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Kang DU, Park JC, Hwang SW, Park SH, Yang DH, Kim KJ, Ye BD, Myung SJ, Yang SK, Byeon JS. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasia with or without the hybrid technique. Colorectal Dis 2020; 22:2008-2017. [PMID: 32866340 DOI: 10.1111/codi.15339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/04/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
AIM The main aim of this study was to compare the long-term outcome of a conventional colorectal endoscopic submucosal dissection (ESD) in which submucosal dissection was continued throughout until the completion of resection (ESD-T) to hybrid endoscopic submucosal dissection (ESD-H) in the colorectum. METHOD Medical records of 836 colorectal neoplasia patients treated by ESD-T or ESD-H were reviewed. ESD-H was defined as colorectal ESD with additional snaring in the final stage of the procedure. Primary outcomes were the overall and metastatic recurrence rates. Secondary outcomes were short-term outcomes such as the en bloc resection rate, procedure time and adverse events. RESULTS The overall recurrence rate was higher in the ESD-H than in the ESD-T group (5.7% vs 0.7%, P = 0.001). The metastatic recurrence rate showed no significant difference between these groups (1.4% vs 1.4%, P = 1.000). Multivariate analysis revealed that a failed en bloc resection (hazard ratio 24.097; 95% CI 5.446-106.237; P < 0.001) and larger tumour size (hazard ratio 1.042; 95% CI 1.014-1.070; P = 0.003) were independently associated with overall recurrence. The ESD-H group showed a lower en bloc resection rate (56.8% vs 96.5%, P < 0.001), shorter procedure time (45.6 vs 54.3 min, P < 0.001) and higher perforation rate (10.3% vs 6.0%, P = 0.029). CONCLUSION Although long-term outcomes in terms of overall recurrence are inferior following ESD-H, a failed en bloc resection and large tumour size are the only independent risk factors for recurrence. Further investigations are warranted to improve the long-term outcomes of ESD-H.
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Affiliation(s)
- D U Kang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J C Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S W Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S H Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D H Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - K J Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - B D Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S J Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S K Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J S Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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102
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Hollenbach M, Feisthammel J, Hoffmeister A. [Endoscopic diagnosis, treatment, and follow-up of polyps of the lower gastrointestinal tract]. Internist (Berl) 2020; 62:151-162. [PMID: 33237438 DOI: 10.1007/s00108-020-00902-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The endoscopic management of polyps of the lower gastrointestinal tract (l-GIT) has emerged in recent years as a result of numerous technological innovations. However, proven expertise and experience are essential. OBJECTIVES Presentation of novel and standard techniques and best-practice recommendations for the characterization and resection of l‑GIT polyps. METHODS Recent specialist literature and current guidelines. RESULTS High-definition endoscopy should be the standard when performing colonoscopy. The (virtual) chromoendoscopy can improve detection and characterization of polyps, but always requires special expertise and experience of the endoscopist in advanced endoscopic imaging. In this regard, computer-aided-diagnosis (CAD) systems have the potential to support endoscopists in the future. Pedunculated polyps should be removed with a hot snare. Small flat polyps can be resected by cold snare or large forceps. Large, non-pedunculated polyps should be treated in an interdisciplinary approach at a referral center with long-standing experience depending on its malignancy potential. After complete resection of small adenoma without high grade dysplasia, surveillance endoscopy is recommended after 5-10 years. Patients with large adenoma or high grade dysplasia should undergo endoscopy after 3 years and patients with multiple adenoma earlier than 3 years. After incomplete or piecemeal resection or insufficient bowel preparation, near-term endoscopy is recommended. CONCLUSIONS Adequate characterization and treatment are essential for the appropriate management of l‑GIT polyps.
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Affiliation(s)
- M Hollenbach
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - J Feisthammel
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - A Hoffmeister
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
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103
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Choi J. Successful Endoscopic Resection of Residual Colonic Mucosa-Associated Lymphoid Tissue Lymphoma after Polypectomy. Clin Endosc 2020; 54:759-762. [PMID: 33153250 PMCID: PMC8505188 DOI: 10.5946/ce.2020.233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022] Open
Abstract
Mucosa-associated lymphoid tissue (MALT) lymphomas are typically found in the stomach, while colonic MALT lymphoma is rarely found. Considering its rarity, definitive treatment of colonic MALT lymphoma has not been established. Different from that in the stomach, Helicobacter pylori infection might play a minor role while determining the treatment of colonic MALT lymphoma. If colonic MALT lymphoma is localized, treatment options are surgical resection, radiation, endoscopic resection, or combination therapy. Here, we report a case of residual colonic MALT lymphoma after endoscopic mucosal resection, which was a 1.5-cm-sized tumor confined to the superficial wall of the rectum. The lesion was successfully treated using the endoscopic submucosal dissection technique. The patient remained disease-free for 4 years. This case provides rationale for endoscopic submucosal dissection treatment as a salvage therapy for residual tumors in properly selected patients with colonic MALT lymphoma.
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Affiliation(s)
- Jeongmin Choi
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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104
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Zwager LW, Bastiaansen BAJ, Bronzwaer MES, van der Spek BW, Heine GDN, Haasnoot KJC, van der Sluis H, Perk LE, Boonstra JJ, Rietdijk ST, Wolters HJ, Weusten BLAM, Gilissen LPL, Ten Hove WR, Nagengast WB, Bekkering FC, Schwartz MP, Terhaar Sive Droste JS, Vlug MS, Houben MHMG, Rando Munoz FJ, Seerden TCJ, Beaumont H, de Ridder R, Dekker E, Fockens P. Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry. Endoscopy 2020; 52:1014-1023. [PMID: 32498100 DOI: 10.1055/a-1176-1107] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic full-thickness resection (eFTR) is a minimally invasive resection technique that allows definite diagnosis and treatment for complex colorectal lesions ≤ 30 mm unsuitable for conventional endoscopic resection. This study reports clinical outcomes from the Dutch colorectal eFTR registry. METHODS Consecutive patients undergoing eFTR in 20 hospitals were prospectively included. The primary outcome was technical success, defined as macroscopic complete en bloc resection. Secondary outcomes were: clinical success, defined as tumor-free resection margins (R0 resection); full-thickness resection rate; and adverse events. RESULTS : Between July 2015 and October 2018, 367 procedures were included. Indications were difficult polyps (non-lifting sign and/or difficult location; n = 133), primary resection of suspected T1 colorectal cancer (CRC; n = 71), re-resection after incomplete resection of T1 CRC (n = 150), and subepithelial tumors (n = 13). Technical success was achieved in 308 procedures (83.9 %). In 21 procedures (5.7 %), eFTR was not performed because the lesion could not be reached or retracted into the cap. In the remaining 346 procedures, R0 resection was achieved in 285 (82.4 %) and full-thickness resection in 288 (83.2 %). The median diameter of resected specimens was 23 mm. Overall adverse event rate was 9.3 % (n = 34/367): 10 patients (2.7 %) required emergency surgery for five delayed and two immediate perforations and three cases of appendicitis. CONCLUSION : eFTR is an effective and relatively safe en bloc resection technique for complex colorectal lesions with the potential to avoid surgery. Further studies assessing the role of eFTR in early CRC treatment with long-term outcomes are needed.
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Affiliation(s)
- Liselotte W Zwager
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Maxime E S Bronzwaer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas W van der Spek
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, The Netherlands
| | - G Dimitri N Heine
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, The Netherlands
| | - Krijn J C Haasnoot
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hedwig van der Sluis
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Svend T Rietdijk
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Hugo J Wolters
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - W Rogier Ten Hove
- Department of Gastroenterology and Hepatology, Alrijne Medical Group, Leiden, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Frank C Bekkering
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - M P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Marije S Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Francisco J Rando Munoz
- Department of Gastroenterology and Hepatology, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Hanneke Beaumont
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location VU, Amsterdam, The Netherlands
| | - Rogier de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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105
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Miyakawa A, Kuwai T, Sakuma Y, Kubota M, Nakamura A, Itobayashi E, Shimura H, Suzuki Y, Shimura K. Learning curve for endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: use of the cumulative sum method. Scand J Gastroenterol 2020; 55:1234-1242. [PMID: 32853052 DOI: 10.1080/00365521.2020.1807597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Although scissor-type knives such as the Stag-Beetle (SB) Knife Jr are expected to result in a safe and easy colorectal endoscopic submucosal dissection (CR-ESD), information regarding the learning curve is lacking. Therefore, this study evaluated the learning curve with using SB Knife Jr. MATERIALS AND METHODS We retrospectively reviewed 507 CR-ESD procedures performed in 464 patients using SB Knife Jr. The primary endpoint was a learning curve to achieve a satisfactory complete resection rate. The secondary endpoints were learning curves to achieve a satisfactory en bloc resection rate, curative resection rate, and resection speed. RESULTS The complete, en bloc, and curative resection rates were 91.9%, 95.9%, and 84.0%, respectively. Moving average analysis showed that 39 cases were required for a complete resection rate of >80%, 41 for an en bloc resection rate of >90%, and 50 for a curative resection rate of >75%. We divided the procedure into three phases using the cumulative sum method: I, II, and III (cases 1-36, 37-119, and 120-507, respectively). Although we found no significant between-phase differences, the complete resection rate showed an increasing trend in Phase III (83.3 vs. 89.2 vs. 93.3%; p = .099). The en bloc resection rate (91.7 vs. 91.6 vs. 97.2%; p = .047) and resection speed (20.5 vs. 7.2 vs. 6.8 min/cm2; p < .001) were greater in Phase III. Despite the larger specimen size (27.3 vs. 38.2 vs. 40.4 mm; p < .001) and more severe fibrosis (p < .001) in Phase III, the procedure time was shorter (73.8 vs. 57.8 vs. 54.2 min; p = .041). The curative resection rate was not significantly different between phases. CONCLUSIONS SB Knife Jr enables safe and easy CR-ESD during the introductory period compared to the conventional tip-type knife and has an acceptable learning curve. Therefore, using this knife will encourage the widespread adoption of CR-ESD in Asian general hospitals and non-Asian countries.
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Affiliation(s)
- Akihiro Miyakawa
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Yukie Sakuma
- Clinical Research Center, Asahi General Hospital, Asahi, Japan
| | - Manabu Kubota
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Akira Nakamura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Ei Itobayashi
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Haruhisa Shimura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Yoshio Suzuki
- Department of Pathology, Asahi General Hospital, Asahi, Japan
| | - Kenji Shimura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
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106
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Yu J, Zhang Y, Qian J. Endoscopic submucosal dissection in the treatment of patients with early colorectal carcinoma and precancerous lesions. J Gastrointest Oncol 2020; 11:911-917. [PMID: 33209487 PMCID: PMC7657837 DOI: 10.21037/jgo-20-393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/12/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Our study aims to explore the indications and clinical efficacy of endoscopic submucosal dissection (ESD) on the early colorectal carcinoma and precancerous lesions. METHODS The clinical data of 29 patients with early colorectal carcinoma and precancerous lesions who were treated with ESD at Nantong First People's Hospital between January 2018 and December 2019 were collected. Then the endoscopic morphology, postoperative pathological classification, tumor resection rate, postoperative complications, and follow-up outcomes were analyzed. RESULTS Colorectal carcinoma lesions were distributed in the left colon, accounting for 89.6%. There were 14 cases (48.3%) with protuberant endoscopic tumors, accounting for the highest proportion, while 2 cases (6.9%) of the flat tumors, accounting for the lowest proportion. The average operation time for ESD was 123 minutes, and en-bloc resection was 100% while the curative resection rate was 89.6%. There were 3 cases (10.3%) with delayed hemorrhage after ESD, and 1 case with persistent hemorrhage during the operation was transferred to surgical treatment. No cases with infection or perforation after ESD. For postoperative pathological classification, villous-tubular adenoma with low-grade epithelioma accounted for 31%; tubular adenoma with high-grade epithelioma only accounted for 3.4%. There was no recurrence in the follow-up for 1-20 months. CONCLUSIONS Control of surgical indications strictly, improvement of operation skills, attention to postoperative pathological feedback, and close follow-up are necessary guarantees to improve the clinical effectiveness of ESD.
