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Liu M, Zhang Y, Wang Y, Zhu H, Xu H. Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta-analysis. J Gastroenterol Hepatol 2020; 35:1869-1877. [PMID: 32542857 DOI: 10.1111/jgh.15148] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/08/2020] [Accepted: 06/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large colorectal lesions. However, colorectal ESD is associated with a high frequency of adverse events (AEs), and the efficacy of prophylactic endoscopic closure after ESD for preventing AEs is still controversial. This meta-analysis was conducted to assess the efficacy of closure on AEs following colorectal ESD. METHODS We searched PubMed, Embase, and the Cochrane Library for eligible studies. The chi-square-based Q statistics and the I2 test were used to test for heterogeneity. Pooling was conducted using a fixed or random effects model. RESULTS We identified eight eligible studies that compared the effects of closure vs non-closure with respect to delayed bleeding, delayed perforation, and post-ESD coagulation syndrome. Compared with non-closure (5.2%), closure was associated with a lower incidence (0.9%) of delayed bleeding (pooled odd ratios [ORs]:0.19, 95% CI: 0.08-0.49) following ESD. The pooled ORs showed no significant differences in incidence of delayed perforation (pooled OR: 0.22; 95% CI: 0.05-1.03) or post-ESD coagulation syndrome (pooled OR:0.75; 95% CI: 0.26-2.18) between the closure and non-closure groups. CONCLUSION Prophylactic endoscopic closure may reduce the incidence of delayed bleeding following ESD of colorectal lesions. Future studies are needed to further illuminate risk factors and stratify high risk subjects for a cost-effective preventive strategy.
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Affiliation(s)
- Mingqing Liu
- Department of Gastroenterology, First Hospital of Jilin University, ChangChun, China
| | - Yangyu Zhang
- Division of Clinical Research, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Yueqi Wang
- Division of Clinical Research, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - He Zhu
- Department of Gastroenterology, First Hospital of Jilin University, ChangChun, China
| | - Hong Xu
- Department of Gastroenterology, First Hospital of Jilin University, ChangChun, China
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Chiba H, Tachikawa J, Arimoto J, Ashikari K, Kuwabara H, Nakaoka M, Goto T, Ohata K, Nakajima A. Predictive Factors of Mild and Severe Fibrosis in Colorectal Endoscopic Submucosal Dissection. Dig Dis Sci 2020; 65:232-242. [PMID: 31312991 DOI: 10.1007/s10620-019-05735-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/11/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND STUDY AIMS Varying degrees of fibrosis in colorectal endoscopic submucosal dissection (ESD) make the procedure difficult. Consensus on the predictive factors of fibrosis degree (mild or severe) has not been established. We conducted a study to identify the predictive factors and to examine the feasibility of ESD for fibrotic lesions. PATIENTS AND METHODS We included 518 patients who had undergone ESD for 558 lesions from April 2012-September 2018. Patients were classified into fibrosis or no-fibrosis groups, and logistic regression analysis was performed to identify predictive factors of fibrosis. Subgroup analyses were performed for fibrosis degree. RESULTS The total incidence of fibrosis was 21.1% (mild: 14.1%; severe: 7.1%). Although the curative resection rate (free margin: invasion depth less than 1000 μm: no lymphatic invasion, vascular involvement) was lower in the fibrosis group compared with the control (80.7% vs. 97.6%), neither the en bloc resection rate (99.1% vs. 100%) nor incidence of perforation (0.9% vs. 0.2%) differed between the two groups. Multivariate analysis revealed that a cecal location, preoperative biopsy, straddling fold, laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) type were predictive of mild fibrosis. The presence of a straddling fold and a protruded lesion were independent predictive factors of severe fibrosis. CONCLUSIONS We identified the predictive factors of mild and severe fibrosis. It is preferable that a more experienced physician performs ESD for the lesions with F2 fibrosis.
