Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort

Outcome and predictive factors for perforation in orthodontic rubber band-assisted endoscopic submucosal dissection of fibrotic colorectal lesions

Endoscopic submucosal dissection (ESD) of fibrotic colorectal lesions is difficult and has a high complication rate. There are only a few reports on the utility of orthodontic rubber band (ORB) traction in reducing the difficulty of this procedure. This study aimed to investigate the risk factors for perforation when applying ORB traction during ESD of fibrotic colorectal lesions. We continuously collected the clinical data of 119 patients with fibrotic colorectal lesions who underwent ESD with ORB and clip traction between January 2019 and January 2024. Possible risk factors for perforation were analyzed. The median ORB-ESD operative time was 40 (IQR 28-62) min, and the en bloc and R0 resection rates were 94.1% and 84.0%, respectively. Perforation occurred in 16 of 119 patients (13.4%). The lesion size, lesion at the right half of the colon or across an intestinal plica, the degree of fibrosis, operation time, and the surgeon's experience were associated with perforation during ORB-ESD (P < 0.05). Multivariate logistic regression analysis showed that lesions in the right colon (OR 9.027; 95% CI 1.807-45.098; P = 0.007) and those across an intestinal plica (OR 7.771; 95% CI 1.298-46.536; P = 0.025) were independent risk factors for perforation during ORB-ESD. ORB-ESD is an effective and feasible approach to treat fibrotic colorectal lesions. Adequate preoperative evaluation is required for lesions in the right colon and across intestinal plicas to mitigate the risk of perforation.

Risk factors for unsuccessful colorectal endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND AND AIMS

Despite its growing popularity, endoscopic submucosal dissection (ESD) for colorectal neoplasms is still technically challenging. The factors contributing to the failure of ESD are not yet comprehensively elucidated. Therefore, this systematic review was conducted to explore the potential risk factors associated with unsuccessful colorectal ESD.

METHODS

A comprehensive search of Medline and Embase databases was conducted to identify relevant publications from inception until March 14, 2023. Unsuccessful ESD was defined as cases involving incomplete resection or the occurrence of adverse events, such as perforation and delayed bleeding.

RESULTS

Among the 2067 citations initially identified, a total of 23 cohort studies and 16 case-control studies met the inclusion criteria. Following meta-analyses, several significant risk factors for incomplete resection were identified, including lesion diameter ≥40 or 50 mm, right-side colonic location, deeper submucosal invasion, and severe fibrosis. Similarly, lesion diameter ≥40 or 50 mm and severe fibrosis emerged as risk factors for perforation. However, no individual factor was found to be statistically associated with delayed bleeding.

CONCLUSIONS

This meta-analysis identified risk factors correlated with incomplete resection and adverse events following ESD. The findings provide valuable insights that can guide clinical decision-making, aiding gastroenterologists in accurately identifying high-risk individuals.

Risk factors and a nomogram for prediction of post-endoscopic submucosal dissection electrocoagulation syndrome for superficial colorectal lesions

BACKGROUND

Post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) is an uncommon complication after colorectal endoscopic submucosal dissection (ESD). This study aimed to explore the risk factors of PEECS for superficial colorectal lesions based on the latest and consistent diagnostic criteria and to establish a predictive nomogram model.

METHODS

This retrospective analysis included patients with superficial colorectal lesions who underwent endoscopic submucosal dissection (ESD) between June 2008 and December 2021 in our center. The independent risk factors of PEECS for superficial colorectal lesions were identified using least absolute shrinkage and selection operator (LASSO) logistic regression analysis, as well as univariate analysis and multivariate logistic regression, and derived predictive nomogram model was constructed.

RESULTS

Among the 555 patients with superficial colorectal lesions enrolled, PEECS occurred in 45 (8.1%) patients. Multivariate logistic regression revealed that female sex (OR 3.94, P < 0.001), age > 50 years (OR 4.28, P = 0.02), injury to muscle layer (OR 10.38, P < 0.001), non-lifting sign (OR 2.20, P = 0.04) and inadequate bowel preparation (OR 5.61, P < 0.001) were independent risk factors of PEECS for superficial colorectal lesions. A predictive nomogram model was constructed based on the above five predictors. For this model, the area under the receiver operating characteristic (ROC) curve was 0.855, the calibration curve exhibited good consistency between the prediction and the actual observation, and the C-index was confirmed as 0.843 by bootstrap method.

CONCLUSION

Female sex, age > 50 years, injury to muscle layer, non-lifting sign and inadequate bowel preparation were independent risk factors of PEECS for superficial colorectal lesions. The proposed nomogram could accurately predict the risk of PEECS for superficial colorectal lesions.

Endoscopic submucosal dissection for colorectal neoplasms: Risk factors for local recurrence and long-term surveillance

Objectives

Endoscopic submucosal dissection (ESD) is an effective procedure for the en bloc resection of colorectal neoplasms. However, risk factors for local recurrence after ESD have not been identified. This study aimed to evaluate such risk factors after ESD for colorectal neoplasms.

Methods

This retrospective study included 1344 patients with 1539 consecutive colorectal lesions who underwent ESD between September 2003 and December 2019. We investigated various factors associated with local recurrence in these patients. The main outcomes were the incidence of local recurrence and its relationship with clinicopathological factors during long-term surveillance.