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Affiliation(s)
- Jing Yu
- Department of Gastroenterology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Yan Zhang
- Department of Gastroenterology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Junbo Qian
- Department of Gastroenterology, the Second Affiliated Hospital of Nantong University, Nantong, China
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107
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Imai K, Hotta K, Ito S, Yamaguchi Y, Kishida Y, Yabuuchi Y, Yoshida M, Kawata N, Tanaka M, Kakushima N, Takizawa K, Ishiwatari H, Matsubayashi H, Mori K, Ono H. A risk-prediction model for en bloc resection failure or perforation during endoscopic submucosal dissection of colorectal neoplasms. Dig Endosc 2020; 32:932-939. [PMID: 31883411 DOI: 10.1111/den.13619] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/25/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Technical difficulties in colorectal endoscopic submucosal dissections (ESD) result in en bloc resection failure or perforation. This study aimed to develop and validate a risk score for predicting en bloc resection failure or perforation in ESD of colorectal neoplasms. METHODS This single-center observational study included 1133 colorectal neoplasms treated with ESD in a Japanese tertiary cancer center. With a derivation set (n = 716), we performed multiple logistic regression to identify significant risk factors for en bloc resection failure or perforation. Based on odds ratios, we developed a risk score, ranging from 0 to 10: 0-1 'low risk' (LR); 2-4 'moderate risk' (MR); and 5-10 'high risk' (HR). An independent validation set comprised prospectively enrolled subjects (n = 417) that underwent ESDs from January 2014 to August 2016. The performance of the risk score for predicting en bloc resection failure or perforation for each risk tier was evaluated. RESULTS The baseline incidences of en bloc resection failure or perforation were 14.5% and 5.5% in the derivation and validation sets, respectively. We identified the following significant risk factors: endoscopist experience, tumor location, morphology, scope operability, underlying fold, and fold convergence. In the validation set, the incidences of en bloc resection failure or perforation were 0% in the LR tier (n = 62; 14.8%), 2.3% in the MR tier (n = 293; 70.4%), and 25.8% in the HR tier (n = 62; 14.8%) (P < 0.001, Cochran-Armitage trend test). CONCLUSIONS A risk scoring system, which was developed and prospectively validated, can successfully estimate the incidence of en bloc resection failure or perforation.
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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108
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Hollenbach M, Feisthammel J, Hoffmeister A. [Interventional endoscopy in the gastrointestinal tract : Indications and limitations]. Internist (Berl) 2020; 61:1017-1030. [PMID: 32748102 DOI: 10.1007/s00108-020-00845-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The spectrum of endoscopic techniques has been greatly enlarged in recent years. Lesions and also (iatrogenic) complications that required surgical procedures in the past can now often be treated endoscopically. Advances in endoscopic mucosal resection and submucosal dissection also enable the resection of large or laterally spreading polyps in the gastrointestinal tract. Full-thickness resection is also possible by means of specially designed clips. By the creation of a submucosal tunnel submucosal lesions can be completely excised and the muscle fibers of the lower esophageal sphincter can be endoscopically severed in achalasia patients. Endosonography-guided interventions have developed into the standard procedure for complicated pancreatitis and the use of cholangioscopy offers new therapeutic procedures for the bile and pancreatic ducts. In this continuing medical education article interventional endoscopic techniques are presented and critically evaluated.
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Affiliation(s)
- M Hollenbach
- Bereich Gastroenterologie, Klinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - J Feisthammel
- Bereich Gastroenterologie, Klinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - A Hoffmeister
- Bereich Gastroenterologie, Klinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
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109
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Zorron Cheng Tao Pu L, Yamamura T, Nakamura M, Esaki M, Kaosombatwattana U, Rodriguez MR, Edwards S, Burt AD, Singh R, Hirooka Y, Fujishiro M. Learning curve for mastery of colorectal endoscopic submucosal dissection: Perspectives from a large Japanese cohort. JGH Open 2020; 4:611-616. [PMID: 32782946 PMCID: PMC7411630 DOI: 10.1002/jgh3.12298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/03/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Leonardo Zorron Cheng Tao Pu
- Faculty of Health and Medical SciencesThe University of Adelaide Adelaide South Australia Australia
- Department of Gastroenterology and HepatologyNagoya University Nagoya Japan
| | | | - Masanao Nakamura
- Department of Gastroenterology and HepatologyNagoya University Nagoya Japan
| | - Masaya Esaki
- Department of EndoscopyNagoya University Hospital Nagoya Japan
| | | | - Miguel R Rodriguez
- Department of Gastroenterology and HepatologyNagoya University Nagoya Japan
| | - Suzanne Edwards
- Faculty of Health and Medical SciencesThe University of Adelaide Adelaide South Australia Australia
| | - Alastair D Burt
- Faculty of Health and Medical SciencesThe University of Adelaide Adelaide South Australia Australia
| | - Rajvinder Singh
- Faculty of Health and Medical SciencesThe University of Adelaide Adelaide South Australia Australia
- Department of GastroenterologyLyell McEwin Hospital Adelaide South Australia Australia
| | - Yoshiki Hirooka
- Department of Liver, Biliary Tract and Pancreas DiseasesFujita Health University Toyoake Japan
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110
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Mehta N, Abushahin A, Sadaps M, Alomari M, Vargo J, Patil D, Lopez R, Kalady M, Delaney CP, Gorgun E, Church J, Saito Y, Burke CA, Bhatt A. Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors. Surg Endosc 2020; 35:2500-2508. [PMID: 32472496 DOI: 10.1007/s00464-020-07660-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD). METHODS In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors. RESULTS A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273). CONCLUSION Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.
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Affiliation(s)
- Neal Mehta
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Desk A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Ashraf Abushahin
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Meena Sadaps
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad Alomari
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Deepa Patil
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Matthew Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Shahidi N, Vosko S, van Hattem WA, Sidhu M, Bourke MJ. Optical evaluation: the crux for effective management of colorectal neoplasia. Therap Adv Gastroenterol 2020; 13:1756284820922746. [PMID: 32523625 PMCID: PMC7235649 DOI: 10.1177/1756284820922746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/06/2020] [Indexed: 02/04/2023] Open
Abstract
Advances in minimally invasive tissue resection techniques now allow for the majority of early colorectal neoplasia to be managed endoscopically. To optimize their respective risk-benefit profiles, and, therefore, appropriately select between endoscopic mucosal resection, endoscopic submucosal dissection, and surgery, the endoscopist must accurately predict the risk of submucosal invasive cancer and estimate depth of invasion. Herein, we discuss the evidence and our approach for optical evaluation of large (⩾ 20 mm) colorectal laterally spreading lesions.
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Affiliation(s)
- Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - W. Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
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112
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Hossain E, Alkandari A, Bhandari P. Future of Endoscopy: Brief review of current and future endoscopic resection techniques for colorectal lesions. Dig Endosc 2020; 32:503-511. [PMID: 31242329 DOI: 10.1111/den.13475] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022]
Abstract
Endoscopic treatment of colorectal lesions has seen major developments in the last decade. It is now considered curative for intramucosal and superficial submucosal cancers. Endoscopic Mucosal Resection in expert hands has very good outcomes with low complication rates but recurrence and inadequate treatment of early cancers remain an issue. This has led to a technical evolution that can lead to one piece resection of neoplasia. This includes a range of techniques from knife assisted snare resection (KAR), endoscopic submucosal dissection (ESD) to full thickness resections. This article reviews all the resection techniques and the evidence base behind them.
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Taşkın OÇ, Aslan F, Kulaç İ, Yılmaz S, Adsay V, Kapran Y. Pathologic Evaluation of Large Colorectal Endoscopic Submucosal Dissections: An Analysis of 279 Cases With Emphasis on the Importance of Multidisciplinary Work and Establishing Examination Protocols. Int J Surg Pathol 2020; 28:600-608. [PMID: 32349582 DOI: 10.1177/1066896920918309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background. Endoscopic submucosal dissections (ESDs) allow removal of large gastrointestinal tumors and help patients avoid major oncologic surgery. In this study, the challenges and development of approaches toward successfully handling ESDs were analyzed in 279 colorectal specimens (114 rectal, 47 left, 118 right colonic; 90% adenoma with/without carcinoma). Methods. Each specimen was processed according to an established protocol including gross photography, mapping, and total submission for histopathologic examination. Results. Mean lesion size was 4.2 cm (range: 0.5-22 cm; 28% ≥5 cm; 6% ≥10 cm). Invasive carcinoma was present in 38 cases (14%), which had a mean overall tumor size of 3.8 cm (range: 1.1-17.5 cm), and mean largest size of the invasive component was 0.93 cm (range: 0.04-3 cm). Fifteen cases were staged as pT1a (submucosal invasion of <1000 µm) and 13 cases as pT1b (submucosal invasion of ≥1000 µm). En-bloc and R0 resection rates were 99.3% and 90.6%, respectively. Conclusion. Various histopathologic challenges were encountered, which were carefully evaluated by dedicated pathologists with familiarity to the subtleties in handling and reporting these specimens. We recommend these specimens to be prepared in the endoscopy suite, submitted to the Pathology Department oriented, pinned, and placed into copious amount of fixative. Total sampling, gross photography, mapping, and proper fixation are crucial components in the histopathologic evaluation. Micromeasurement of invasion depth and substaging per European/Japanese guidelines as well as accurate measurement of the distance from the resection margins are highly recommended. In conclusion, ESD is an adequate method that can be successfully implemented in a tertiary care center to perform en-bloc and margin-free resections of clinically selected large colorectal superficial lesions.
