Recent Development of Techniques and Devices in Colorectal Endoscopic Submucosal Dissection

Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.

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.

Endoscopic Submucosal Dissection of Superficial Colorectal Neoplasms at "Challenging Sites" Using a Double-Balloon Endoluminal Interventional Platform: A Single-Center Study

BACKGROUND

Colonic endoscopic submucosal dissection (ESD) at "challenging sites" such as the cecum, ascending colon, and colonic flexures could be difficult even for expert endoscopists due to poor endoscope stability/maneuverability, steep angles, and thinner wall thickness. A double-balloon endoluminal intervention platform (EIP) has been introduced in the market to fasten and facilitate ESD, particularly when located at difficult sites. Here, we report our initial experience with an EIP comparing the outcomes of an EIP versus standard ESD (S-ESD) at "challenging sites".

MATERIALS AND METHODS

We retrospectively collected data on consecutive patients with colonic lesions located in the right colon and at flexures who underwent ESD in our tertiary referral center between March 2019 and May 2023. Endoscopic and clinical outcomes (technical success, en bloc resection rate, R0 resection rate, procedure time, time to reach the lesion, and adverse events) and 6-month follow-up outcomes were analyzed.

RESULTS

Overall, 139 consecutive patients with lesions located at these challenging sites were enrolled (EIP: 31 and S-ESD: 108). Demographic characteristics did not differ between groups. En bloc resection was achieved in 92.3% and 93.5% of patients, respectively, in the EIP and S-ESD groups. Both groups showed a comparable R0 resection rate (EIP vs. S-ESD: 92.3% vs. 97.2%). In patients undergoing EIP-assisted ESD, the total procedure time was shorter (96.1 [30.6] vs. 113.6 [42.3] minutes, p = 0.01), and the mean size of the resected lesions was smaller (46.2 ± 12.7 vs. 55.7 ± 17.6 mm, p = 0.003). The time to reach the lesion was significantly shorter in the EIP group (1.9 ± 0.3 vs. 8.2 ± 2.7 min, p ≤ 0.01). Procedure speed was comparable between groups (14.9 vs. 16.6 mm2/min, p = 0.29). Lower adverse events were observed in the EIP patients (3.8 vs. 10.2%, p = 0.31).

CONCLUSIONS

EIP allows results that do not differ from S-ESD in the resection of colorectal superficial neoplasms localized in "challenging sites" in terms of efficacy and safety. EIP reduces the time to reach the lesions and may more safely facilitate endoscopic resection.

Long-Term Outcomes of Endoscopic Submucosal Dissection for Colorectal Epithelial Neoplasms: A Systematic Review

In this review, we summarize up-to-date reports with five-year observation after colorectal endoscopic submucosal dissection (ESD). Five-year cause-specific survival rates ranged from 98.6 to 100%. The local recurrence rates ranged from 1.1 to 2.2% in complete resection and 7.5 to 25.0% in incomplete resection. Incomplete resection was a risk factor for local recurrence. In non-curative ESD, five-year cause-specific survival rates ranged from 93.8 to 100% with additional surgery, and 92.7 to 99.1% without surgery. The choice of additional surgery should be based on the individual patient's age, concomitant diseases, wishes, life expectancy, and the risk of lymph node metastasis. The metachronous cancer rates ranged from 0.22 to 1.1%. Both local recurrence and metachronous tumors should be checked with a follow-up colonoscopy after ESD.

The usefulness of a double-balloon endolumenal interventional platform for colorectal endoscopic submucosal dissection by non-expert endoscopists in a porcine model (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is an optimal treatment for colorectal tumors; however, it is technically difficult, especially for non-experts. Therefore, a device that helps non-experts perform colorectal ESD would be beneficial. A double-balloon endolumenal interventional platform (DEIP) was recently developed to assist colorectal ESD through endoscope stabilization and traction. This study assessed the usefulness of colorectal ESD using the DEIP (DEIP-ESD) by endoscopists, including non-experts, in a living porcine model.

METHODS

Two pigs were used to perform eight DEIP-ESD and eight conventional cap-assisted ESD (C-ESD) procedures. Three experts and five non-experts each resected one lesion using DEIP-ESD and one using C-ESD. We evaluated the treatment outcomes and performed stratified analyses between the experts and non-experts.

RESULTS

Dissection speed was significantly faster in DEIP-ESD than in C-ESD (13.3 mm²/min vs 28.5 mm²/min, P = 0.002). However, the total procedure time did not differ significantly between DEIP-ESD and C-ESD. In the stratified analyses, the dissection speed of non-experts was significantly faster in DEIP-ESD than in C-ESD (10.9 mm²/min vs 25.1 mm²/min, P = 0.016), while that of experts increased in DEIP-ESD but to a lesser extent (19.1 mm²/min vs 28.8 mm²/min, P = 0.1). The total procedure time did not differ between DEIP-ESD and C-ESD for both experts and non-experts. The self-completion rate of non-experts also increased in DEIP-ESD. Moreover, the number of muscularis propria injuries induced by non-experts was fewer in DEIP-ESD than in C-ESD.