Results

The en bloc resection rate was 98.6%, the R0 resection rate was 97.2%, and the histologically complete resection rate was 92.7%. Local recurrence was observed in 7/1344 (0.5%) patients and the median follow-up period was 72 months (range 4-195 months). The incidence of local recurrence was significantly higher in lesions ≥40 mm in diameter (hazard ratio [HR] 15.68 [1.88-130.5]; p = 0.011), piecemeal resection (HR 48.42 [10.7-218.7]; p < 0.001), non-R0 resection (HR 41.05 [9.025-186.7]; p < 0.001), histologically incomplete resection (HR 16.23 [3.627-72.63]; p<0.001), and severe fibrosis (F2; HR 9.523 [1.14-79.3]; p = 0.037).

Conclusions

Five risk factors for local recurrence after ESD were identified. Patients with such factors should undergo careful surveillance colonoscopy.

A strategy combining endoscopic hand-suturing with clips for closure of rectal defects after endoscopic submucosal dissection with or without myectomy (with video)

BACKGROUND AND AIMS

Endoscopic hand-suturing (EHS) has been preliminarily demonstrated to be effective in closing defects after endoscopic submucosal dissection (ESD), but it is not easily performed. We proposed a strategy combining EHS with clips (EHS-Clips) and explored its effectiveness in closing rectal defects after ESD or ESD with myectomy (ESD-ME).

METHODS

In this observational study, data from patients with rectal defects closed using EHS-Clips were reviewed. EHS-Clips refers to a strategy where defects are sutured as much as possible by EHS first, with clips being used to close the remaining parts of defects that cannot be completely sutured. The primary endpoints included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for the sustained closure.

RESULTS

All 49 (100%) defects (42 ESD defects and 7 ESD-ME defects) were completely closed through the strategy of EHS-Clips, with 35 (71.4%) through EHS alone and 14 (28.6%) through EHS and additional clips. No patients experienced DB. Thirty-six (73.5%) defects remained sustained closure on postoperative days 3 to 5 (73.8% for ESD defects vs 71.4% for ESD-ME defects). The multivariate analyses identified a stitch margin of ≥5 mm (hazard ratio, 0.313; 95% confidence interval, 0.023-0.781; P = .009) as the only independent advantage factor for the sustained closure.

CONCLUSIONS

EHS-Clips can be used to effectively close the rectal defects after ESD or ESD-ME and prevent DB. Complete suture with a stitch margin of ≥5 mm may achieve more reliable sustained closure.

Efficacy of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulant therapy: Multicenter prospective study

OBJECTIVES

The high rate of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) in patients undergoing anticoagulant therapy remains a problem. Whether prophylactic clip closure reduces the rate of delayed bleeding in these patients is unclear. This study aimed to evaluate the efficacy of prophylactic clip closure in patients receiving anticoagulants.

METHODS

This multicenter prospective interventional trial was conducted at nine referral centers in Japan. Patients regularly taking anticoagulants, including warfarin potassium or direct oral anticoagulants, and undergoing ESD for colorectal neoplasms were enrolled. The discontinuation of anticoagulants was minimized according to recent guidelines. After the ESD, post-ESD ulcers were prophylactically closed using endoclips. The primary end-point was the incidence of delayed bleeding. The sample size was 45 lesions, and prophylactic clip closure was considered effective when the upper limit of the 90% confidence interval (CI) for delayed bleeding did not exceed 20%.

RESULTS

Forty-five lesions were used, and three were excluded. Complete closure was achieved in 41/42 lesions (97.6%). The overall delayed bleeding rate was low, at 4.9% (2/41; 90% [CI] 0.8-14.5), which was significantly lower than that at the prespecified threshold of 20% (P = 0.007). The median closure procedure time was 17 min, and the median number of clips was nine. No massive delayed bleeding requiring transfusion, interventional radiology, or surgery was observed, and no thromboembolic events were observed.

CONCLUSION

Prophylactic clip closure may reduce the risk of delayed bleeding following colorectal ESD in patients receiving anticoagulants.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (UMIN000036734).

Endoscopic full-thickness resection versus endoscopic submucosal dissection for challenging colorectal lesions: a randomized trial

BACKGROUND AND AIMS

The optimal endoscopic resection method of challenging colorectal lesions (ie, adenomatous recurrences, nongranular laterally spreading tumors [LST-NGs], lesions without lifting sign <30 mm) is still under debate. The aim of this study was to directly compare endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) for the resection of challenging colorectal lesions in a randomized trial.

METHODS

A multicenter, prospective, randomized study was performed in 4 Italian referral centers. Consecutive patients referred for endoscopic resection of challenging lesions were randomly assigned to undergo EFTR or ESD. Primary outcomes were complete (R0) resection and en bloc resection of lesions. Technical success, procedure time, procedure speed, area of the resected specimen, adverse event rate, and local recurrence rate at 6 months were also compared.

RESULTS

Overall, 90 patients were included in the study, equally representing the 3 challenging lesion types. Age and sex were comparable in the 2 groups. En bloc resection was obtained in 95.5% of the EFTR group and in 93.3% of the ESD group. R0 resection rate was comparable in the 2 groups (EFTR vs ESD, 42 [93.3%] vs 36 [80%]; P = .06). The EFTR group exhibited a significantly shorter total procedure time (25.6 ± 10.6 minutes vs 76.7 ± 26.4 minutes, P ≤ .01), as well as overall procedure speed (16.8 ± 11.8 mm2/min vs 11.9 ± 9.2 mm2/min, P = .03). The EFTR group had a significantly smaller mean lesion size (21.6 ± 8.3 mm vs 28.7 ± 7.7 mm, P ≤ .01). Adverse events were reported less frequently in patients in the EFTR group (4.44% vs 15.5%, P = .04).