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Affiliation(s)
- Orhun Çığ Taşkın
- Department of Pathology, Koç University Hospital, Istanbul, Turkey
| | - Fatih Aslan
- Department of Gastroenterology, Koç University Hospital, Istanbul, Turkey
| | - İbrahim Kulaç
- Department of Pathology, Koç University Hospital, Istanbul, Turkey
| | - Serpil Yılmaz
- Department of Pathology, VKV American Hospital, Istanbul, Turkey
| | - Volkan Adsay
- Department of Pathology, Koç University Hospital, Istanbul, Turkey
| | - Yersu Kapran
- Department of Pathology, Koç University Hospital, Istanbul, Turkey
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Shahidi N, Sidhu M, Vosko S, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Holt B, Hourigan LF, Lee EY, Burgess NG, Bourke MJ. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69:673-680. [PMID: 31719129 DOI: 10.1136/gutjnl-2019-319785] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/17/2019] [Accepted: 10/26/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs. DESIGN EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC). RESULTS Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027). CONCLUSION EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,University Hospital of Gent, Gent, Belgium
| | - Bronte Holt
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Luke F Hourigan
- Department of Gastrenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Eric Yt Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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115
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Zhang X, Ly EK, Nithyanand S, Modayil RJ, Khodorskiy DO, Neppala S, Bhumi S, DeMaria M, Widmer JL, Friedel DM, Grendell JH, Stavropoulos SN. Learning Curve for Endoscopic Submucosal Dissection With an Untutored, Prevalence-Based Approach in the United States. Clin Gastroenterol Hepatol 2020; 18:580-588.e1. [PMID: 31220645 DOI: 10.1016/j.cgh.2019.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 06/01/2019] [Accepted: 06/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic submucosal dissection (ESD) is widely used in Asia to resect early-stage gastrointestinal neoplasms, but use of ESD in Western countries is limited. We collected data on the learning curve for ESD at a high-volume referral center in the United States to guide development of training programs in the Americas and Europe. METHODS We performed a retrospective analysis of consecutive ESDs performed by a single operator at a high-volume referral center in the United States from 2009 through 2017. ESD was performed in 540 lesions: 449 mucosal (10% esophageal, 13% gastric, 5% duodenal, 62% colonic, and 10% rectal) and 91 submucosal. We estimated case volumes required to achieve accepted proficiency benchmarks (>90% for en bloc resection and >80% for histologic margin-negative (R0) resection) and resection speeds >9cm2/hr. RESULTS Pathology analysis of mucosal lesions identified 95 carcinomas, 346 premalignant lesions, and 8 others; the rate of en bloc resection increased from 76% in block 1 (50 cases) to a plateau of 98% after block 5 (250 cases). The rate of R0 resection improved from 45% in block 1 to >80% after block 5 (250 cases) and ∼95% after block 8 (400 cases). Based on cumulative sum analysis, approximately 170, 150, and 280 ESDs are required to consistently achieve a resection speed >9cm2/hr in esophagus, stomach, and colon, respectively. CONCLUSIONS In an analysis of ESDs performed at a large referral center in the United States, we found that an untutored, prevalence-based approach allowed operators to achieve all proficiency benchmarks after ∼250 cases. Compared with Asia, ESD requires more time to learn in the West, where the untutored, prevalence-based approach requires resection of challenging lesions, such as colon lesions and previously manipulated lesions, in early stages of training.
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Affiliation(s)
- Xiaocen Zhang
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York; Department of Internal Medicine, Mount Sinai St Luke's-West Hospital Center, New York, New York
| | - Erin K Ly
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Sagarika Nithyanand
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Rani J Modayil
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Dmitriy O Khodorskiy
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Sivaram Neppala
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Sriya Bhumi
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Matthew DeMaria
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Jessica L Widmer
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - David M Friedel
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - James H Grendell
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, New York University-Winthrop Hospital, Mineola, New York.
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Arribas Anta J, Cañete Ruiz Á, Álvarez-Nava Torrego T, Piedracoba-Cadahía C, Rafael de la Cruz Esteban D, Rodríguez Carrasco M, Romero Romero E, Del Pozo-García AJ, Rodríguez Muñoz S, Díaz-Tasende J, Marín-Gabriel JC. Long-term follow-up after endoscopic submucosal dissection of colorectal lesions in a Spanish cohort. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:172-177. [PMID: 32054276 DOI: 10.17235/reed.2020.6268/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION ESD in the colon is an increasingly important technique in Western countries. There are few studies that include long term follow-up. AIM to analyze the long term recurrence free survival rate after ESD and to compare recurrence rates according to different variables. METHODS this was a prospective observational study of patients with a planned ESD from September 2008 to December 2015. When it was not possible to achieve an ESD, hybrid ESD was performed, either en bloc or piecemeal. Kaplan-Meier survival curves were used to assess the five year local recurrence free survival rate and the recurrence rate. The results were compared according to different factors. RESULTS of the 89 patients scheduled for ESD who were initially enrolled in the study, 69 were finally included for follow-up. ESD was performed in 31 (45%) patients, KAR in eleven (16%) and pKAR in 27 (39%). The median follow-up was 27 months (range 6-60). The five year disease free survival rate was 81%. The average number of endoscopies needed to eliminate recurrence was two (range 2-7) and no patient required surgery for this reason. The recurrence rate was significantly higher in piecemeal resections vs en bloc resections (27% vs 15%, p = 0.036) and R1 resections vs R0 resections (26% vs 0%, p = 0.034). The presence of affected or unknown lateral margins in en bloc resections without other poor prognosis factors had higher recurrence rates but the difference was not statistically significant (28% vs 0%, p = 0.09). CONCLUSIONS in our study, the five year disease free survival rate was 81% and no patient required surgery during follow-up. Piecemeal and R1 resections had significantly higher recurrence rates, as well as LM involvement, although this was not statistically significant.
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Affiliation(s)
- Julia Arribas Anta
- Medicina Aparato Digestivo. Unidad de Endoscopia, Hospital Universitario 12 de Octubre, España
| | - Ángel Cañete Ruiz
- Medicina Aparato Digestivo. Unidad de Endoscopia, Hospital Universitario 12 de Octubre, España
| | | | | | | | | | - Esteban Romero Romero
- Medicina Aparato Digestivo. Unidad de Endoscopia, Hospital Universitario 12 de Octubre
| | | | | | - José Díaz-Tasende
- Medicina Aparato Digestivo. Unidad de Endoscopia, Hospital Universitario 12 de Octubre, España
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Maselli R, Iacopini F, Azzolini F, Petruzziello L, Manno M, De Luca L, Cecinato P, Fiori G, Staiano T, Rosa Rizzotto E, Angeletti S, Caruso A, Coppola F, Andrisani G, Viale E, Missale G, Panarese A, Mazzocchi A, Cesaro P, Campanale M, Occhipinti P, Tarantino O, Crosta C, Brosolo P, Sferrazza S, Rondonotti E, Amato A, Fuccio L, Costamagna G, Repici A. Endoscopic submucosal dissection: Italian national survey on current practices, training and outcomes. Dig Liver Dis 2020; 52:64-71. [PMID: 31629705 DOI: 10.1016/j.dld.2019.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 09/05/2019] [Accepted: 09/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Most of the evidence supporting endoscopic submucosal dissection (ESD) comes from Asia. European data are primarily reported by specialized referral centers and thus may not be representative of common European ESD practice. The aim of this study is to understand the current state of ESD practice across Italian endoscopy centers. METHODS All Italian endoscopists who were known to perform ESD were invited to complete a structured questionnaire including: operator features and competencies, ESD training details and clinical outcomes over a 2-year period. RESULTS Twenty-nine operators from 23 centers (69% response rate) completed the questionnaire: 18 (62%) were <50 years old; 7 (24%) were female; 16 (70%) were located in Northern Italy. Overall ESD volume was <40 cases in 9 (31%) operators, 40-80 in 8 (27.5%), 80-150 in 4 (13.8%) and >150 in 8 (27.5%). Colorectal ESD was predominant for operators with an experience >80 cases. En-bloc resection rates ranged from 77.2 to 97.2% depending on the anatomic location with an R0 resection rate range of 75.3-93.6%. ESD perforation rates in the colon and rectum were significantly lower when experience was >150 compared to 80-150 cases (p < 0.0001 and p = 0.006 for colon and rectum, respectively). CONCLUSION ESD in Italy is performed by a significant number of operators. Overall, Italian endoscopists performing ESD have achieved a good competence level. However, there is much variability in training protocols, initial supervision of procedures, practice settings, case mix and procedural volume/year that are likely responsible for some of the suboptimal resectional outcomes and increased perforation risk, mainly in the colon. Standardized training programs, practice parameters and auditing of outcomes are required.
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Affiliation(s)
- Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy.
| | | | - Francesco Azzolini
- Division of Gastroenterology & G.I. Endoscopy, Vita Salute San Raffaele University, Milan, Italy
| | - Lucio Petruzziello
- Digestive Endoscopy Unit, Division of Gastroenterology Fondazione A. Gemelli-Università Cattolica del Sacro Cuore Hospital, IRCCS, Rome, Italy
| | - Mauro Manno
- Digestive Endoscopy Unit, USL Modena, Carpi Hospital, Italy
| | - Luca De Luca
- Division of Gastroenterology & G.I. Endoscopy, Ospedali Riuniti Marche Nord Hospital, Pesaro, Italy
| | - Paolo Cecinato
- Unit of Gastroenterology and Digestive Endoscopy, USL-IRCCS Reggio Emilia Hospital, Reggio Emilia,Italy
| | - Giancarla Fiori
- IEO, Digestive Endoscopy Unit, Istituto Europeo di Oncologia IRCCS Hospital, Milano, Italy
| | - Teresa Staiano
- Digestive Endoscopy Unit, FPO-IRCCS Candiolo Cancer Institute, Candiolo, TO, Italy
| | - Erik Rosa Rizzotto
- Division of Gastroenterology & G.I. Endoscopy, S. Antonio Hospital, Padova, Italy
| | - Stefano Angeletti
- Digestive Endoscopy Unit, Sant'Andrea Hospital, a Sapienza university, Roma, Italy
| | - Angelo Caruso
- Division of Gastroenterology & G.I. Endoscopy, Baggiovara Hospital, AOU di Modena, Italy
| | - Franco Coppola
- Digestive Endoscopy Unit, Division of Gastroenterology, ASLTO4, Turin, Italy
| | | | - Edi Viale
- Division of Gastroenterology & G.I. Endoscopy, Vita Salute San Raffaele University, Milan, Italy
| | - Guido Missale
- Digestive Endoscopy Unit, ASST Spedali Civili, Brescia University, Italy
| | - Alba Panarese
- Department of Gastroenterology and Digestive Endoscopy, National Research Institute specialized in Gastroenterology ¨S. De Bellis¨ , Castellana Grotte, BA, Italy
| | - Alessandro Mazzocchi
- Gastroenterology Endoscopy Unit, San Giovanni Battista Hospital, San Giovanni battista, Italy
| | - Paola Cesaro
- Endoscopy Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Mariachiara Campanale
- Digestive Endoscopy Unit, Division of Gastroenterology Fondazione A. Gemelli-Università Cattolica del Sacro Cuore Hospital, IRCCS, Rome, Italy
| | - Pietro Occhipinti
- Division of Gastroenterology, ¨ Maggiore della CaritਠHospital and University, Novara, Italy
| | - Ottaviano Tarantino
- Division of Gastroenterology & G.I. Endoscopy, San Giuseppe Hospital, ASL Toscana centro, Empoli, Italy
| | - Cristiano Crosta
- IEO, Digestive Endoscopy Unit, Istituto Europeo di Oncologia IRCCS Hospital, Milano, Italy
| | - Piero Brosolo
- Division of Gastroenterology, Hospital of Pordenone, Pordenone, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, APSS, Trento, Italy
| | - Emanuele Rondonotti
- Gastroenterology and Digestive Endoscopy Unit, Valduce Hospital, Como, Italy
| | - Arnaldo Amato
- Gastroenterology and Digestive Endoscopy Unit, Valduce Hospital, Como, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Cattolica del Sacro CuoreUniversity, Centre for Endoscopic Research Therapeutics and Training CERTT, Roma, Italy; Université de Strasbourg Institut d'Etudes Avancées USIAS, Strasbourg, France
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy; Humanitas University, Department of Biomedical Science, Milan, Italy
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Multiloop as a novel traction method in accelerating colorectal endoscopic submucosal dissection. Gastrointest Endosc 2020; 91:185-190. [PMID: 31521780 DOI: 10.1016/j.gie.2019.08.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/25/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Traction methods have been reported to speed up endoscopic submucosal dissection (ESD). We used the multiloop (M-loop) method as a traction method for colorectal ESD and recorded the submucosal dissection time (SDT) and submucosal dissection speed (SDS). METHODS From January to August 2018, we used the M-loop method for colorectal ESD procedures and timed the duration and recorded the outcomes. Two experts and eight nonexperts performed the procedures, which were carried out at a tertiary endoscopic center in Japan. RESULTS A total of 50 patients were treated by colorectal ESD using the M-loop method. The mean SDT was 42.1 ± 4.16 minutes and the mean SDS was 28.0 ± 2.89 mm2/minutes. The mean SDS was 38.9 ± 6.9 mm2/minutes for experts and 25.3 ± 3.1 mm2/minutes for nonexperts. En bloc resection was achieved in 100% of cases. There were 3 adverse events and unfavorable outcomes. CONCLUSIONS Traction by the M-loop method improved SDS in colorectal ESD. The method can be an effective tool to assist colorectal ESD. Further evaluation of the usefulness of the M-loop method is required in direct comparison with conventional ESD.