CONCLUSIONS

DEIP could facilitate colorectal ESD by improving dissection efficiency without increasing adverse events, especially when performed by non-experts.

Snare devices with thinner loop wire may provide higher performance for cold snare polypectomy in an experimental model

Background and study aims  Snare devices play an important role in treatment of intestinal polyps. However, there are no objective measurements for the characteristics of the various types of snare devices. Materials and methods  Seven types of snare devices from four manufacturers were evaluated based on original measurements. The evaluated factors were stiffness, cutting quality, and change in force required for cutting depending on sheath shape. The latter two factors were evaluated by measuring the force required to cut 20 % gelatin cylinders, which simulated intestinal polyps. The cutting sharpness was evaluated by observing the sectional surface of cut gelatin cylinders using a stereomicroscope. The correlations between these measurements and characteristics of the snare devices were investigated. Results  A strong positive correlation, with an R 2 value of 0.863, was shown between the force required to cut gelatin cylinders and loop wire diameter. Loop wire diameter also had a strong correlation, with an R 2 value of 0.7997, with the change in force required for cutting gelatin cylinders depending on sheath shape. No correlations were detected between loop stiffness and characteristics of snare devices. The edge-enhanced image revealed that the rougher surfaces of the gelatin cylinders were cut by snares with a thicker diameter. Conclusions  Thinner loop wire may provide higher performance in cold snare polypectomy in an experimental model.

Effectiveness of S-O Clip-Assisted Colorectal Endoscopic Submucosal Dissection

This study aimed to assess the utility of the S-O clip during colorectal endoscopic submucosal dissection (ESD). We conducted a retrospective study on 185 patients who underwent colorectal ESD from January 2015 to January 2020. The patients were divided into two groups: before and after the introduction of the S-O clip. Forty-two patients underwent conventional ESD (CO group) and 29 patients underwent ESD using the S-O clip (SO group). We compared the surgery duration, dissection speed, en bloc resection rate, and complication rate between both groups. Compared with the CO group, the SO group had a significantly shorter surgery duration (70.7 ± 37.9 min vs. 51.2 ± 18.6 min; p = 0.017), a significantly higher dissection speed (15.1 ± 9.0 min vs. 26.3 ± 13.8 min; p < 0.001), a significantly higher en bloc resection rate (80.9% vs. 98.8%; p ≤ 0.001), and a significantly lower perforation rate (4.3% vs. 1.3%). In the right colon, the surgery duration was significantly shorter and the dissection speed was significantly higher in the SO group than in the CO group. Moreover, the rate of en bloc resection improved significantly in the right colon. S-O clip-assisted ESD reduces the procedure time and improves the treatment effects, especially in the right colon.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Clip-with-Line Traction Suture Method for Closing Mucosal Defects after Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is a technically difficult endoscopic procedure for treating gastrointestinal diseases. Procedure time is longer, and complications such as mucosal defects, intraoperative perforation, and bleeding occur frequently. Here, to solve these problems, we described the clip-with-line traction suture method that applied and performed for closing mucosal defects after ESD in three representative cases.

A Novel Technique of Endoscopic Papillectomy with Hybrid Endoscopic Submucosal Dissection for Ampullary Tumors: A Proof-of-Concept Study (with Video)

BACKGROUND

Endoscopic papillectomy (EP) carries a potential risk of procedure-related adverse events and incomplete resection. Since hybrid endoscopic submucosal dissection (ESD) had been established as an alternative option for relatively large and difficult gastrointestinal tumors, we evaluated a novel EP with hybrid ESD (hybrid ESD-EP) for curative safe margin in this proof-of-concept study.

METHODS

A total of eight cases who underwent hybrid ESD-EP between 2018 and 2020 were identified from our prospectively maintained database. Hybrid ESD-EP involved a (sub)circumferential incision with partial submucosal dissection, and subsequent snare resection of ampullary tumors, which was performed by two endoscopists with expertise in ESD or endoscopic retrograde cholangiopancreatography. Demographic data and clinicopathological outcomes were retrospectively evaluated.

RESULTS

En bloc resection was achieved by hybrid ESD-EP in all eight cases, with the median procedure time of 112 (range: 65-170) minutes. The median diameters of the resected specimens and tumors were 18 and 12 mm, respectively. All lateral margins were clear, whereas vertical margin was uncertain in three (38%), resulting in the complete resection rate of 63%. Postoperative bleeding and pancreatitis developed in each one (13%). No tumor recurrence was observed even in those cases with uncertain vertical margin, after a median follow-up of 244 (range, 97-678) days.