CONCLUSIONS

EFTR is comparable to ESD in the treatment of challenging colorectal lesions in terms of safety and efficacy. EFTR is considerably faster than ESD in the treatment of nonlifting lesions and adenoma recurrences. (Clinical trial registration number: NCT05502276.).

Multicenter randomized control study of the efficacy of SO clip in colorectal endoscopic submucosal dissection (ESD). (SO clip study in colorectal ESD): Randomized controlled trial

INTRODUCTION

Endoscopic submucosal dissection (ESD) allows the en bloc resection of colorectal epithelial tumors regardless of size. Although ESD is minimally invasive and yields favorable outcomes, it is technically difficult and requires a long procedure time. In addition, colorectal ESD is associated with a particularly high risk of complications, due to the thin bowel wall, bowel flexion, and peristalsis.Direct visualization of the submucosal layer by traction of the lesion after mucosal dissection would make ESD performance easier. S-O clips traction lesions toward the lumen, facilitating direct visualization of the submucosal layer, resulting in efficient dissection due to the traction effect and adequate dissection depth. Use of this traction device can contribute to shortening the procedure time and reducing the risk of complications. This multicenter randomized controlled trial will evaluate the usefulness of the S-O clip in colorectal ESD and assess the procedure time and frequency of complications associated with the procedure.

METHODS/DESIGN

This multicenter, randomized control trial will enroll 200 patients at 4 hospitals in Japan undergoing ESD for colorectal epithelial tumors. Patients who meet the inclusion and exclusion criteria will be randomized to undergo ESD using S-O clips or conventional ESD. Patients will be randomized by a computer-generated random sequence with stratification by operator experience (trainee or expert), tumor location (colon/rectum), and institution. The primary endpoint will be ESD procedure time, defined as the time from the start of the local injection into the submucosal layer to the end of dissection. Other outcomes will include the rates of procedural complications, en bloc resection and cure.

DISCUSSION

ESD using the S-O clip is expected to shorten procedure time, reduce the incidence of adverse events, and standardize the procedure. This study may resolve clinical questions about whether ESD using the S-O clip traction device is more effective and safer than conventional ESD.

Efficacy of self-assembling peptide in mitigating delayed bleeding after advanced endoscopic resection of gastrointestinal lesions: A meta-analysis

Background and study aims  Advanced endoscopic resection techniques carry a risk of delayed bleeding (DB). A novel fully synthetic self-assembling peptide (SAP) has shown promising results in mitigating this risk. In this meta-analysis, we evaluated all available data and analyzed the effectiveness of SAP in reducing DB after advanced endoscopic resection of gastrointestinal luminal lesions. Patients and methods  Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the use of SAP solution in patients undergoing advanced endoscopic resection of gastrointestinal lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. Results  The initial search identified 277 studies, of which 63 relevant articles were reviewed. The final analysis included data from six studies comprising 307 patients that met inclusion criteria. The pooled rate of DB was 5.73 % (95 % confidence interval [CI] = 3.42-8.59). Mean patient age was 69.40 years ± 1.82. The weighted mean size of resected lesions was 36.20 mm (95 % CI = 33.37-39.02). Endoscopic submucosal dissection was used in 72.69 % (95 % CI = 67.62-77.48), while endoscopic mucosal resection was used in 26.42 % (95 % CI = 21.69-31.44) of the procedures. Among the 307 patients, 36 % were on antithrombotic medications. No adverse events (AEs) were attributable to using SAP, with a pooled rate of 0.00 % (95 % CI = 0.00-1.49). Conclusions  SAP solution appears promising in reducing post-procedural DB after advanced endoscopic resection of high-risk gastrointestinal lesions with no reported AEs.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic submucosal dissection for colorectal polyps: outcome determining factors

BACKGROUND

Endoscopic submucosal dissection (ESD) has gained increasing popularity in the management of complicated colorectal polyps. However, clinical outcomes for ESD have remained highly inconsistent worldwide. This study investigated and analysed factors that significantly affect ESD outcomes.

METHODS

We conducted a single-centred retrospective study on 220 colorectal polyps removed by ESD from 1st January 2016 to 31st December 2020. Data were collected and retrieved from clinical records. Variables studied included patient demographics, ESD technicalities and polyp characteristics. The primary outcome was completeness of resection based on en bloc and R0 resection rates. The secondary outcomes were recurrence, complications and hospital stay. Further analysis was performed for significant outcome determining factors.

RESULTS

The en bloc resection and R0 resection rates were 97.3% and 65% respectively. Intraprocedural and delayed perforation rates were 3.2% and 0.5% respectively. Intraprocedural and delayed bleeding rates were both 1.8%. Post-polypectomy syndrome rate was 2.7%. The median hospital stay was 4 days. Submucosal fibrosis was a significant determining factor for lower en bloc resection (p = 0.004), lower R0 resection (p = 0.002), intraprocedural perforation (p = 0.001), intraprocedural bleeding (p = 0.025) and post-polypectomy syndrome (p = 0.039). Hybrid snaring was associated with lower en bloc resection (p < 0.001), while longer ESD time was associated with lower R0 resection (p = 0.003) and post-polypectomy syndrome (p = 0.025). Other significant factors for post-polypectomy syndrome included young age (p = 0.021) and large polyp size (p = 0.018). Secondary analysis showed that submucosal fibrosis was significantly associated with non-granular lesions (p < 0.001) and prior biopsy (p = 0.003).