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Ebigbo A, Freund S, Probst A, Römmele C, Gölder SK, Frauenschuh J, Marienhagen J, Messmann H. Outcomes of endoscopic submucosal dissection (ESD) during live endoscopy events (LEE) - a 13-year follow-up. Endosc Int Open 2019; 7:E1723-E1728. [PMID: 31828208 PMCID: PMC6904243 DOI: 10.1055/a-1035-9240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/30/2019] [Indexed: 12/28/2022] Open
Abstract
Background and study aims There are no data showing the outcome of ESD during live endoscopy events (LEE). ESD performed during the Augsburg Endo-Update LEE were compared with matched routine procedures with the aim of demonstrating non-inferiority of LEE ESD. Patients and methods ESD performed during the Endo-Update between 2006 and 2018 were reviewed. The controls were routine procedures matched according to age, location and lesion size. Resection, recurrence, survival and complication rates, procedure time and propofol sedation were assessed. Clinically relevant margins were assumed for resection and complication rates, procedure time and propofol sedation quantity. Results Thirty-eight ESD were performed in the given time period, and were compared with 38 matched routine ESD. En bloc and curative resection rates in the LEE group and in the control group were 100 % and 87 % as well as 84 % and 71 % respectively, while procedure times were 135 and 125 minutes, respectively. Non-inferiority was demonstrated for resection rates and procedure time. The complication rate was lower in the LEE group as compared with the control group (5 % vs 13 %) while propofol sedation was similar in both groups (863 mg vs 872 mg). Recurrence and 5-year survival rates for both groups were 4 % vs 0 % and 70 % vs 65% respectively. Conclusions The resection rate and procedure time of ESD during LEE was non-inferior to those of routine ESD procedures. Comparison of the complication rates, however, was inconclusive owing to the low patient number and complication risk in both groups.
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Affiliation(s)
- Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany,Corresponding author Dr. Alanna Ebigbo Universitätsklinikum AugsburgStenglinstr. 286156 AugsburgGermany+0049-821-400-2748
| | - Simone Freund
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany
| | - Christoph Römmele
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany
| | - Stefan K. Gölder
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany
| | - Julia Frauenschuh
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany
| | | | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Germany
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120
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Yang D, Aihara H, Perbtani YB, Wang AY, Aadam AA, Tomizawa Y, Hwang JH, Zou B, Natov NS, Siegel A, Khoshknab MP, Khashab MA, Ngamruengphong S, Khara HS, Diehl DL, Maniere T, Andrawes S, Benias P, Kumta NA, Ramay F, Kim RE, Samarasena J, Chang K, Hashimoto R, Tharian B, Inamdar S, Lan G, Sethi A, Nosler MJ, Tabash A, Othman MO, Draganov PV. Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience. Endosc Int Open 2019; 7:E1714-E1722. [PMID: 31803823 PMCID: PMC6887644 DOI: 10.1055/a-1010-5663] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023] Open
Abstract
Background and aims Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA,Corresponding author Dennis Yang, MD 1329 SW 16th StreetRoom #5252GainesvilleFL 32608USA+1-352-627-9002
| | - Hiroyuki Aihara
- Division of Gastroenterology and Hepatology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Yaseen B. Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Andrew Y. Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Medical Center, Chicago, IL, USA
| | - Yutaka Tomizawa
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA, USA
| | - Baiming Zou
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Nikola S. Natov
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Amanda Siegel
- Division of Gastroenterology and Hepatology, Northwestern University Medical Center, Chicago, IL, USA
| | | | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | - Harshit S. Khara
- Division of Gastroenterology and Hepatology, Geisinger Health System, Danville, PA, USA
| | - David L. Diehl
- Division of Gastroenterology and Hepatology, Geisinger Health System, Danville, PA, USA
| | - Thibaut Maniere
- Division of Gastroenterology and Hepatology, Universite de Sherbrooke, Sherbrook, QC, Canada
| | - Sherif Andrawes
- Division of Gastroenterology and Hepatology, Northwell Health, Staten Island, NY, USA
| | - Petros Benias
- Division of Gastroenterology and Hepatology, Northwell Health, Staten Island, NY, USA
| | - Nikhil A. Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, NY, USA
| | - Fariha Ramay
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD, USA
| | - Raymond E. Kim
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD, USA
| | - Jason Samarasena
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, CA, USA
| | - Kenneth Chang
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, CA, USA
| | - Rintaro Hashimoto
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, CA, USA
| | - Benjamin Tharian
- Division of Gastroenterology and Hepatology, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Gloria Lan
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital, New York, NY, USA
| | - Amrita Sethi
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital, New York, NY, USA
| | | | - Abdalaziz Tabash
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, TX, USA
| | - Mohamed O. Othman
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, TX, USA
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
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Surgery Versus Endoscopic Mucosal Resection Versus Endoscopic Submucosal Dissection for Large Polyps: Making Sense of When to Use Which Approach. Gastrointest Endosc Clin N Am 2019; 29:675-685. [PMID: 31445690 DOI: 10.1016/j.giec.2019.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic resection for large colorectal lesion is effective and cost-saving than surgery. Piecemeal resections are often effective if applied meticulously but endoscopic submucosal dissection (ESD) allows meritorious removal of large lesions in one piece. For rectal lesions, transanal endoscopic microsurgery or transanal minimally invasive surgery offers more radical transmural resection but ESD is also effective for removal of complex rectal lesions. Surgical resection with lymph node dissection is the gold standard for invasive cancer; however, the management of low-risk early-stage colorectal cancer is worth debating. Treatment selection for large colorectal lesions is discussed based on lesion factor and treatment outcomes.
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122
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Yang DH, Kim J, Song EM, Chang K, Lee SH, Hwang SW, Park SH, Ye BD, Byeon JS, Myung SJ, Yang SK. Outcomes of ulcerative colitis-associated dysplasia patients referred for potential endoscopic submucosal dissection. J Gastroenterol Hepatol 2019; 34:1581-1589. [PMID: 30724389 DOI: 10.1111/jgh.14623] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/28/2019] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The feasibility of endoscopic submucosal dissection (ESD) as a treatment option for dysplasia in ulcerative colitis (UC) has been reported, but the associated therapeutic decision-making and clinical outcomes have not been extensively investigated. METHODS We retrospectively reviewed 25 UC patients who were referred for potential ESD of non-polypoid or sessile dysplasia. We analyzed the treatment decisions and the ESD and colectomy outcomes for this patient group. RESULTS All lesions were located at the colitic segments. The median UC duration was 13.4 years. A colectomy was recommended for 10 patients because of ulceration with indistinct borders (one patient), non-ulceration with indistinct borders (two patients), and non-lifting signs (seven patients). The remaining 15 patients underwent ESD. The en bloc and R0 resection rates were 93.3% and 80%, respectively. The median hospitalization periods were 1 (range, 1-2) day after ESD and 7 (range, 5-30) days after colectomy. No procedure-related complications occurred after ESD, but early and late postoperative complications occurred in two (22.2%) and six (66.7%) of the colectomized patients, respectively. Fourteen ESD cases were followed endoscopically for a median period of 24.7 (range, 5.2-64.8) months. Local recurrence occurred in 2 (14.3%) patients, and metachronous recurrence was identified in two separate patients (14.3%). CONCLUSIONS Endoscopic submucosal dissection is a feasible endoscopic treatment option for UC-associated dysplasia showing noninvasive pit or vascular patterns, no surface ulceration, distinct borders, and appropriate lifting after submucosal injection. Meticulous endoscopic surveillance is essential to monitor for local or metachronous recurrence of dysplasia after ESD.
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Affiliation(s)
- Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Mi Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kiju Chang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun-Ho Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Yamashina T, Uedo N, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, Kawamura T, Takeuchi Y, Fujii S, Kusaka T, Shimokawa T. Comparison of Underwater vs Conventional Endoscopic Mucosal Resection of Intermediate-Size Colorectal Polyps. Gastroenterology 2019; 157:451-461.e2. [PMID: 30981791 DOI: 10.1053/j.gastro.2019.04.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic mucosal resection (EMR) with submucosal injection is an established method for removing colorectal polyps, although the en bloc resection rate decreases when polyp size exceeds 10 mm. Piecemeal resection increases local recurrence. Underwater EMR (UEMR) is an effective technique for removal of sessile colorectal polyps and we investigated whether it is superior to conventional EMR (CEMR). METHODS We conducted a multicenter randomized controlled trial at 5 institutions in Japan. Patients with endoscopically diagnosed, intermediate-size (10-20 mm) sessile colorectal lesions were randomly assigned to undergo UEMR or CEMR. Only the most proximal lesion was registered. The UEMR procedure included immersion of the entire lumen in water and snare resection of the lesion without submucosal injection of normal saline. We analyzed outcomes of 108 colorectal lesions in the UEMR group and 102 lesions in the CEMR group. R0 resection was defined as en bloc resection with a histologically confirmed negative resection margin. The primary endpoint was the difference in the R0 resection rates between groups. RESULTS The proportions of R0 resections were 69% (95% confidence interval [CI] 59%-77%) in the UEMR group vs 50% (95% CI 40%-60%) in the CEMR group (P = .011). The proportions of en bloc resections were 89% (95% CI 81%-94%) in the UEMR group vs 75% (95% CI 65%-83%) in the CEMR group (P = .007). There was no significant difference in median procedure time (165 vs 175 seconds) or proportions of patients with adverse events (2.8% in the UEMR group vs 2.0% in the CEMR group). CONCLUSIONS In a multicenter randomized controlled trial, we found that UEMR significantly increased the proportions of R0 resections for 10- to 20-mm sessile colorectal lesions without increasing adverse events or procedure time. Use of this procedure should be encouraged. Trials registry number: UMIN000018989.
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Affiliation(s)
- Takeshi Yamashina
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan; Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan; Department of Gastroenterology and Hepatology, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Taro Iwatsubo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuki Nakatani
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuji Akamatsu
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuji Kawamura
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shigehiko Fujii
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshihiro Kusaka
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshio Shimokawa
- Department of Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
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124
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Podboy A, Friedland S. Endoscopic submucosal dissection in the West. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019; 8:106-109. [DOI: 10.18528/ijgii190014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/22/2019] [Accepted: 07/22/2019] [Indexed: 08/30/2023] Open
Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University Hospital, Redwood City, CA, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University Hospital, Redwood City, CA, USA
- Department of Gastroenterology and Hepatology, VA Palo Alto Health Care System, Palo Alto, CA, USA
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125
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Enhancement of the safety and efficacy of colorectal endoscopic submucosal dissection using a CO2 laser. Lasers Med Sci 2019; 35:421-427. [DOI: 10.1007/s10103-019-02839-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/27/2019] [Indexed: 12/28/2022]
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126
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Akahoshi K, Shiratsuchi Y, Oya M, Koga H, Kubokawa M, Nakama N, Akahoshi K, Ihara E. Endoscopic submucosal dissection with a grasping-type scissors for early colorectal epithelial neoplasms: a large single-center experience. VideoGIE 2019; 4:486-492. [PMID: 31709338 PMCID: PMC6831854 DOI: 10.1016/j.vgie.2019.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Background and aims The Clutch Cutter (CC) can grasp, pull, coagulate, and incise targeted tissue with the use of electrosurgical current. It was developed as a biopsy technique to reduce the technical difficulty of endoscopic submucosal dissection (ESD) with knives. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early colorectal epithelial neoplasms (ECENs). Methods In this prospective study, we enrolled 437 consecutive patients with a diagnosis of ECEN between January 2009 and January 2018. They all satisfied the Japanese colorectal cancer treatment guidelines for ESD; namely, confirmation by preliminary endoscopy, EUS, and endoscopic biopsy. The CC was used for all steps of ESD (mucosal incision, submucosal dissection, and hemostatic treatment); therapeutic efficacy and safety were assessed. Results The en bloc resection rate was 99.3% (434/437), and the R0 resection rate was 87.0% (380/437). The mean operating time was 88.3 minutes. Perforation occurred in 10 cases (2.3%) and was managed with conservative medical treatment. Post-ESD-CC bleeding occurred in 10 cases (2.3%) and was successfully treated by endoscopic hemostatic treatment. Conclusions ESD-CC is a technically efficient, safe, and easy method for resecting ECEN.