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Affiliation(s)
- Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan.
| | - Jun Tachikawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Keiichi Ashikari
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Toru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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Chiba H, Ohata K, Tachikawa J, Arimoto J, Ashikari K, Kuwabara H, Nakaoka M, Goto T, Nakajima A. Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection: When Is Emergency Colonoscopy Needed? Dig Dis Sci 2019; 64:880-887. [PMID: 30284133 DOI: 10.1007/s10620-018-5310-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is an effective treatment for early-colorectal cancer. Although delayed bleeding is a serious potential complication, there is no consensus on the optimal protocol to determine which cases require emergency colonoscopy. AIMS This study aimed to assess the risk factors for delayed bleeding after ESD and evaluate the "watch and wait" strategy for delayed bleeding. The "watch and wait" strategy was used for delayed bleeding, unless the shock index was ≥ 1 and/or a moderate amount of hematochezia occurred more than five occurrences. METHODS This study included 404 patients who had undergone endoscopic resection for 439 lesions between April 2012 and February 2018. Patients were classified into the bleeding group or the no-bleeding group to investigate the risk factors for delayed bleeding, and to assess the necessity of emergency colonoscopy. RESULTS Twenty-seven patients into the bleeding group and 412 into the no-bleeding group were classified. However, no case required emergency colonoscopy for hemostasis under "watch and wait strategy." Multivariate analysis revealed the risk factors for bleeding were rectal lesion (OR 5.547, 95% CI 1.456-21.130; P = 0.012) and lesion size ≥ 40 mm (OR 3.967, 95% CI 1.003-15.696; P = 0.05). CONCLUSIONS Risk factors for delayed bleeding are rectal lesions and lesion size ≥ 40 mm. This watch and wait strategy resulted in no requirements for emergency colonoscopy or blood transfusion, and no serious conditions caused by delayed bleeding.
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Affiliation(s)
- Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan.
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Keiichi Ashikari
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Toru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Ota-Ku, Tokyo, 143-8527, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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Lee MJ, Connelly TM. Head and neck subcutaneous emphysema, a rare complication of iatrogenic perforation during colonoscopy: management review of reported cases from 2000-2016. Expert Rev Gastroenterol Hepatol 2017; 11:849-856. [PMID: 28678570 DOI: 10.1080/17474124.2017.1351294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Subcutaneous face and neck emphysema secondary to colonic perforation is a rare complication of colonoscopy. Presentation may be complicated by pneumothorax and/or respiratory distress. Evidence limited to case studies. Therefore, no management consensus of these rarely reported cases exists. METHODS All cases published on PubMed between 1 January 2000-1 November 2016 reporting subcutaneous face and/or neck emphysema after colonoscopy are included. Management is discussed with trends identified. We report a case of a patient undergoing routine polypectomy who developed subcutaneous emphysema of the face, neck and thorax with a pneumothorax and pneumoretroperitoneum. RESULTS 37 cases were found (mean age = 64.1 ± 15.09 years). The majority (n = 24) were managed non-operatively. Conservative and operative management had mean inpatient stays of 7.6 ± 4.65 and 19.5 +/- 21.62 days respectively. Sixteen cases had a concomitant pneumothorax with nine (56.3%) requiring decompression. No mortalities occurred. CONCLUSION An understanding of anatomy heightens awareness of the rare complication of face and/or neck surgical emphysema, secondary to pneumoretroperitoneum and pneumothorax, after perforation of the colon during endoscopy. Management remains controversial with expectant conservative bowel rest with antibiotics and operative intervention described. Conservative management had a shorter inpatient stay and was more common in younger patients.