CONCLUSION

Submucosal fibrosis, hybrid snaring, ESD time, age and polyp size were significant outcome determining factors for ESD. By identifying these factors, strategies may be formulated to improve ESD outcomes.

Left colonic localization, non-granular morphology, and pit pattern independently predict submucosal fibrosis of naïve colorectal neoplasms before endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) represents the method of choice for removal of large colorectal neoplasms with suspected submucosal invasion. Presence and degree of submucosal fibrosis increases ESD duration and technical complexity, reduces the rate of curative resection and reduces safety profile. The aim of the study was to identify pre-procedural predictive factors of submucosal fibrosis in naïve colorectal neoplasms and to assess the impact of fibrosis on technical and clinical ESD outcomes.

METHODS

All consecutive ESD performed between 2014 and 2021 were retrieved from a prospectively collected database. For each patient, pre-procedural, procedural, and post-procedural data were recorded. Logistic regression was used to identify pre-procedural predictive factors for submucosal fibrosis. The study was approved by Institutional Reviewer Board and registered on ClinicalTrials.gov (NCT04780256).

RESULTS

One hundred-74 neoplasms (46.6% rectum, 21.8% left colon, 31.6% right colon; size 34.9 ± 17.5 mm) from 169 patients (55.0% male; 69.5 ± 10.4-year-old) were included. 106 (60.9%) neoplasms were granular type laterally spreading tumor (LST-G), 42 (24.1%) non-granular (LST-NG), and 26 (14.9%) sessile; invasive pit pattern was observed in 90 (51.7%) lesions. No fibrosis (F0) mild (F1) and severe (F2) were observed in 62 (35.6%), 92 (52.9%), and 20 (11.5%), respectively. Left colonic localization [OR 3.23 (1.1-9.31)], LST-NG morphology [OR 5.84 (2.03-16.77)] and invasive pit pattern [OR 7.11 (3.11-16.23)] were independently correlated to submucosal fibrosis. Lower curative resection rate (59.8% vs. 93.5%, P < 0.001) was observed in case of fibrosis; the incidence of adverse events was higher in case of severe fibrosis (35.5%) compared to no (3.2%) and mild fibrosis (3.3%; P < 0.001). Procedure time was significantly impacted by presence and degree of fibrosis (P < 0.001).

CONCLUSIONS

Left colonic localization, LST-NG morphology, and invasive pit pattern are independent predictors of fibrosis, affecting technical and clinical ESD outcomes. Pre-procedural stratification is pivotal to estimate procedure time, required operator's experience and advanced dissection techniques. Cecinato P et al. Left colonic localization, non-granular morphology, and pit pattern independently predict submucosal fibrosis of colorectal neoplasms before endoscopic submucosal dissection. Surg Endosc. 2023.

Post-endoscopic submucosal dissection electrocoagulation syndrome: a clinical overview

INTRODUCTION

Post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) is a rare complication following endoscopic submucosal dissection (ESD). However, many aspects of PEECS are still controversial and there is a lack of up-to-date review. The aim of this article is to provide a comprehensive review on PEECS.

AREAS COVERED

The English-language literature was searched for articles on PEECS, with a focus on its pathogenesis, definition, and diagnosis, incidence rate, risk factors, prevention, management, and prognosis.

EXPERT OPINION

Many aspects of PEECS are still controversial such as etiology, diagnostic criteria, prevention and management. The recent studies tend to agree on the diagnostic criteria for PEECS, defined as localized abdominal tenderness and fever or inflammatory response without delayed perforation. Most patients with PEECS have a favorable prognosis with conservative treatment and more high-quality studies are needed in the controversial aspects mentioned above.

Efficacy of the pocket-creation method with a traction device in endoscopic submucosal dissection for residual or recurrent colorectal lesions

Background/Aims

Endoscopic submucosal dissection (ESD) for residual or recurrent colorectal lesions after incomplete resection is challenging because of severe fibrosis. This study aimed to compare the efficacy of the pocket-creation method (PCM) with a traction device (TD) with that of conventional ESD for residual or recurrent colorectal lesions.

Methods

We retrospectively studied 72 patients with residual or recurrent colorectal lesions resected using ESD. Overall, 31 and 41 lesions were resected using PCM with TD and conventional ESD methods, respectively. We compared patient background and treatment outcomes between the PCM with TD and conventional ESD groups, respectively. The primary endpoints were en bloc resection and R0 resection rates. The secondary endpoints were the dissection speed and incidence of adverse events.

Results

En bloc resection was feasible in all cases with PCM with TD, but failed in 22% of cases of conventional ESD. The R0 resection rates for PCM with TD and conventional ESD were 97% and 66%, respectively. Dissection was significantly faster in the PCM with TD group (13.0 vs. 7.9 mm²/min). Perforation and postoperative bleeding were observed in one patient in each group.

Conclusions

PCM with TD is an effective method for treating residual or recurrent colorectal lesions after incomplete resection.