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Affiliation(s)
- Kazuya Akahoshi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Yuki Shiratsuchi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Masafumi Oya
- Department of Pathology, Aso Iizuka Hospital, Iizuka, Japan
| | - Hidenobu Koga
- Department of Health Information Management, Aso Iizuka Hospital, Iizuka, Japan
| | - Masaru Kubokawa
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Naotaka Nakama
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Kazuaki Akahoshi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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127
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Shah SC, Itzkowitz SH. Management of Inflammatory Bowel Disease-Associated Dysplasia in the Modern Era. Gastrointest Endosc Clin N Am 2019; 29:531-548. [PMID: 31078251 PMCID: PMC7354094 DOI: 10.1016/j.giec.2019.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article begins with a brief overview of risk factors for colorectal neoplasia in inflammatory bowel disease to concretize the approach to risk stratification. It then provides an up-to-date review of diagnosis and management of dysplasia in inflammatory bowel disease, which integrates new and emerging data in the field. This is particularly relevant in an era of increased attention to cost- and resource-containment from the health systems vantage point, coupled with a heightened prioritization of patient quality of life and shared decision-making. Also provided is a brief discussion of the status of newer therapeutic techniques, such as endoscopic submucosal dissection.
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Affiliation(s)
- Shailja C. Shah
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven H. Itzkowitz
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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128
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Morita Y, Ariyoshi R, Honda GNN, Hazama H, Kodama Y, Awazu K. New Development for Safer Endoscopic Submucosal Dissection using the Carbon Dioxide (CO 2) Laser (Secondary publication). Laser Ther 2019; 28:89-96. [PMID: 32921906 DOI: 10.5978/islsm.19-or-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endoscopic Submucosal Dissection (ESD) has been increasingly accepted as a minimally invasive treatment for the patients with early gastrointestinal cancers. However, reliable ESD technique demands high maneuverability, and the success of the operation is dependent on each operator's skill. We have developed a novel laser endoscopic system for ESD to overcome such technique-related difficulties. Compared to conventional ESD using electrosurgical knives, an ESD method using the CO2 laser offers the advantages of less risk of perforation and the prevention of extensive thermal damage, because the CO2 laser is strongly absorbed by water. Furthermore, due to the non-contact technique associated with the CO2 laser and adequate visualization of the treatment area, the laser system may provide every endoscopist with more precise and safer treatment.
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Affiliation(s)
- Yoshinori Morita
- Department of Gastroenterology, Kobe University International Clinical Cancer Research Center.,Department of Gastroenterology, Kobe University Graduate School of Medicine
| | - Ryusuke Ariyoshi
- Department of Gastroenterology, Kobe University Graduate School of Medicine
| | - Given-Names Norihiro Honda
- Division of Sustainable Energy and Environmental Engineering, Graduate School of Engineering, Osaka University.,Institute of Innovative Research, Osaka University
| | - Hisanao Hazama
- Division of Sustainable Energy and Environmental Engineering, Graduate School of Engineering, Osaka University
| | - Yuzo Kodama
- Department of Gastroenterology, Kobe University Graduate School of Medicine
| | - Kunio Awazu
- Division of Sustainable Energy and Environmental Engineering, Graduate School of Engineering, Osaka University.,Graduate School of Frontier Biosciences, Osaka University.,Global Center for Medical Engineering and Informatics, Osaka University
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129
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Bahin FF, Heitman SJ, Bourke MJ. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2019; 68:1130. [PMID: 29778995 DOI: 10.1136/gutjnl-2018-316660] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/30/2018] [Accepted: 05/05/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Steven J Heitman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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130
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Watanabe D, Hayashi H, Kataoka Y, Hashimoto T, Ichimasa K, Miyachi H, Tanaka S, Toyonaga T. Efficacy and safety of endoscopic submucosal dissection for non-ampullary duodenal polyps: A systematic review and meta-analysis. Dig Liver Dis 2019; 51:774-781. [PMID: 31014942 DOI: 10.1016/j.dld.2019.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 03/09/2019] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is commonly used to treat early-stage digestive cancer because it results in a higher frequency of en-bloc resection and a lower frequency of local recurrence. However, the efficacy and safety of duodenal ESD remain unclear. Therefore, present study is aimed at evaluating clinical outcomes of duodenal ESD. METHODS To evaluate the efficacy and safety of duodenal ESD, electronic databases (MEDLINE, CENTRAL and EMBASE) were searched by two independent reviewers. The authors were contacted for additional information. A meta-analysis was performed to evaluate the efficacy and safety of duodenal ESD. RESULTS A total of 7 studies (203 patients) were included in the quantitative synthesis analysis. The pooled proportions of the frequencies of en-bloc resection, need for surgical intervention, bleeding, intraoperative perforation and delayed perforation were 87%, 4%, 2%, 15% and 2%, respectively. The quality of evidence regarding on surgical intervention outcomes was rated as moderate, whereas that of en-bloc resection was rated as low because of its marked inconsistency. CONCLUSIONS Duodenal ESD produced acceptable outcomes in terms of the en-bloc R0 resection, but the incidence of procedure-related adverse events is high (PROSPERO register, CRD42017057110).
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Affiliation(s)
- Daisuke Watanabe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroki Hayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yuki Kataoka
- Hospital Care Research Unit/Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Japan.
| | | | - Katsuro Ichimasa
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Japan
| | - Hideyuki Miyachi
- Department of Gastroenterology, Kakogawa Central City Hospital, Japan
| | - Shinwa Tanaka
- Department of Endoscopic Medicine, Kobe University Hospital, Japan
| | - Takashi Toyonaga
- Department of Endoscopic Medicine, Kobe University Hospital, Japan
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131
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Ye L, Yuan X, Pang M, Bethge J, Ellrichmann M, Du J, Zeng X, Tang C, Schreiber S, Hu B. Magnetic bead-assisted endoscopic submucosal dissection: a gravity-based traction method for treating large superficial colorectal tumors. Surg Endosc 2019; 33:2034-2041. [PMID: 31020434 PMCID: PMC6505494 DOI: 10.1007/s00464-019-06799-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Colorectal endoscopic submucosal dissection (ESD) has always been challenging for endoscopists, but the procedure can be facilitated after adequate exposure of submucosal layer and cutting line. We developed a traction method based on gravity for facilitating colorectal ESD, referred as magnetic bead-assisted ESD (MBA-ESD). This study aimed to compare the safety and effectiveness of MBA-ESD and conventional ESD for treating large superficial colorectal tumors. METHODS This retrospective study included consecutive patients with large (≥ 20 mm in their maximal diameter) superficial colorectal tumors who underwent MBA-ESD or conventional ESD at our endoscopy center between June 2017 to January 2018. Each patient in the MBA-ESD group was matched to a patient in the conventional ESD group using propensity scores. RESULTS Thirteen patients in each group were matched for the analyses. The baseline characteristics were balanced after propensity matching. The incidence of overall complications was significantly lower in the matched MBA-ESD group (0% vs. 38.5%, P = 0.039), while similar rates of en bloc resection, R0 resection, curative resection, and tumor recurrence were noted. Although without statistic difference, dissection time and speed were improved when using MBA-ESD (33 min vs. 40 min, P = 0.111; and 21 mm2/min vs. 16 mm2/min, P = 0.143, respectively). CONCLUSIONS MBA-ESD is a feasible, safe, and effective method for treating large superficial colorectal tumors. Further large, prospective and controlled studies are needed to fully assess this method.
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Affiliation(s)
- Liansong Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu, 610041, Sichuan, China
| | - Xianglei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu, 610041, Sichuan, China
| | - Maoyin Pang
- Department of Gastroenterology, Georgetown University Hospital, Washington, DC, USA
| | - Johannes Bethge
- Department of Gastroenterology, University Medical Center Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Mark Ellrichmann
- Department of Gastroenterology, University Medical Center Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Jiang Du
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu, 610041, Sichuan, China
| | - Xianhui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu, 610041, Sichuan, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu, 610041, Sichuan, China
| | - Stefan Schreiber
- Department of Gastroenterology, University Medical Center Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu, 610041, Sichuan, China.
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Nepal P, Mori S, Kita Y, Tanabe K, Baba K, Sasaki F, Nasu Y, Ido A, Uchikado Y, Kurahara H, Arigami T, Sakoda M, Maemura K, Natsugoe S. Combined endoscopic submucosal dissection and transanal minimally invasive surgery for the management of lower rectal adenoma extending above the dentate line: A case report. Medicine (Baltimore) 2019; 98:e15289. [PMID: 31083160 PMCID: PMC6531252 DOI: 10.1097/md.0000000000015289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RATIONALE Minimally invasive surgery is used to treat early colorectal tumors. Endoscopic submucosal dissection (ESD) for resection of tumors extending above the dentate line (particularly those with concomitant hemorrhoids) is technically difficult. We present a case of a patient with a lower rectal adenoma extending above the dentate line, which underwent combined ESD and transanal minimally invasive surgery (TAMIS) to achieve accurate excision and prevent complications. PATIENT CONCERNS A 68-year-old man with a history of blood in stool over 2 to 3 years underwent colonoscopy, which revealed an adenoma measuring 3 cm in size in the lower rectum extending above the dentate line. The part extending above the dentate line was a type Is lesion and that of oral side was a type IIa lesion. Histopathologically, the lesion was diagnosed as a low-grade intramucosal tubulovillous adenoma. DIAGNOSIS Intramucosal low-grade adenoma with sessile polyp (type Is). INTERVENTIONS The cranial portion of the lesion was dissected via ESD and the anal portion via TAMIS with minimal bleeding. En bloc resection of the tumor was performed. OUTCOMES His postoperative period was uneventful, and he was discharged and regularly followed-up. LESSONS Combined ESD and TAMIS is effective in patients with benign and early neoplastic lesions of the anorectum extending above the dentate line with concomitant hemorrhoids and can prevent complications.
