Treatment outcomes of endoscopic submucosal dissection and surgery for colorectal neoplasms in patients with ulcerative colitis

Efficacy and safety of endoscopic submucosal dissection for colorectal dysplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND/AIMS

In this meta-analysis, we studied the safety and efficacy of endoscopic submucosal dissection (ESD) for colorectal dysplasia in patients with inflammatory bowel disease (IBD).

METHODS

Multiple databases were searched, and studies were retrieved based on pre-specified criteria until October 2022. The outcomes assessed were resection rates, procedural complications, local recurrence, metachronous tumors, and the need for surgery after ESD in IBD. Standard meta-analysis methods were followed using the random-effects model, and I2% was used to assess heterogeneity.

RESULTS

Twelve studies comprising 291 dysplastic lesions in 274 patients were included with a median follow-up of 25 months. The pooled en-bloc resection, R0 resection, and curative resection rates were 92.5% (95% confidence interval [CI], 87.9%-95.4%; I2=0%), 81.5% (95% CI, 72.5%-88%; I2=43%), and 48.9% (95% CI, 32.1%-65.9%; I2=87%), respectively. The local recurrence rate was 3.9% (95% CI, 2%-7.5%; I2=0%). The pooled rates of bleeding and perforation were 7.7% (95% CI, 4.5%-13%; I2=10%) and 5.3% (95% CI, 3.1%-8.9%; I2=0%), respectively. The rates of metachronous recurrence and additional surgery following ESD were 10% (95% CI, 5.2%-18.2%; I2=55%) and 13% (95% CI, 8.5%-19.3%; I2=54%), respectively.

CONCLUSIONS

ESD is safe and effective for the resection of dysplastic lesions in IBD with an excellent pooled rate of en-bloc and R0 resection.

Characteristics of flat-type ulcerative colitis-associated neoplasia on chromoendoscopic imaging with indigo carmine dye spraying

OBJECTIVES

Despite recent advances in endoscopic equipment and diagnostic techniques, early detection of ulcerative colitis-associated neoplasia (UCAN) remains difficult because of the complex background of the inflamed mucosa of ulcerative colitis and the morphologic diversity of the lesions. We aimed to describe the main diagnostic patterns for UCAN in our cohort, including lateral extension surrounding flat lesions.

METHODS

Sixty-three lesions in 61 patients with flat-type dysplasia that were imaged with dye chromoendoscopy (DCE) were included in this analysis. These DCE images were analyzed to clarify the dye-chromoendoscopic imaging characteristics of flat dysplasia, and the lesions were broadly classified into dysplastic and nondysplastic mucosal patterns.

RESULTS

Dysplastic mucosal patterns were classified into two types: small round patterns with round to roundish structures, and mesh patterns with intricate mesh-like structures. Lesions with a nondysplastic mucosal pattern were divided into two major types: a ripple-like type and a gyrus-like type. Of note, 35 lesions (55.6%) had a small round pattern, and 51 lesions (80.9%) had some type of mesh pattern. About 70% of lesions with small round patterns and 49% of lesions with mesh patterns were diagnosed as high-grade dysplasia or carcinoma, while about 30% of lesions with small round patterns and 51% of lesions with mesh patterns were diagnosed as low-grade dysplasia.

CONCLUSION

When a characteristic mucosal pattern, such as a small round or mesh pattern, is found by DCE, the possibility of UCAN should be considered.

Predictors of severe submucosal fibrosis during endoscopic submucosal dissection in patients with ulcerative colitis: Retrospective cohort study

OBJECTIVES

Severe submucosal fibrosis is a crucial technical difficulty encountered during endoscopic submucosal dissection (ESD) in patients with ulcerative colitis (UC). We aimed to identify predictors of severe submucosal fibrosis in patients with UC.

METHODS

We retrospectively included 55 tumors resected using ESD from 48 consecutive patients with UC. We analyzed the clinicopathological characteristics and treatment outcomes between the F0/1 (none to mild submucosal fibrosis) group (n = 28) and F2 (severe submucosal fibrosis) group (n = 27).