New traction method (traction ring) for colorectal endoscopic submucosal dissection

OBJECTIVES

Colorectal endoscopic submucosal dissection (ESD) is challenging because of the difficulty in adequately visualizing the submucosal layer. Many traction methods have been developed to facilitate submucosal dissection; however, they are not widely applied. Therefore, we designed a new traction device, a traction ring, and conducted this pilot study to evaluate its feasibility and safety for colorectal ESD.

METHODS

Twenty patients with colorectal lesions who underwent traction ring-assisted ESD were retrospectively included. The main outcomes included en bloc resection rate, R0 resection rate, procedure time, resection time, and intraoperative and postoperative complications.

RESULTS

The median procedure time was 74.5 min (range 35-269 min). The median resection time was 55 min (range 25-209 min). Application of the traction system accounted for only 2.7% of the entire procedure time. The en bloc resection rate was 95.0% (19/20), whereas the R0 resection rate was 90.0% (18/20). All traction rings were successfully set and retrieved. Significant intraoperative bleeding was not observed. One patient experienced perforation after treatment, but no further intervention was required. No delayed complications were observed within 1 month post-ESD.

CONCLUSION

Traction ring is an effective and safe method for colorectal ESD and can be used at any location in the colorectum.

Fever and electrocoagulation syndrome after colorectal endoscopic submucosal dissection for patients with immunosuppressants and steroids

Objectives

Transient fever and electrocoagulation syndrome after colorectal endoscopic submucosal dissection (ESD) remain a challenge. The aim of this study was to assess the risk factors of post‐ESD fever and post‐ESD coagulation syndrome (PECS), focusing on the involvement of immunosuppressive drugs and steroids (IM).

Methods

This retrospective analysis included 510 patients who underwent colorectal ESD at Okayama University Hospital from 2015 to 2020. The incidence rate, clinical outcome, and factors associated with post‐ESD fever and PECS were investigated.

Results

Post‐ESD fever and PECS occurred in 63 patients (12.4%) and 43 patients (8.4%), respectively. In multivariate analysis, the American Society of Anesthesiologists Physical Status ≥3, the use of immunosuppressants or prednisolone ≥5mg (IM group), and injury to muscle layer/perforation were significantly associated with post‐ESD fever. In PECS, IM group, tumors located on the right side, treatment time ≥60 min, injury to the muscle layer, and multiple lesions were independent risk factors. Both post‐ESD fever and PECS improved conservatively in the IM group, and no serious complication was observed.

Conclusions

The use of IM was a risk factor for both post‐ESD fever and PECS. However, there were no serious complications in colorectal ESD for patients taking IM.

Endoscopic submucosal dissection for colorectal laterally spreading tumors: Clinical outcomes and predictors of technical difficulty

OBJECTIVE

We aimed to investigate the clinical outcomes of endoscopic submucosal dissection (ESD) for the treatment of colorectal laterally spreading tumors (LSTs) and the factors related to technical difficulty.

METHODS

Consecutive patients who underwent ESD for colorectal LSTs between June 2013 and January 2019 were retrospectively included. Factors associated with difficult ESD procedures (defined as conversion to piecemeal resection or discontinuation of endoscopic procedure), and dissection with a slow speed (<8 mm² /min), were determined using the logistic regression analysis.

RESULTS

A total of 325 patients with 342 colorectal LSTs (median size 20.0 mm) were enrolled. The proportions of granular (LST-G) and non-granular LST (LST-NG) were 62.9% and 37.1%, respectively. The overall en bloc and complete resection rates were 89.8% and 81.9%, respectively. The endoscopic procedure was discontinued in four lesions (1.2%), and 31 (9.1%) converted to piecemeal resection because of technical difficulty. Using multivariate analysis, positive non-lifting sign (odds ratio [OR] 19.9, P < 0.001), tumor size ≥20 mm (OR 10.0, P < 0.001), and less experienced endoscopists (OR 3.7, P = 0.005) were independent factors for technically difficult procedure. Positive non-lifting sign (OR 3.7, P = 0.004), lesion size <20 mm (OR 3.7, P < 0.001), LST-NG type (OR 1.8, P = 0.034), and less colorectal ESD experience (OR 1.9, P = 0.016) were independent factors of slow-speed dissection.

CONCLUSIONS

ESD was feasible and safe for treating colorectal LSTs. Positive non-lifting sign and tumor ≥20 mm indicated difficult ESD procedures. Technical failure was more likely to occur in lesions resected by less-experienced endoscopists. Dissection speed might be improved with more experienced operators.

Risk Factors for Fever After Esophageal Endoscopic Submucosal Dissection and Its Derived Technique

Background

Fever is one of the postoperative adverse events of endoscopic submucosal dissection and its derived technique, but the probability and risk factors of postoperative fever are still unclear. The aim of the current study was to investigate the incidence and risk factors of postoperative fever after esophageal lesion removal.

Methods

We conducted a retrospective study of 446 patients who underwent esophageal endoscopic submucosal dissection and its derived technique between January 2014 and January 2020. Cases included in this study were divided into fever and non-fever groups.

Results

Postoperative fever developed in 135 patients (30.3%). The median (range) highest fever temperature was 38 (37.8–38.4)°C, the median (range) duration of fever was 1 (1–2) day, and 127 (94.1%) patients developed fever within 24 h after operation. Through logistic regression analysis, factors associated with postoperative fever were age (OR: 1.740, 95% CI: 1.005–3.013, p = 0.048), lesion size (OR: 2.007, 95% CI: 1.198–3.362, p = 0.008), operation time (OR: 3.007, 95% CI: 1.756–5.147, p < 0.001) and nasogastric tube placement (OR: 1.881, 95% CI: 1.165–3.037, p = 0.010), while prophylactic antibiotics (OR: 0.181, 95% CI: 0.082–0.401, p < 0.001) were negatively associated with fever.