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Affiliation(s)
- Pramod Nepal
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Kan Tanabe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Kenji Baba
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Fumisato Sasaki
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuichiro Nasu
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Akio Ido
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Masahiko Sakoda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Kosei Maemura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
| | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine
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Yang D, Othman M, Draganov PV. Endoscopic Mucosal Resection vs Endoscopic Submucosal Dissection For Barrett's Esophagus and Colorectal Neoplasia. Clin Gastroenterol Hepatol 2019; 17:1019-1028. [PMID: 30267866 DOI: 10.1016/j.cgh.2018.09.030] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 09/06/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023]
Abstract
Endoscopic resection has become the first-line therapy for the management of superficial neoplasia throughout the gastrointestinal tract. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established yet distinct techniques for the treatment of superficial gastrointestinal neoplasia. EMR is simpler and faster but is limited by its ability to resect large lesions en bloc. Limitations of piecemeal EMR of large lesions include a high rate of recurrence and a less-than-ideal tissue specimen for accurate histologic evaluation. ESD, on the other hand, allows en bloc resection regardless of lesion size, reducing risk for recurrence and facilitating precise histologic staging. However, ESD can take longer than EMR, is technically more complex, and traditionally has been associated with a higher rate of adverse events. Ultimately, the optimal endoscopic technique should be selected based on organ location, type of neoplastic lesion, and local expertise. The role of ESD has expanded in Eastern regions, beyond squamous cell lesions in the esophagus and gastric cancer to include superficial Barrett's esophagus (BE) and colon neoplasia. However, there is controversy in Western regions over use of ESD for BE and colon neoplasia. We discuss the clinical outcomes of EMR and ESD for the treatment of superficial BE and colon neoplasia, focusing on practical considerations for formulating the most appropriate endoscopic resection approach for each patient.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Mohamed Othman
- Division of Gastroenterology and Hepatology, Baylor St. Luke's Medical Center, Houston, Texas
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida.
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Seo M, Song EM, Cho JW, Lee YJ, Lee BI, Kim JS, Jeon SW, Jang HJ, Yang DH, Ye BD, Byeon JS. A risk-scoring model for the prediction of delayed bleeding after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2019; 89:990-998.e2. [PMID: 30521794 DOI: 10.1016/j.gie.2018.11.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 11/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Delayed bleeding is an important adverse event after colorectal endoscopic submucosal dissection (ESD). We aimed to investigate the incidence and risk factors of delayed bleeding after colorectal ESD and to develop a risk-scoring model for predicting delayed bleeding. METHODS This retrospective study was performed at 5 centers. The derivation and validation cohorts comprised 1189 patients from 1 center and 415 patients from the other 4 centers. We investigated the incidence and risk factors of delayed bleeding. Then, we developed a risk-scoring model for predicting delayed bleeding by using the data of the derivation cohort. We validated the scoring system in the validation cohort. RESULTS Delayed bleeding occurred in 34 patients (2.9%) in the derivation cohort. In multivariate analysis, the risk factors of delayed bleeding were tumor location in the rectosigmoid colon (odds ratio [OR], 6.49; 95% confidence interval [CI], 1.96-21.42; P = .002), large tumor (≥30 mm) (OR, 2.10; 95% CI, 1.01-4.40; P = .048), and use of antiplatelet agents except for aspirin alone (OR, 4.04; 95% CI, 1.44-11.30; P = .008). These 3 factors were incorporated into a risk-scoring model for prediction of delayed bleeding. As the score based on this system increased, the incidence of delayed bleeding increased in the validation cohort. CONCLUSION The risk-scoring model incorporating tumor location, tumor size, and use of antiplatelet agents can quantitatively predict the risk of delayed bleeding after colorectal ESD.
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Affiliation(s)
- Myeongsook Seo
- Department of Internal Medicine, Konkuk University Chungju Hospital, Chungju, Korea
| | - Eun Mi Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jin Woong Cho
- Department of Gastroenterology, Presbyterian Medical Center, Jeonju, Korea
| | - Young Jae Lee
- Department of Gastroenterology, Presbyterian Medical Center, Jeonju, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Woo Jeon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Hyun Joo Jang
- Department of Gastroenterology, Hallym University School of Medicine, Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Are Morphologic and Histologic Risk Factors for T1 Colorectal Cancer Friends or Enemies? Clin Gastroenterol Hepatol 2019; 17:1035-1036. [PMID: 30315946 DOI: 10.1016/j.cgh.2018.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 02/07/2023]
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Kaosombatwattana U, Yamamura T, Limsrivilai J, Nakamura M, Leelakusolvong S, Hirooka Y, Goto H. Preoperative endoscopic predictors of severe submucosal fibrosis in colorectal tumors undergoing endoscopic submucosal dissection. Endosc Int Open 2019; 7:E421-E430. [PMID: 30931372 PMCID: PMC6428675 DOI: 10.1055/a-0848-8225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 12/27/2018] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Endoscopic submucosal dissection (ESD) enables en bloc removal of colorectal neoplasms regardless of size. Submucosal fibrosis is a significant factor for technical difficulty and poor outcomes. We assessed the predictive factors for severe submucosal fibrosis and the ESD outcomes. Patients and methods Patients undergoing ESD from January 2006 to September 2017 were retrospectively reviewed. The degree of submucosal fibrosis was classified into three types: no fibrosis (F0), mild fibrosis (F1), and severe fibrosis (F2). F0 and F1 cases were grouped as non-severe fibrosis for comparison with the severe fibrosis group. Predictors of severe submucosal fibrosis and ESD outcomes were evaluated. Results ESD was performed in 524 lesions (60 % male; mean age, 67.8 years). Eighty lesions with severe fibrosis (15.3 %) were observed. The overall en bloc resection rate and curative resection rate were 94.3 % and 77.7 %, respectively. Rates of en bloc resection (91.2 % vs. 94.8 %, P = 0.2) and perforation (7.5 % vs. 5.6 %, P = 0.45) were no different between severe fibrosis and non-severe fibrosis groups. However, incidences of non-curative resection and low resection speed were significantly higher in the severe fibrosis group. Among protruding lesions, tumor height and volume were significantly greater in the severe counterparts. A diameter ≥ 40 mm, endoscopic finding of the tumor beyond fold, and fold convergence were independent risk factors for severe fibrosis. Conclusions Severe submucosal fibrosis is a significant risk factor for non-curative resection and a long procedural time. Tumor size and morphology might help to predict the severity of fibrosis.
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Affiliation(s)
- Uayporn Kaosombatwattana
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand,Corresponding author Uayporn Kaosombatwattana Division of GastroenterologyDepartment of MedicineFaculty of MedicineSiriraj Hospital, Mahidol University2 Wanglang Road, BangkoknoiBangkokThailand 10700+662-411-5013
| | - Takeshi Yamamura
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Somchai Leelakusolvong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yang DH, Rey I. Endoscopic Submucosal Dissection for Colitis-Associated Dysplasia. Clin Endosc 2019; 52:120-128. [PMID: 30914628 PMCID: PMC6453849 DOI: 10.5946/ce.2019.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/17/2019] [Indexed: 12/15/2022] Open
Abstract
Dysplasia is a precancerous lesion of colorectal cancer in patients with long-standing inflammatory bowel diseases (IBDs), such as ulcerative colitis and Crohn’s disease. Recent guidelines suggest endoscopic resection as a key modality for the treatment of endoscopically resectable dysplasia in patients with colitis. Endoscopic submucosal dissection (ESD) has been suggested as one of the therapeutic options for dysplasia that is potentially resectable but not suitable for the conventional endoscopic mucosal resection technique. Several recent studies supported the feasibility of ESD for the treatment of colitis-associated dysplasia in terms of the en bloc and complete resection rates and the risk of procedure-related complications. However, these studies were performed exclusively in expert centers. Moreover, the local and metachronous recurrence rates were relatively high, and long-term outcome data are still lacking. Endoscopists should be highly skilled in colorectal ESD and have an intensive understanding of not only the lesions but also the conditions of patients with IBDs. Therefore, the decision to perform ESD for colitis-associated dysplasia should be made scrupulously after careful discussion with patients, in collaboration with a multidisciplinary IBD team including physicians, surgeons, and pathologists specialized in IBDs.
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Affiliation(s)
- Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Imelda Rey
- Division of Gastroenterohepatology, Department of Internal Medicine, University of Sumatera Utara, Adam Malik General Hospital, Medan, Indonesia
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Thorlacius H, Rönnow CF, Toth E. European experience of colorectal endoscopic submucosal dissection: a systematic review of clinical efficacy and safety. Acta Oncol 2019; 58:S10-S14. [PMID: 30724676 DOI: 10.1080/0284186x.2019.1568547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is an advanced method allowing en bloc resection of large and complex lesions in colon and rectum. Herein, the European experience of colorectal ESD was systematically reviewed in the medical literature to determine the clinical efficacy and safety of colorectal ESD in Europe. MATERIAL AND METHODS A systematic search of PubMed for full-text studies including more than 20 cases of colorectal ESD emanating from European centres was performed. Data were independently extracted by two authors using predefined data fields, including efficacy and safety. RESULTS We included 15 studies containing a total of 1404 colorectal ESD cases (41% in the colon) performed between 2007 and 2018. Lesion size was 40 mm (range 24-59 mm) and procedure time was 102 min (range 48-176 min). En bloc resection rate was 83% (range 67-93%) and R0 resection rate was 70% (range 35-91%). Perforation rate was 7% (range 0-19%) and bleeding rate was 5% (range 0-12%). The percentage of ESD cases undergoing emergency surgery was 2% (range 0-6%). Additional elective surgery was performed in 3% of all cases due to histopathological findings showing deep submucosal invasion or more advanced cancer. The recurrence rate was 4% (range 0-12%) after a median follow-up time of 12 months (range 3-24 months). CONCLUSIONS This review shows that ESD is effective and safe for treating large and complex colorectal lesions in Europe although there is room for improvement. Thus, it is important to develop standardized and high-quality educational programs in colorectal ESD in Europe.
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Affiliation(s)
- Henrik Thorlacius
- Department of Clinical Sciences, Section of Surgery Skåne University Hospital Lund University, Malmö, Sweden
| | - Carl-Fredrik Rönnow
- Department of Clinical Sciences, Section of Surgery Skåne University Hospital Lund University, Malmö, Sweden
| | - Ervin Toth
- Department of Clinical Sciences, Section of Gastroenterology, Skåne University Hospital Lund University, Malmö, Sweden
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139
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Baldaque-Silva F, Marques M, Andrade AP, Sousa N, Lopes J, Carneiro F, Macedo G. Endoscopic submucosal dissection of gastrointestinal lesions on an outpatient basis. United European Gastroenterol J 2019; 7:326-334. [PMID: 31080617 DOI: 10.1177/2050640618823874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Endoscopic submucosal dissection (ESD) is usually associated with hospital admission. Objectives To evaluate, prospectively, the feasibility, safety and efficacy of outpatient gastrointestinal ESD. Methods Patients with suitable lesions were invited to participate. Those that dwelt more than 1 hour from the hospital, lived alone, had severe co-morbidities, were <18 years old, had duodenal lesions, or that had ESD-related complications were admitted. The remaining patients were discharged if no complications were detected. A patients' inquiry was performed. Results Of the 164 ESD patients, 122 were outpatient-based, corresponding to 115 patients, 47% male and mean age 63 ± 12 years-old. Outpatients tended to be younger, female, to have gastric lesions, less advanced lesions, and shorter and less complicated ESDs (all p < 0.05). Outpatients' mean tumour size was 38 mm, en bloc and R0 resection rates were 88 and 78%, respectively. Seven ESD outpatients (5.7%) had complications: delayed bleeding (n = 4), pneumonitis (n = 2) or emphysema (n = 1), all managed conservatively. Colorectal location of the lesions was predictive of hospital admission (p = 0.03). In total, 97% of patients were satisfied with the outpatient strategy. Conclusion Risks of ambulatory ESD are low and complications can be successfully managed. This strategy has high patient satisfaction. More studies are needed to evaluate its implications on costs and patients' management.