RESULTS

No significant difference was found between the F0/1 and F2 groups in en bloc resection rate (100% vs. 96%, P = 0.49), the R0 resection rate (100% vs. 93%, P = 0.24), and the dissection speed (0.18 vs. 0.13 cm2 /min, P = 0.07). Intraoperative perforation was more common in the F2 group (30%) than in the F0/1 group (8%; P = 0.01). Multivariable analysis showed that a longer duration of UC (≥10 years; odds ratio [OR] 6.11; 95% confidence interval [CI] 1.20-31.03; P = 0.03) and scarring of background mucosa of the tumor (OR 39.61; 95% CI 3.91-400.78; P < 0.01) were independent predictors of severe submucosal fibrosis.

CONCLUSION

Long UC duration and scarring background mucosa were predictors of severe submucosal fibrosis associated with perforation during ESD.

Advancements in Endoscopic Resection for Colitis-Associated Colorectal Neoplasia in Inflammatory Bowel Disease: Turning Visible into Resectable

Patients suffering from inflammatory bowel disease (IBD) face a two to three-fold higher risk of developing colorectal cancer (CRC) compared to the general population. In recent years, significant progress has been made in comprehending the natural history of IBD-associated CRC (IBD-CRC) and refining its treatment strategies. The decreased incidence of IBD-CRC can be attributed to improved therapeutic management of inflammation, advancements in endoscopy, and early detection of precancerous lesions via surveillance programs. Advanced imaging technologies have made previously undetectable dysplasia visible in most cases, allowing for a much more precise and detailed examination of the mucosa. Additionally, new tools have facilitated the endoscopic resection (ER) of visible lesions in IBD. Particularly, the key to effectively manage colitis-associated colorectal neoplasia (CAN) is to first identify it and subsequently guarantee a complete ER in order to avoid surgery and opt for continuing surveillance. Advanced ER techniques for CAN include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and hybrid ESD-EMR (h-ESD). This narrative review aims to consolidate the current literature on IBD-CRC, providing an overview of advanced techniques for ER of CAN in IBD, with a particular emphasis on the impact of ESD on the long-term outcomes of IBD patients.

Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers

Background and study aims Overcoming logistical obstacles for the implementation of colorectal endoscopic submucosal dissection (ESD) requires accurate prediction of procedure times. We aimed to evaluate existing and new prediction models for ESD duration. Patients and methods Records of all consecutive patients who underwent single, non-hybrid colorectal ESDs before 2020 at three Dutch centers were reviewed. The performance of an Eastern prediction model [GIE 2021;94(1):133-144] was assessed in the Dutch cohort. A prediction model for procedure duration was built using multivariable linear regression. The model's performance was validated using internal validation by bootstrap resampling, internal-external cross-validation and external validation in an independent Swedish ESD cohort. Results A total of 435 colorectal ESDs were analyzed (92% en bloc resections, mean duration 139 minutes, mean tumor size 39 mm). The performance of current unstandardized time scheduling practice was suboptimal (explained variance: R 2 =27%). We successfully validated the Eastern prediction model for colorectal ESD duration <60 minutes (c-statistic 0.70, 95% CI 0.62-0.77), but this model was limited due to dichotomization of the outcome and a relatively low frequency (14%) of ESDs completed <60 minutes in the Dutch centers. The model was more useful with a dichotomization cut-off of 120 minutes (c-statistic: 0.75; 88% and 17% of "easy" and "very difficult" ESDs completed <120 minutes, respectively). To predict ESD duration as continuous outcome, we developed and validated the six-variable cESD-TIME formula ( https://cesdtimeformula.shinyapps.io/calculator/ ; optimism-corrected R 2 =61%; R 2 =66% after recalibration of the slope). Conclusions We provided two useful tools for predicting colorectal ESD duration at Western centers. Further improvements and validations are encouraged with potential local adaptation to optimize time planning.

Endoscopic management of patients with high-risk colorectal colitis-associated neoplasia: a Delphi study

BACKGROUND AND AIMS

Current guidelines recommend endoscopic resection of visible and endoscopically resectable colorectal colitis-associated neoplasia (CAN) in patients with inflammatory bowel disease (IBD). However, patients with high-risk CAN (HR-CAN) are often not amenable to conventional resection techniques, and a consensus approach for the endoscopic management of these lesions is presently lacking. This Delphi study aims to reach consensus among experts on the endoscopic management of these lesions.