Conclusions

Age ≥52 years old, lesion size ≥19 mm, operation time ≥37 min, and nasogastric tube placement are risk factors for postoperative fever after esophageal endoscopic submucosal dissection and its derived technique, prophylactic antibiotic use after operation may help reduce fever rate. Attention should be paid to such patients to minimize the risk of postoperative fever.

Prognosis and risk factors of electrocoagulation syndrome after endoscopic submucosal dissection in the colon and rectum. Large cohort study

BACKGROUND

There are few studies on electrocoagulation syndrome after colorectal endoscopic submucosal dissection (ESD). This study aimed to investigate the various risk factors associated with thermal injury and to determine the prognosis of post-colorectal ESD electrocoagulation syndrome (PECS).

METHODS

We conducted a retrospective analysis of the medical records of 395 colorectal neoplasms of 508 patients who were treated with colorectal ESD between January 2013 and December 2019. The incidence, risk factors, and clinical outcomes of colorectal PECS were evaluated and analyzed.

RESULTS

Colorectal PECS occurred in 25 patients (6.3%). The PECS group had a larger lesion size (≥ 40 mm), lesions with fibrosis, longer procedure time, older age, and a larger amount of submucosal injection per square meter than the non-PECS group. In multivariate analysis, lesion with size ≥ 40 mm (odds ratio [OR] 16.941, 95% confidence interval [CI] 3.869-74.178), lesions with fibrosis (OR 7.127, 95% CI 2.541-19.984), old age (OR 1.068, 95% CI 1.010-1.130), and amount of submucosal injection per square meter (OR 1.067, 95% CI 1.015-1.121) were independent risk factors. The PECS group had more fasting days (3.08 vs 1.56 days, P < 0.001), longer hospital stays (7.04 vs 4.09 days, P < 0.001), and higher medical costs (2367 vs 2046, US$, P = 0.004) than the non-PECS group.

CONCLUSION

Lesions with size ≥ 40 mm, lesions with fibrosis, old age, and amount of submucosal injection per square meter were independent risk factors. Therefore, caution should be exercised when performing colorectal ESD in patients with these risk factors.

Performance of perioperative antibiotics against post-endoscopic submucosal dissection coagulation syndrome: a multicenter randomized controlled trial

BACKGROUND AND AIMS

This study aimed to evaluate the efficacy of perioperative antibiotics against post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) in patients undergoing colorectal ESD.

METHODS

A prospective, multicenter, randomized controlled, parallel, superiority trial was conducted at 21 Japanese tertiary institutions. Patients with superficial colorectal lesions ≥20 mm and those undergoing ESD management for a single lesion were eligible. Patients with perforation during and after ESD were withdrawn. Before the ESD procedure, participants were randomly assigned (1:1) to either undergo conventional treatment (nonantibiotic group) or investigational treatment (antibiotic group). In the antibiotic group, 3 g of ampicillin-sulbactam was administered just before, 8 hours after, and the morning after ESD. The primary endpoint was the incidence of PECS. The onset of PECS was defined as localized abdominal pain (both spontaneous pain and tenderness) and fever (≥37.6°C) or inflammatory response (leukocytosis [≥10,000 cells/μL] or elevated C-reactive protein level [≥.5 mg/dL]).

RESULTS

From February 5, 2019 to September 7, 2020, 432 patients were enrolled and assigned to the antibiotic group (n = 216) or nonantibiotic group (n = 216). After withdrawal of 52 patients, 192 in the antibiotic group and 188 in the nonantibiotic group were analyzed. PECS occurred in 9 of 192 patients (4.7%) in the antibiotic group and 14 of 188 patients (7.5%) in the nonantibiotic group, with an odds ratio of .61 (95% confidence interval, .23-1.56; P = .29).

CONCLUSIONS

Perioperative use of antibiotics was not effective in reducing the incidence of PECS in patients undergoing colorectal ESD. (Clinical trial registration number: UMIN000035178.).

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

Risk factors for adverse events of colorectal endoscopic submucosal dissection: a systematic review and meta-analysis

Colorectal endoscopic submucosal dissection (ESD) is already an established treatment for superficial colorectal tumors. However, its technical difficulty and high adverse events rates, compared to endoscopic piecemeal mucosal resection, are a concern to some specialists and have probably contributed to discouragement in its widespread adoption. The debate mentioned above stimulated us to perform a systematic review aiming to identify risk factors for colorectal ESD-related adverse events. We conducted this study following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement and registered in the PROSPERO (University of York) international database (CRD42016042625). We searched MEDLINE, EMBASE, Cochrane Library and LILACS for the publications focused on risk factors for colorectal ESD-related adverse events from inception until April 2020. We included a total of 22 qualified studies in this analysis. We found that fibrosis had an odds ratio (OR) for perforation of 2.90 [95% confidence interval, (1.83-4.59)], right colon location of 2.35 (1.58-3.50), colonic location of 2.20 (1.44-3.35) and larger size of 2.17 (1.47-3.21), as well as one protective factor, the endoscopist experience OR = 0.62 (0.45-0.86). For bleeding, we considered rectal location a risk factor [OR = 3.55 (2.06-6.12)]. Through the several meta-analyses that we performed in this article, we could summarize the main risk factors for perforation and bleeding on colorectal ESD. Therefore, we provide insightful information for clinical judgment on regions where colorectal ESD is already widespread and help in the learning process of this challenging technique.