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Affiliation(s)
- Francisco Baldaque-Silva
- Department of Digestive Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | - Margarida Marques
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | | | - Nuno Sousa
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Joanne Lopes
- Department of Pathology, São João University Hospital, Porto, Portugal
| | - Fatima Carneiro
- Department of Pathology, São João University Hospital, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
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Draganov PV, Wang AY, Othman MO, Fukami N. AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States. Clin Gastroenterol Hepatol 2019; 17:16-25.e1. [PMID: 30077787 DOI: 10.1016/j.cgh.2018.07.041] [Citation(s) in RCA: 255] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/21/2018] [Accepted: 07/26/2018] [Indexed: 02/07/2023]
Abstract
Endoscopic submucosal dissection (ESD) is an established endoscopic resection method in Asian countries, which is increasingly practiced in Europe and by early adopters in the United States for removal of early cancers and large lesions from the luminal gastrointestinal tract. The intent of this expert review is to provide an update regarding the clinical practice of ESD with a particular focus on its use in the United States. This review is framed around the 16 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects our experience as advanced endoscopists with extensive experience in performing and teaching others to perform ESD in the United States. Best Practice Advice 1: Endoscopic submucosal dissection should be recognized as a mature endoscopic technique that enables complete removal of lesions that are too large for en bloc endoscopic mucosal resection or are at increased risk of containing cancer. Best Practice Advice 2: The safety and feasibility of endoscopic submucosal dissection for early gastric cancer is well established. The absolute indications for curative endoscopic resection include moderately and well-differentiated, nonulcerated, mucosal lesions that are ≤2 cm in size. Best Practice Advice 3: Other relative (expanded) indications for gastric endoscopic submucosal dissection include moderately and well-differentiated superficial cancers that are >2 cm, lesions ≤3 cm with ulceration or that contain early submucosal invasion, and poorly differentiated superficial cancers ≤2 cm in size. The risk of lymph node metastasis when endoscopic submucosal dissection is performed for these indications is higher than when it is performed for absolute indications but remains acceptably low. Best Practice Advice 4: Endoscopic submucosal dissection may be considered in selected patients with Barrett's esophagus with the following features: large or bulky area of nodularity, lesions with a high likelihood of superficial submucosal invasion, recurrent dysplasia, endoscopic mucosal resection specimen showing invasive carcinoma with positive margins, equivocal preprocedural histology, and intramucosal carcinoma. Best Practice Advice 5: Endoscopic submucosal dissection is the primary modality for treatment of squamous cell dysplasia and cancer confined to the superficial esophageal mucosa. Any degree of submucosal invasion caries an increased risk of lymph node metastasis and alternative/additional therapy should be considered. Best Practice Advice 6: Duodenal endoscopic submucosal dissection is associated with an increased risk of intraprocedural perforation and delayed adverse events. Duodenal endoscopic submucosal dissection should be limited to endoscopists with extensive experience in performing endoscopic submucosal dissection in other locations. It is strongly suggested that endoscopists in the United States refrain from performing duodenal endoscopic submucosal dissection during the early phase of their endoscopic submucosal dissection practice. Best Practice Advice 7: All colorectal lesions should be evaluated for suitability for endoscopic resection. Accumulating evidence has shown that the majority of colorectal neoplasms without signs of deep submucosal invasion or advanced cancer can be treated by advanced endoscopic resection techniques. Best Practice Advice 8: Colorectal neoplasms containing dysplasia confined to the mucosa have no risk for lymph node metastasis and endoscopic resection should be considered as the criterion standard. Best Practice Advice 9: Large (>2 cm) colorectal lesions frequently (>43%) require piecemeal removal when endoscopic mucosal resection is used, which is associated with increased (up to 20%) rates of recurrent neoplasia. Endoscopic submucosal dissection enables higher rates of en bloc resection and lower recurrence rates for these lesions. Patients with large complex colorectal polyps should be referred to a high-volume, specialized center for endoscopic removal by endoscopic mucosal resection or endoscopic submucosal dissection. Best Practice Advice 10: Endoscopic resection for colorectal lesions offers significant cost benefit compared with surgery, and case-based endoscopic submucosal dissection selection for high-risk lesions could offer cost savings. Best Practice Advice 11: Endoscopists in the United States embarking on performing endoscopic submucosal dissection should be familiar with currently available endoscopic tissue closure devices. Both clip closure and endoscopic suturing techniques have been shown to be effective in managing intraprocedural perforation. Complete closure of a post-endoscopic submucosal dissection site may be considered in certain circumstances based on patient factors, procedural factors, and the location of the lesion. Best Practice Advice 12: Careful coagulation of exposed blood vessels in the resection site may reduce the risk of delayed bleeding after endoscopic submucosal dissection. The use of low-voltage coagulation current is recommended for this technique. Best Practice Advice 13: Endoscopists should affix the endoscopic submucosal dissection specimen to a flat surface (eg, pin the specimen to cork board) and immerse it in formalin. An expert gastrointestinal pathologist should evaluate the specimen for margin involvement, degree of differentiation, presence or absence of lymphovascular invasion, depth of submucosal invasion (if present), and tumor budding. Best Practice Advice 14: Acquiring high-level competency in endoscopic submucosal dissection is achievable in the United States. Alternative educational models should be used in the United States because of the limited number of experts and the differing prevalence of gastrointestinal luminal diseases as compared with Asia. Best Practice Advice 15: The endoscopic submucosal dissection educational model most suited for the current environment in the United States is a stepwise approach consisting of didactic self-study, attending training courses with increasing levels of complexity, self-practice on animal models, and observation of live cases performed by experts. Endoscopists should perform their initial endoscopic submucosal dissections on patients with lesions that have well-established indications for endoscopic submucosal dissection and are of the lowest technical complexity. Best Practice Advice 16: Endoscopists in the United States who perform endoluminal resection should educate referring physicians to avoid practices that may induce submucosal fibrosis hampering future endoscopic mucosal resection or endoscopic submucosal dissection. These practices include tattooing in close proximity to or beneath a lesion for marking and partial snare resection of a portion of a lesion for histopathology.
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Affiliation(s)
- Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Mohamed O Othman
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona
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Subramaniam S, Kandiah K, Thayalasekaran S, Longcroft-Wheaton G, Bhandari P. Haemostasis and prevention of bleeding related to ER: The role of a novel self-assembling peptide. United European Gastroenterol J 2018; 7:155-162. [PMID: 30788128 DOI: 10.1177/2050640618811504] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/08/2018] [Indexed: 12/26/2022] Open
Abstract
Background Endoscopic resection is now commonly used for removal of early gastrointestinal lesions. However, the risk of the procedure may be heightened by intraprocedural or delayed bleeding. A novel, self-assembling peptide (PuraStat®) was recently licensed for use as a haemostat. Objective The aim of this study was to assess the efficacy and safety of this haemostat when used to control intraprocedural bleeding or to prevent delayed bleeding in endoscopic resection. Methods PuraStat® was used on 100 patients undergoing endoscopic resection in a tertiary referral centre. The efficacy, safety, feasibility of use and delayed bleeding rates were measured. Results Forty-eight oesophageal, 31 colorectal, 11 gastric and 10 duodenal procedures were included. The mean lesion size was 3.7 cm and 30% of the patients were on antithrombotic therapy. Intraprocedural bleeding occurred in 64%. PuraStat® was an effective haemostat in 75% of these cases. Only a small amount was required for haemostasis (mean = 1.76 ml) and it took on average 69.5 seconds to stop a bleed. The delayed bleeding rate was 3%. Conclusions PuraStat® is an effective haemostat for use in controlling bleeds during endoscopic resection. It is safe, easy to use and did not interfere with the procedure.
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Affiliation(s)
| | - Kesavan Kandiah
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | | | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Bahin FF, Heitman SJ, Rasouli KN, Mahajan H, McLeod D, Lee EYT, Williams SJ, Bourke MJ. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67:1965-1973. [PMID: 28988198 DOI: 10.1136/gutjnl-2017-313823] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/29/2017] [Accepted: 09/10/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of endoscopic submucosal dissection (ESD) and wide-field endoscopic mucosal resection (WF-EMR) for removing large sessile and laterally spreading colorectal lesions (LSLs) >20 mm. DESIGN An incremental cost-effectiveness analysis using a decision tree model was performed over an 18-month time horizon. The following strategies were compared: WF-EMR, universal ESD (U-ESD) and selective ESD (S-ESD) for lesions highly suspicious for containing submucosal invasive cancer (SMIC), with WF-EMR used for the remainder. Data from a large Western cohort and the literature were used to inform the model. Effectiveness was defined as the number of surgeries avoided per 1000 cases. Incremental costs per surgery avoided are presented. Sensitivity and scenario analyses were performed. RESULTS 1723 lesions among 1765 patients were analysed. The prevalence of SMIC and low-risk-SMIC was 8.2% and 3.1%, respectively. Endoscopic lesion assessment for SMIC had a sensitivity and specificity of 34.9% and 98.4%, respectively. S-ESD was the least expensive strategy and was also more effective than WF-EMR by preventing 19 additional surgeries per 1000 cases. 43 ESD procedures would be required in an S-ESD strategy. U-ESD would prevent another 13 surgeries compared with S-ESD, at an incremental cost per surgery avoided of US$210 112. U-ESD was only cost-effective among higher risk rectal lesions. CONCLUSION S-ESD is the preferred treatment strategy. However, only 43 ESDs are required per 1000 LSLs. U-ESD cannot be justified beyond high-risk rectal lesions. WF-EMR remains an effective and safe treatment option for most LSLs. TRIAL REGISTRATION NUMBER NCT02000141.
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Affiliation(s)
- Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Steven J Heitman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Khalid N Rasouli
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Hema Mahajan
- Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Duncan McLeod
- Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Rönnow CF, Uedo N, Toth E, Thorlacius H. Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe. Endosc Int Open 2018; 6:E1340-E1348. [PMID: 30410955 PMCID: PMC6221812 DOI: 10.1055/a-0733-3668] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/31/2018] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results Median size was 4 cm (range 1 - 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 - 588) and median proficiency was 7.2 cm 2 /h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 - 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm 2 /h) and the last study period (10.8 cm 2 /h). Conclusions This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.
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Affiliation(s)
- Carl-Fredrik Rönnow
- Department of Clinical Sciences, Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ervin Toth
- Department of Clinical Sciences, Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Henrik Thorlacius
- Department of Clinical Sciences, Surgery, Skåne University Hospital, Lund University, Malmö, Sweden,Corresponding author Henrik Thorlacius, MD, PhD Department of Clinical Sciences, MalmöSection of SurgerySkåne University HospitalLund UniversityS-205 02 MalmöSweden+46-40-336207
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144
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Dahan M, Pauliat E, Liva-Yonnet S, Brischoux S, Legros R, Tailleur A, Carrier P, Charissoux A, Valgueblasse V, Loustaud-Ratti V, Taibi A, Durand-Fontanier S, Valleix D, Sautereau D, Kerever S, Jacques J. What is the cost of endoscopic submucosal dissection (ESD)? A medico-economic study. United European Gastroenterol J 2018; 7:138-145. [PMID: 30788126 DOI: 10.1177/2050640618810572] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/23/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction Endoscopic submucosal dissection (ESD) is the gold-standard treatment for superficial lesions of the digestive tract. No medico-economic study has been conducted in Europe. Material and methods A monocentric study was conducted including all patients undergoing ESD between January 2015 and December 2017. The global cost of hospital stays was measured by microcosting, and revenue was based on the diagnosis-related group (DRG) system. The primary objective was to assess the cost/revenue balance. A medico-economic comparison with surgery was performed as a secondary outcome. Results A total of 193 patients were prospectively included. The cost per procedure was €3463.79, subtracted from a €2726.84 revenue, with a deficit of -€736.96 per stay. Presence of comorbidities/complications increasing DRG value was the only predictive factor for a positive budgetary balance in a multivariate analysis (odds ratio 49.21, 95% confidence interval 11.3-214.25, p < 0.0001). In comparison with surgery, ESD was associated with shorter length of stay (11 vs 2 days; p < 0.0001) and lower morbidity (28% vs 14%; p = 0.061), lower cost (€8960 vs €1770; p < 0.0001). Conclusion The ESD cost/revenue balance is negative in 80% of cases. Given the benefits of ESD in terms of patient morbidity and financial savings compared with surgery, the implementation of a specific ESD reimbursement is warranted.