METHODS

A 3-round modified Delphi process was conducted to reach consensus among worldwide IBD and/or endoscopy experts (n = 18) from 3 continents. Consensus was considered if ≥75% agreed or disagreed. Quality of evidence was assessed by the criteria of the Cochrane Collaboration group.

RESULTS

Consensus was reached on all statements (n = 14). Experts agreed on a definition for CAN and HR-CAN. Consensus was reached on the examination of the colon with enhanced endoscopic imaging before resection, the endoscopic resectability of an HR-CAN lesion, and endoscopic assessment and standard report of CAN lesions. In addition, experts agreed on type of resections of HR-CAN (< 20 mm, >20 mm, with or without good lifting), endoscopic success (technical success and outcomes), histologic assessment, and follow-up in HR-CAN.

CONCLUSIONS

This is the first step in developing international consensus-based recommendations for endoscopic management of CAN and HR-CAN. Although the quality of available evidence was considered low, consensus was reached on several aspects of the management of CAN and HR-CAN. The present work and proposed standardization might benefit future studies.

Role of Interventional Inflammatory Bowel Disease (IBD) in the Management of Complex IBD: Initial Prospective Experience from a Tertiary Center in India

Background/Aims With the growing multidisciplinary model of practice in the management of complex inflammatory bowel disease (IBD) and rising incidence of IBD, interventional IBD (IIBD) promises to play a key role. We aimed to evaluate current the role of IIBD in India and its short-term outcomes.

Methods IBD patients undergoing IIBD procedures for stricture, bleeding, colitis-associated neoplasia, therapeutic small bowel endoscopy including retained capsule retrieval and postsurgical complications were enrolled prospectively between September 2021 and May 2022. Demographic and disease details, indications, initial and redo procedure details, technical/clinical success, and complications were recorded.

Results IIBD procedures were performed in total 54 patients (61% males, median age: 37.5 years, range: 21–74 years, Crohn's disease [CD]: 42, ulcerative colitis [UC]: 12 between September 2021 and April 2022). Endoscopic balloon dilation (EBD) was performed in 44 patients (56 strictures, 9% anastomotic, 9% pouch) who underwent total 83 EBD procedures in 63 sessions. Short-term clinical efficacy after maximal dilation, technical success (i.e., scope passage after EBD), and complications (all mild) were noted in 95.4, 81.8, and 9.1%, respectively. Recurrent symptoms were seen in 27.3% on short-term follow-up (1–8 months, median: 5 months) for which redilation, surgery, and endoscopic stricturotomy were done in 22.7, 2.3, and 2.3% respectively. During small bowel EBD, motorized spiral enteroscopy-guided retained capsule endoscope retrieval was done in four patients. Ulcerative colitis-associated neoplasia (UCAN) was resected endoscopically in six patients (endoscopic submucosal dissection (ESD)—1, endoscopic mucosal resection (EMR)—5). High-grade dysplasia was resected in two patients (1 ESD for recurrent UCAN, 1 EMR had residual neoplasia on follow-up treated with underwater EMR). R0 resection was achieved in 83.3%. Endoscopic hemostasis was done with hemoclipping and sclerotherapy for UC-related bleeding in two, whereas a case of CD with proximal ileal bleeding was controlled with antegrade single-balloon enteroscopy-assisted hemoclipping.

Conclusions IIBD is a promising modality in resource-limited settings like India acting as a bridge between medical therapy and surgery. Surgery can be avoided in a significant proportion with good short-term outcomes. Long-term outcomes need to be evaluated.