Construction of a novel predictive nomogram for difficult procedure of endoscopic submucosal dissection for colorectal neoplasms

OBJECTIVES

To determine the predictors of difficult colorectal endoscopic submucosal dissection (ESD) and to develop a preoperative predictive model for difficult colorectal ESD procedures.

METHODS

Colorectal neoplasms intended to be resected by ESD in our center between August 2013 and February 2019 were retrospectively enrolled. An ESD procedure which took more than 30 min, failed to remove the lesions en bloc or converted to surgery was defined as difficulty. Logistic regression analysis was conducted to find out the predictors of difficult ESD. A nomogram integrating independent predictors was developed and validated with respect to its discrimination, calibration and clinical application, using the receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA), respectively.

RESULTS

A total of 368 colorectal neoplasms in 355 patients were included. The independent predictors for difficult colorectal ESD were size ≥2 cm (odds ratio [OR] = 6.102, p < .001), positive non-lifting sign (OR = 6.569, p = .005), lesions located in left colon (OR = 2.475, p = .036) or rectum (OR = 2.183, p = .048), laterally spreading tumors (LSTs) (OR = 2.501, p = .008) and less colorectal ESD experience (≤20 cases) (OR = 2.3091, p = .028). The nomogram model incorporating the above predictors performed well in both of the training and validation sets (area under the cure [AUC] = 0.786 and 0.784, respectively). DCA demonstrated the clinical benefit of the nomogram was superior to that of each independent predictor alone.

CONCLUSIONS

The nomogram incorporating tumor size, location, morphology, non-lifting sign and ESD experience of operator can be conveniently used to facilitate the preoperative prediction of difficult colorectal ESD.

Hybrid endoscopic mucosal resection and full-thickness resection for large colonic polyps harboring a small focus of invasive cancer: a case series

Endoscopic treatment of large laterally spreading tumors (LSTs) with a focus of submucosally invasive colorectal cancer (T1 CRC) can be challenging. We evaluated outcomes of a hybrid resection technique using piecemeal endoscopic mucosal resection (pEMR) and endoscopic full-thickness resection (eFTR) in patients with large colonic LSTs containing suspected T1 CRC. Six hybrid pEMR-eFTR procedures for T1 CRCs were registered in a nationwide eFTR registry between July 2015 and December 2019. In all cases, the invasive part of the lesion was successfully isolated with eFTR; with eFTR, histologically complete resection of the invasive part was achieved in 5 /6 patients (83.3 %). No adverse events occurred during or after the procedure. The median follow-up time was 10 months (range 6-27), with all patients having undergone ≥ 1 surveillance colonoscopy. One patient had a small adenomatous recurrence, which was removed endoscopically. In conclusion, hybrid pEMR-eFTR is a promising noninvasive treatment modality that seems feasible for a selected group of patients with large LSTs containing a small focus of T1 CRC.

Current Endoscopic Resection Techniques for Gastrointestinal Lesions: Endoscopic Mucosal Resection, Submucosal Dissection, and Full-Thickness Resection

Background

Endoscopic resection of dysplastic lesions in early stages of cancer reduces mortality rates and is recommended by many national guidelines throughout the world. Snare polypectomy and endoscopic mucosal resection (EMR) are established techniques of polyp removal. The advantages of these methods are their relatively short procedure times and acceptable complication rates. The latter include delayed bleeding in 0.9% and a perforation risk of 0.4-1.3%, depending on the size and location of the resected lesion. EMR is a recent modification of endoscopic resection. A limited number of studies suggest that larger lesions can be removed en bloc with low complication rates and short procedure times. Novel techniques such as endoscopic submucosal dissection (ESD) are used to enhance en bloc resection rates for larger, flat, or sessile lesions. Endoscopic full-thickness resection (EFTR) is employed for non-lifting lesions or those not easily amenable to resection. Procedures such as ESD or EFTR are emerging standards for lesions inaccessible to EMR techniques.

Summary

Endoscopic treatment is now regarded as first-line therapy for benign lesions.

Key Message

Endoscopic resection of dysplastic lesions or early stages of cancer is recommended. A plethora of different techniques can be used dependent on the lesions.

Concepts and prospects of minimally invasive colorectal cancer surgery

It is important that clinical radiologists understand and appreciate the minimally invasive surgery (MIS) options available to surgeons. Operative technologies are constantly evolving, and accurate, informed interpretation of clinical imaging is essential for optimum surgical management. Concurrent advancements in both MIS and radiological staging have certainly improved treatment decisions and outcomes. This article outlines the history, current concepts, evolving techniques, and future prospects of MIS as it pertains to colorectal cancer surgery.

A retrospective cohort study of factors influencing long procedure times in colorectal endoscopic submucosal dissection

OBJECTIVE

To evaluate the outcomes and factors influencing colorectal endoscopic submucosal dissection (ESD) with a long procedure time.

MATERIALS AND METHODS

In this single-center, retrospective study, we included 1,100 patients with 1,199 lesions who underwent colorectal ESD between April 2016 and December 2020. ESD was performed using an advanced system knife for lesions >20 mm. An S-O clip was used as the traction device. The long-time group (LP; procedure time >120 min) and normal-time group (NP; procedure time <120 min) were compared.

