p = 0.034), the long diameter of the resected lesion (p = 0.001), and lesion location (p = 0.046).

CONCLUSIONS

Collectively, PCM-ESD appeared to be a safer and more effective treatment for EGCs than c-ESD. In addition, PCM-ESD could significantly improve the speed of tumor resection.

Use of a novel articulation arm device for endoscopic submucosal dissection of a rectal laterally spreading tumor

Video 1.

Low risk of local recurrence after a successful en bloc endoscopic submucosal dissection for noninvasive colorectal lesions with positive horizontal resection margins (R-ESD study)

BACKGROUND : During endoscopic submucosal dissection (ESD), the normal mucosa is cut under constant optical control. We studied whether a positive horizontal resection margin after a complete en bloc ESD predicts local recurrence.

METHODS

 In this European multicenter cohort study, patients with a complete en bloc colorectal ESD were selected from prospective registries. Cases were defined by a horizontal resection margin that was positive or indeterminate for dysplasia (HM1), whereas controls had a free resection margin (HM0). Low risk lesions with submucosal invasion (T1) and margins free of carcinoma were analyzed separately. The main outcome was local recurrence.

RESULTS

 From 928 consecutive ESDs (2011-2020), 354 patients (40 % female; mean age 67 years, median follow-up 23.6 months), with 308 noninvasive lesions and 46 T1 lesions, were included. The recurrence rate for noninvasive lesions was 1/212 (0.5 %; 95 %CI 0.02 %-2.6 %) for HM0 vs. 2/96 (2.1 %; 95 %CI 0.57 %-7.3 %) for HM1. The recurrence rate for T1 lesions was 1/38 (2.6 %; 95 %CI 0.14 %-13.5 %) for HM0 vs. 2/8 (25 %; 95 %CI 7.2 %-59.1 %) for HM1.

CONCLUSION

 A positive horizontal resection margin after an en bloc ESD for noninvasive lesions is associated with a marginal nonsignificant increase in the local recurrence rate, equal to an ESD with clear horizontal margins. This could not be confirmed for T1 lesions.

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.

Randomized controlled trial comparing conventional and traction endoscopic submucosal dissection for early colon tumor (CONNECT-C trial)

OBJECTIVES

Endoscopic submucosal dissection (ESD) is a widely used treatment for early gastrointestinal cancer. However, colon ESD remains challenging. Previous studies on colon ESD using the traction method used a small sample, single-center design, providing insufficient evidence of this procedure's efficacy. We thus aimed to investigate the efficacy and safety of the traction method in colon ESD in this multicenter randomized trial.

METHODS

We conducted a prospective, multicenter, randomized, two-arm controlled trial at 10 facilities in Japan. A 1:1 allocation was conducted for the conventional ESD (C-ESD) and traction ESD (T-ESD) groups. The primary end-point was ESD procedure time.

RESULTS

We included 128 C-ESD and 123 T-ESD cases from April 2020 to August 2021. The median procedure times for C-ESD and T-ESD were 61 (40-100) and 53 (40-76) min (P = 0.18), respectively, and no significant differences were observed between the groups. Subgroup analysis showed that the median procedure times for patients with a lesion diameter of ≥30 mm in the C-ESD and T-ESD groups were 89 (57-80) and 69 (50-104) min (P = 0.05), respectively, and for nonexpert operators were 81 (62-120) and 64 (52-109) min (P = 0.07), respectively.

CONCLUSIONS

The traction method did not contribute to a significantly shortened ESD procedure time. However, this method may be useful when the tumor diameter is large or if the procedure is conducted by nonexpert endoscopists.