Use of advanced endoscopic technology for optical characterization of neoplasia in patients with ulcerative colitis: Systematic review

OBJECTIVES

Advances in endoscopic technology, including magnifying and image-enhanced techniques, have been attracting increasing attention for the optical characterization of colorectal lesions. These techniques are being implemented into clinical practice as cost-effective and real-time approaches. Additionally, with the recent progress in endoscopic interventions, endoscopic resection is gaining acceptance as a treatment option in patients with ulcerative colitis (UC). Therefore, accurate preoperative characterization of lesions is now required. However, lesion characterization in patients with UC may be difficult because UC is often affected by inflammation, and it may be characterized by a distinct "bottom-up" growth pattern, and even expert endoscopists have relatively little experience with such cases. In this systematic review, we assessed the current status and limitations of the use of optical characterization of lesions in patients with UC.

METHODS

A literature search of online databases (MEDLINE via PubMed and CENTRAL via the Cochrane Library) was performed from 1 January 2000 to 30 November 2021.

RESULTS

The database search initially identified 748 unique articles. Finally, 25 studies were included in the systematic review: 23 focused on differentiation of neoplasia from non-neoplasia, one focused on differentiation of UC-associated neoplasia from sporadic neoplasia, and one focused on differentiation of low-grade dysplasia from high-grade dysplasia and cancer.

CONCLUSIONS

Optical characterization of neoplasia in patients with UC, even using advanced endoscopic technology, is still challenging and several issues remain to be addressed. We believe that the information revealed in this review will encourage researchers to commit to the improvement of optical diagnostics for UC-associated lesions.

Evolving roles of magnifying endoscopy and endoscopic resection for neoplasia in inflammatory bowel diseases

Magnifying endoscopy is a useful technique to differentiate neoplasia from non-neoplastic lesions. Data regarding the clinical utility of magnifying endoscopy for neoplasia in patients with inflammatory bowel disease (IBD) has been emerging. While Kudo’s pit pattern types III-V are findings suggestive of neoplasia in non-IBD patients, these pit patterns are predictive of IBD-associated neoplasia as well. However, active chronic inflammatory processes, particularly regenerative changes, can mimic neoplastic pit patterns and may affect a meticulous evaluation of pit pattern diagnosis in patients with IBD. The clinical evidence regarding the utility of magnifying endoscopy with narrow band imaging or endocytoscopy has also been evolving in regard to the diagnosis of IBD-associated neoplasia. These advanced endoscopic techniques are promising for multiple reasons; not only for making an accurate diagnosis of neoplasia, but also in determining if endoscopic resection is appropriate for such lesions in patients with IBD. In this review, we discuss the diagnostic accuracy and limitations of magnifying endoscopy in assessing IBD-associated neoplasia and examine the feasibility and outcomes of endoscopic resection for these lesions.

Network pharmacology for systematic understanding of Schisandrin B reduces the epithelial cells injury of colitis through regulating pyroptosis by AMPK/Nrf2/NLRP3 inflammasome

Ulcerative colitis (UC) is a chronic inflammatory disease with increasing incidence and prevalence in many countries. The purpose of this study is to explore the function of Schisandrin B and its underlying molecular mechanisms in colitis.

In this study, mice with colitis were induced by giving 2.0% dextran sulfate sodium (DSS, MP) in the drinking water for seven days. Furthermore, TCMSP server and GEO DataSets were used to analyze the mechanism of Schisandrin B in colitis.

It was found that Schisandrin B presented colitis in mice model. At the same time, Schisandrin B not only reduced inflammation in vivo and vitro model of colitis, but also suppressed the nucleotide-binding oligomerization domain, leucine-rich repeat and pyrin domain-containing 3 (NLRP3) inflammasome in vivo and vitro model of colitis. In addition, Schisandrin B induced AMP-activated protein kinase (AMPK) / Nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway in model of colitis, and regulated AMPK protein at 316 sites. The inhibition of AMPK reduced the anti-inflammation effects of Schisandrin B on NLRP3 inflammasome. Apart from that, Schisandrin B decreased reactive oxygen species (ROS)-induced mitochondrial damage and reduced epithelial cells damage of colitis through regulating pyroptosis.

Collectively, our novel findings for first time showed that, Schisandrin B suppressed NLRP3 inflammasome activation-mediated interleukin-1beta (IL-1β) level and pyroptosis in intestinal epithelial cells of colitis model through the activation of AMPK/Nrf2 dependent signaling-ROS-induced mitochondrial damage, which may be a significant therapeutic approach in the treatment of acute colitis.