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Affiliation(s)
- Mathew John Lee
- a General Surgery , Royal College of Surgeons , Dublin , Ireland
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Chiba H, Tachikawa J, Kurihara D, Ashikari K, Goto T, Takahashi A, Sakai E, Ohata K, Nakajima A. Safety and efficacy of simultaneous colorectal ESD for large synchronous colorectal lesions. Endosc Int Open 2017; 5:E595-E602. [PMID: 28670616 PMCID: PMC5482740 DOI: 10.1055/s-0043-110567] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/20/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Multiple large colorectal lesions are sometimes diagnosed during colonoscopy. However, there have been no investigations of the feasibility of simultaneous endoscopic submucosal dissection (ESD) for multiple lesions. This study aims to reveal the strategy of simultaneous ESD for multiple large colorectal lesions. PATIENTS AND METHODS 246 patients who underwent ESD for 274 colorectal lesions were retrospectively evaluated in this study. Fifty-one large colorectal lesions among 23 patients were treated by ESD simultaneously (simultaneous group), and 223 patients were treated with ESD for a single lesion (single group). RESULTS En-bloc resection and curative resection rates did not differ. Compared with the single group, each procedure time was faster (31.8 ± 23.6 min vs. 45.8 ± 44.8, P = 0.002), but total procedure time was significantly longer in the simultaneous group (70.6 ± 33.4 vs. 45.8 ± 44.8 min, P = 0.01). Rates of adverse events including bleeding and perforation were not higher in the simultaneous group but the mean blood pressure, incidence of bradycardia and the amount of sedative drug used during ESD were significantly higher in the simultaneous group. Multiple logistic regression analysis identified non-experienced physician, lesion size ≥ 40 mm and submucosal fibrosis as an independent risk factor for procedure duration (≥ 90 min) (Odds ratio 11.852, 18.280, and 3.672; P < 0.05, respectively). CONCLUSIONS Simultaneous ESD for multiple synchronous colorectal lesions is safe and feasible compared with single ESD and can reduce the burden to patients, length of hospital stay and medical expense. These results need to be elucidated by further studies.
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Affiliation(s)
- Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan,Corresponding author Hideyuki Chiba MD, PhD Department of Gastroenterology, Omori Red Cross Hospital4-30-1 Chuo, Ota-KuTokyo, 143-8527Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Daisuke Kurihara
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Keiichi Ashikari
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Toru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Akihiro Takahashi
- Department of Gastroenterology, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Eiji Sakai
- Department of Gastroenterology, Tokyo, Japan
| | - Ken Ohata
- Department of Gastroenterology, Tokyo, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
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Ohata K, Nonaka K, Misumi Y, Tsunashima H, Takita M, Minato Y, Tashima T, Sakai E, Muramoto T, Matsuyama Y, Hiejima Y, Matsuhashi N. Usefulness of training using animal models for colorectal endoscopic submucosal dissection: is experience performing gastric ESD really needed? Endosc Int Open 2016; 4:E333-9. [PMID: 27004253 PMCID: PMC4798938 DOI: 10.1055/s-0042-101022] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 01/04/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Despite the clinical advantages of colorectal endoscopic submucosal dissection (ESD), an effective training system, especially for Western endoscopists, has been challenging to establish. Herein, we propose a novel training program using ex vivo animal models and evaluate the learning curve of colorectal ESD trainees without gastric ESD experience. PATIENTS AND METHODS A total of 80 colorectal lesions were prospectively collected and removed by two novice operators. Before human ESD procedures, they received ESD training using an ex vivo porcine "proximal colon" model, which simulates a lumen with many folds and flexions. To assess the validity of our training system, the self-completion and en bloc R0 resection rates, the operation time, and prevalence of complications were compared between the first and latter period. Moreover the factors associated with prolonged operation time were evaluated. RESULTS The overall rates of self-completion and en bloc R0 resection were 98 % (78/80) and 100 % (80/80), respectively. The operation time during the first period was significantly longer than that during the latter period (86 ± 50 minutes vs. 60 ± 36 minutes, P = 0.01). Regarding complications, only two cases of perforations and delayed hemorrhage were observed during the first period; however, all of the complications were successfully managed endoscopically. The presence of fibrosis was identified as a significant independent predictor of a prolonged operation time during the first period (coefficient, 5.90; 95 %CI, 2.36 - 9.44, P = 0.002). CONCLUSIONS Our trainees achieved high rates of self-completion and R0 resection without severe complications even during the first 20 cases, suggesting that our training programs using ex vivo animal models are useful for trainees without gastric ESD experience. STUDY REGISTRATION UMIN000013566.
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Affiliation(s)
- Ken Ohata
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan,Corresponding author Ken Ohata, MD Division of GastroenterologyNTT Medical Center5-9-22 Higashi-gotandaShinagawa-kuTokyo141-8625Japan+81-3-34486541
| | - Kouichi Nonaka
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yoshitsugu Misumi
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Maiko Takita
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yohei Minato
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Tomoaki Tashima
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Eiji Sakai
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takashi Muramoto
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yasushi Matsuyama
- Division of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yoshimitsu Hiejima
- Graduate School of Healthcare, Tokyo Healthcare University, Tokyo, Japan
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