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Affiliation(s)
- Martin Dahan
- Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | | | - Sandra Liva-Yonnet
- Information Médicale et de l'information, CHU Dupuytren, Limoges, France
| | | | - Romain Legros
- Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | | | - Paul Carrier
- Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | | | | | | | - Abdelkader Taibi
- Chirurgie digestive et endocrinienne, CHU Dupuytren, Limoges, France
| | | | - Denis Valleix
- Chirurgie digestive et endocrinienne, CHU Dupuytren, Limoges, France
| | | | - Sébastien Kerever
- Biostatistique et information médicale, Hôpital Saint Louis APHP, Paris, France
| | - Jérémie Jacques
- Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France.,Xlim, BioEM, UMR 7252, CNRS, Limoges, France
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Factors Predictive of Complete Excision of Large Colorectal Neoplasia Using Hybrid Endoscopic Submucosal Dissection: A KASID Multicenter Study. Dig Dis Sci 2018; 63:2773-2779. [PMID: 29876776 DOI: 10.1007/s10620-018-5140-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) with snaring (hybrid ESD) bridges the gap between ESD and endoscopic mucosal resection. We evaluated factors predictive of en bloc and complete resection of large colorectal neoplasms using hybrid ESD. METHODS This was a prospective clinical study of 78 patients who underwent hybrid ESD for excision of colorectal neoplasms (≥ 2 cm) between May 2015 and September 2016 at six university hospitals. We evaluated lesion and patient characteristics, endoscopist experience level (< 50 or ≥ 50 cases with colorectal ESD), and technical factors such as concurrent fibrosis, completion of a circumferential incision, degree of submucosal dissection (< 50 or ≥ 50%), and visualization during snaring (< 50 or ≥ 50%). RESULTS Multivariate analyses showed that the en bloc resection rate was significantly related to the degree of visualization during snaring (odds ratio (OR) 7.811, 95% confidence interval [CI] 1.722-35.426; p = 0.008) and the presence of fibrosis (OR 0.258, 95% CI 0.68-0.993; p = 0.049). The complete resection rate was significantly related to the colorectal ESD endoscopist skill level (OR 5.626, 95% CI 1.485-21.313; p = 0.011) and gross lesion type (OR 0.145, 95% CI 0.022-0.936; p = 0.042). When all three technical factors, i.e., completion of circumferential incision, ≥ 50% submucosal dissection, and ≥ 50% visualization during snaring, were satisfied performing hybrid ESD, the en bloc resection rate (87.5%) was similar to that of ESD. CONCLUSIONS Visualization during snaring, presence of fibrosis, gross lesion type, and endoscopist colorectal ESD experience level affect en bloc or complete resection of large colorectal neoplasia using hybrid ESD.
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147
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Pérez-Cuadrado-Robles E, Quénéhervé L, Margos W, Shaza L, Ivekovic H, Moreels TG, Yeung R, Piessevaux H, Coron E, Jouret-Mourin A, Deprez PH. Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors. Endosc Int Open 2018; 6:E1008-E1014. [PMID: 30083592 PMCID: PMC6075950 DOI: 10.1055/a-0577-7546] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. PATIENTS AND METHODS This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. RESULTS One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31 - 83, 42.7 % males) were resected by ESD (n = 37) or EMR (n = 129) and included. The median procedure time (81 vs. 50 min, P = 0.007) and tumor size (25 vs. 20 mm, P = 0.01) were higher in the ESD group. The global malignancy rate was 50.3 %. There were no differences in en-bloc resection (29.7 % vs. 44.2 %, P = 0.115), complete resection (19.4 % vs. 35.5 %, P = 0.069), and local recurrence (14.7 % vs. 16.7 %, P = 0.788) rates. Tumor size was associated with recurrence (28 vs. 20 mm, P = 0.008), with a median follow-up of 6.5 months. Focal recurrence (n = 22, 13.3 %) was treated endoscopically in 86.4 %. En-bloc resection in the ESD group was comparable in large ( ≥ 20 mm) and small lesions (27.6 % vs. 37.5 %, P = 0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4 % vs. 75 %, P < 0.001). Nine perforations were confirmed in 6 lesions (16.2 %) resected by ESD and 3 (2.3 %) by EMR ( P = 0.001). Endoscopic therapy was successful in all but 1 patient (88.9 %) presenting with a delayed perforation. CONCLUSIONS ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.
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Affiliation(s)
- Enrique Pérez-Cuadrado-Robles
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lucille Quénéhervé
- Institut des Maladies de l’Appareil digestif, University Hospital of Nantes, France
| | - Walter Margos
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Leila Shaza
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Hrvoje Ivekovic
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Tom G. Moreels
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ralph Yeung
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Hubert Piessevaux
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Emmanuel Coron
- Institut des Maladies de l’Appareil digestif, University Hospital of Nantes, France
| | - Anne Jouret-Mourin
- Department of Pathology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre H. Deprez
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium,Corresponding author Pierre H. Deprez Department of Hepato-GastroenterologyCliniques universitaires Saint-LucUniversité Catholique de LouvainBrusselsBelgium
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148
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Rönnow CF, Elebro J, Toth E, Thorlacius H. Endoscopic submucosal dissection of malignant non-pedunculated colorectal lesions. Endosc Int Open 2018; 6:E961-E968. [PMID: 30083585 PMCID: PMC6070376 DOI: 10.1055/a-0602-4065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/12/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is an established method for en bloc resection of large non-pedunculated colorectal lesions in Asia but dissemination of ESD in Western countries is limited. The aim of this study was to evaluate the role of ESD in the management of malignant non-pedunculated colorectal lesions in a European center. PATIENTS AND METHODS Among 255 patients undergoing colorectal ESD between 2014 and 2016, 29 cases were identified as submucosal invasive cancers and included in this study. The main outcomes were en bloc, R0 and curative resection as well as procedural time, complications and recurrence. RESULTS Median tumor size was 40 mm (range 20 - 70 mm). Thirteen cancers were located in the colon and 16 were located in the rectum. Procedural time was 89 minutes (range 18 - 594 minutes). Complete resection was achieved in 28 cases, en bloc and R0 resection rates were 83 % and 69 %, respectively. Curative resection rate was 38 %. One case had a perforation in the sigmoid colon requiring emergency surgery. No significant bleeding occurred. Six patients underwent additional surgery after ESD, one of whom had residual tumor. One recurrence was detected in 20 patients that were followed-up endoscopically, median follow-up time was 13 months (range 2 - 30 months). CONCLUSION ESD seems to be a safe and effective method for treating non-pedunculated malignant colorectal lesions after careful patient selection and proper endoscopic training.
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Affiliation(s)
- Carl-Fredrik Rönnow
- Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Jacob Elebro
- Department of Clinical Sciences, Malmö, Section of Pathology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Ervin Toth
- Department of Clinical Sciences, Malmö, Section of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Henrik Thorlacius
- Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden,Corresponding author Henrik Thorlacius, MD, PhD Department of Clinical Sciences, MalmöSection of SurgerySkåne University HospitalLund UniversityS-205 02 MalmöSweden+46-40-336207
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149
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Fuccio L, Repici A, Hassan C, Ponchon T, Bhandari P, Jover R, Triantafyllou K, Mandolesi D, Frazzoni L, Bellisario C, Bazzoli F, Sharma P, Rösch T, Rex DK. Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. Gut 2018; 67:1464-1474. [PMID: 29208675 DOI: 10.1136/gutjnl-2017-315103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 µm or less than one-third of the submucosa) on colorectal lesions removed by ESD. DESIGN A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions. RESULTS 51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2%; 95% CI 78.8% to 85.3%) were adenomas (low- and high-grade dysplasia, 26.8% and 55.4%, respectively). Overall, 15.7% were submucosal cancers, but only slightly more than half (8.0%; 95% CI 6.1% to 10.3%) had an infiltration depth of ≤1000 µm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3% (95% CI 52.2% to 89.4%) for malignant lesions, the prevalence of curative resection lowered to 6% (95% CI 4.2% to 7.2%) with an NNT of 16.7. CONCLUSION The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.
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Affiliation(s)
- Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research and University Hospital, Rozzano, Italy
| | | | - Thierry Ponchon
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | | | - Rodrigo Jover
- Service of Digestive Medicine, Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain
| | - Konstantinos Triantafyllou
- Ηepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Daniele Mandolesi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology (CPO), University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Prateek Sharma
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas, Missouri, USA.,Department of Gastroenterology, Veteran Affairs Medical Center, Kansas, Missouri, USA
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
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150
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Kinugasa H, Higashi R, Miyahara K, Moritou Y, Hirao K, Ogawa T, Kunihiro M, Nakagawa M. Dexmedetomidine for conscious sedation with colorectal endoscopic submucosal dissection: a prospective double-blind randomized controlled study. Clin Transl Gastroenterol 2018; 9:167. [PMID: 29970896 PMCID: PMC6030068 DOI: 10.1038/s41424-018-0032-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/23/2018] [Accepted: 05/15/2018] [Indexed: 12/12/2022] Open
Abstract
Objective Conscious sedation for colorectal endoscopic submucosal dissection (ESD) has not been standardized, and there are no studies of sedation for colorectal ESD. Methods We conducted a prospective double-blind randomized controlled trial to clarify the usefulness of DEX during colorectal ESD. In total 80 patients with colorectal ESD from April 2016 to May 2017 were assigned to the placebo group or the DEX group (40 cases each). The primary outcome was patient satisfaction (visual analogue scale: VAS). Secondary outcomes were evaluated for 13 factors, including patient pain level (VAS), endoscopist satisfaction (VAS), objective patient pain level viewed from the endoscopist’s perspective (VAS), rate of patient response, rate of side effects, etc., from the patient’s and endoscopist’s perspectives. Results Patient satisfaction was 8.4 and 9.1 (P = 0.018) in the placebo group and the DEX group, respectively. Secondary outcomes of patient pain level, endoscopist satisfaction, objective patient pain level from the endoscopist’s perspective for the placebo and DEX groups were 1.2 and 0.4 (P = 0.045), 8.2 and 9.3 (P < 0.001), and 1.2 and 0.5 (P = 0.002), respectively. All of these were significantly positive results (more comfortable and less pain) in the DEX group. The rate of a patient response was 100% in all cases. The side effects (hypoxia/bradycardia/hypotension) were 0%/0%/0% and 7.5%/7.5%/5% (P = 0.030). However, these rates were less than the reported side effect occurrence rate, and no additional medication was needed. Conclusion DEX enables conscious sedation, and is useful not only for patient and endoscopist satisfaction but also for pain relief. DEX is an effective sedation method for colorectal ESD.
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Affiliation(s)
- Hideaki Kinugasa
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan. .,Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan.
| | - Reiji Higashi
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
| | - Koji Miyahara
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
| | - Yuki Moritou
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
| | - Ken Hirao
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
| | - Tsuneyoshi Ogawa
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
| | - Masaki Kunihiro
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
| | - Masahiro Nakagawa
- Department of Gastroenterology and Hepatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, 730-8518, Japan
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