CONCLUSIONS

Hybrid ESD-EP seems to be feasible and promising in ensuring the lateral resection margin. However, further investigations, especially to secure the vertical margin and to shorten the procedure time, should be required.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect

BACKGROUND

Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD.

METHODS

We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques.

RESULTS

A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed.

CONCLUSIONS

Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Efficacy and suitable indication of colorectal endoscopic submucosal dissection using a balloon-assisted endoscope

Background and Aim

Cases of colorectal endoscopic submucosal dissection (ESD) with poor maneuverability are often encountered. We aimed to evaluate the efficacy of balloon‐assisted endoscopy (BAE) for such cases.

Methods

We confirmed maneuverability preoperatively in 400 consecutive cases of colorectal ESD performed at a single center from April 2011 to April 2018. A total of 83 deep colon cases judged as having poor maneuverability were retrospectively reviewed; 54 cases underwent BAE with a single balloon endoscope (group B), and 29 cases underwent conventional procedures without BAE (group C). Tumor size, procedure duration, dissection speed, en bloc resection rate, histology, and associated complications were compared between groups.

Results

The mean tumor size, tumor invasiveness, fibrosis, and complications did not differ between groups. Although the en bloc resection rate did not differ (both 98%), the groups significantly differed with regard to the R0 resection rate (B: 96%; C: 83%; P = 0.048). Overall, the procedure duration (B: 51 min; C: 70 min; P = 0.17) and dissection speed (B: 19.4 mm²/min; C: 17.4 mm²/min; P = 0.13) were not significantly different between groups. However, the dissection speed for lesions in the cecum/ascending colon was significantly faster in group B than in group C (B: 22.3 mm²/min; C: 11.3 mm²/min; P = 0.037).

Conclusions

In cases of colorectal ESD with poor maneuverability, the use of BAE contributed to an improvement in the R0 resection rate. In addition, BAE contributed to a quicker dissection speed for lesions located in the cecum/ascending colon.

Task Deconstruction of Colonic Endoscopic Submucosal Dissection (cESD): An Expert Consensus

BACKGROUND

Slow adoption of colonic ESD (cESD) in the US is multifactorial due to: lack of clinical training construct (e.g., gastric ESD in Japan), complication risks, and technical difficulty. More than 28,000 patients/year undergo colonic resection for benign lesions that could be managed effectively with cESD. Selected patients could avoid surgery if procedural adoption of cESD increased due to more accessible training. Current US cESD training is scarce, and existing programs are piecemeal. There is a need to develop an effective national training program for practicing endoscopists. A prerequisite to training development is a comprehensive task list delineating procedural steps. The aim of this work was to describe an evidence-based method of deconstructing cESD into the essential steps to provide a task list to guide teaching and assessment.

METHODS

Subject-matter experts (SMEs) performed a literature review to create an initial procedural step list. Eleven clinical cESD SMEs and four educational SMEs formed a 'cESD Working Group' to develop consensus regarding steps. Through a two-stage modified Delphi process, a consensus on a comprehensive standard cESD deconstructed task list was reached. The aim was to standardize cESD teaching to efficiently bring a novice to safe performance.

RESULTS

A literature review identified eight initial cESD steps. First-round Delphi consensus was gained on seven steps. Semi-structured focus group discussions resulted in consensus on a modified version of 7 of the initial steps, with addition of two steps. Consensus on procedural actions needed to perform each step was achieved after the hands-on laboratory. The final result was a ten-step deconstructed task list for standard cESD.

CONCLUSION

The development of a standardized cESD procedural task list provides a foundation to safely and efficiently teach cESD to practicing endoscopists. This list can be used to develop a training pathway to increase procedural adoption. Selected patients currently undergoing colonic resections could benefit from increased adoption of cESD.

Cost Analysis of Endoscopic Submucosal Dissection for the Treatment of Colorectal Lesions in China

Aim

The aim of the study was to evaluate costs associated with colonic endoscopic submucosal dissection (ESD) for treatment of colorectal cancer.

Methods

The study is a retrospective analysis of data on 395 patients treated by colonic ESD.

Results

The operation, consumable items, and medication accounted for 71% of the total costs for colonic ESD treatment. Medication and consumable items' costs were higher if lesions occurred in the transverse colon and right hemicolon compared to the left hemicolon. Medication, consumable items, and total costs were higher for larger lesions. Lesion numbers and carcinoma were associated with higher medication, consumable items, operation, and total costs. Positive surgical margins and complications of hemorrhage or perforation were positively correlated with higher costs for medication, consumable items, and total costs.

Conclusion

Labor costs for doctors and nurses remain low in China. Costs for medication and consumable items were higher for treatment involving the transverse colon or right hemicolon (vs. the left hemicolon), larger lesions, carcinoma, and a positive surgical margin. A benchmark cost estimate for ESD treatment including 4 days of postoperative hospitalization was determined to be approximately 5400 USD.