RESULTS

The procedure times were 166.86 and 44.72 min in the LP and NP groups, respectively. The completion rate was higher in the NP group (96.5% vs. 83.5%, p = .001); the completed lesions were resected en bloc. Multivariate analysis revealed 18.8% and 7.8% of submucosal fibrosis in the LP and NP groups, respectively (odds ratio [OR] = 2.410, p = .026). Compared to the NP group, the LP group presented larger maximum lesion sizes and higher rates of R1 resection, and traction device use. Time to introduction of traction device use was longer in the LP than in the NP group (126.05 vs. 21.72 min; p < .001). Fibrosis tends to occur cecal lesions (OR 2.436, p = .011) and laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) (OR 2.6181, p = .001).

CONCLUSIONS

Lesion size and fibrosis were factors associated with a long procedure time in colonic ESD. For fibrotic lesions (LST-NG-PD and cecal lesions), it is necessary to consider early use of traction devices and advisable to plan a strategy for the use of traction devices.

Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20-30 mm colorectal polyps

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) for large polyps provides a high en bloc resection rate, accurate pathological diagnosis, and low recurrence rate. However, ESD requires advanced techniques, and underwater endoscopic mucosal resection (UEMR) is an alternative. We investigated the efficacy and safety of UEMR for 20-30 mm colorectal lesions compared with ESD.

METHODS

We retrospectively evaluated systematically collected data of patients who underwent UEMR or ESD for 20-30 mm sessile colorectal lesions. Outcome measures were the incidence of local recurrence, procedure time, en bloc resection rate, and incidence of adverse events. We performed propensity score matching and inverse probability weighting adjustment to control for possible confounders.

RESULTS

We evaluated 125 patients undergoing UEMR and 306 patients undergoing ESD. Using propensity score matching, we analyzed 74 lesions in each group. UEMR had a shorter procedure time than ESD [6.7 min (95% confidence interval (CI), 5.3-8.1 min) vs 64.8 min (95% CI, 57.4-72.2 min), respectively]. Although the en bloc resection rate with UEMR was inferior to ESD [61% (95% CI, 49-72%) vs 99% (95% CI, 93-100%), respectively], there was no significant difference in the local recurrence rate between the procedures [0% (95% CI, 0-4.0%) in each group]. Inverse probability weighting adjustment revealed that neither ESD nor UEMR had a significant association with local recurrence.

CONCLUSIONS

Underwater endoscopic mucosal resection for 20-30  mm colorectal lesions was comparable with ESD regarding long-term outcomes, with a shorter procedure time, despite the lower en bloc resection rate.

Factors Associated with Fibrosis during Colorectal Endoscopic Submucosal Dissection: Does Pretreatment Biopsy Potentially Elicit Submucosal Fibrosis and Affect Endoscopic Submucosal Dissection Outcomes?

BACKGROUND

Submucosal fibrosis observed during colorectal endoscopic submucosal dissection (ESD) is an important factor related to incomplete resection. Biopsy is generally accepted as having the potential to elicit submucosal fibrosis, but few reports have presented definitive proof. This study investigated the relation between submucosal fibrosis and colorectal ESD outcomes and assessed factors related to fibrosis, including pretreatment biopsy.

METHODS

After reviewing 369 records of colorectal ESD performed between January 2011 and December 2016, we assessed the relation between fibrosis and ESD outcomes. Multiple logistic regression analysis revealed fibrosis risk factors.

RESULTS

Severe fibrosis was related significantly to ESD outcomes such as the mean procedure time (p < 0.001), en bloc resection rate (p < 0.001), and R0 resection rate (p = 0.011). Multivariate analyses indicated residual lesions (ORs 175.4, p < 0.001), pretreatment biopsy (ORs 8.30, p = 0.002), nongranular-type laterally spreading tumors (LST-NG; ORs 5.86, p = 0.025), and invasive carcinoma (ORs 5.83, p = 0.03) as independent risk factors of severe fibrosis. In each macroscopic type, LST-NG was more strongly related to fibrosis induced by pretreatment than granular-type laterally spreading tumors with adjust ORs of 50.8 and 4.69.

CONCLUSIONS

Pretreatment biopsy causes submucosal fibrosis resulting in prolonged procedure times and incomplete resection. These findings suggest important benefits of avoiding biopsy before ESD.

Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta-analysis

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large colorectal lesions. However, colorectal ESD is associated with a high frequency of adverse events (AEs), and the efficacy of prophylactic endoscopic closure after ESD for preventing AEs is still controversial. This meta-analysis was conducted to assess the efficacy of closure on AEs following colorectal ESD.

METHODS

We searched PubMed, Embase, and the Cochrane Library for eligible studies. The chi-square-based Q statistics and the I² test were used to test for heterogeneity. Pooling was conducted using a fixed or random effects model.

RESULTS

We identified eight eligible studies that compared the effects of closure vs non-closure with respect to delayed bleeding, delayed perforation, and post-ESD coagulation syndrome. Compared with non-closure (5.2%), closure was associated with a lower incidence (0.9%) of delayed bleeding (pooled odd ratios [ORs]:0.19, 95% CI: 0.08-0.49) following ESD. The pooled ORs showed no significant differences in incidence of delayed perforation (pooled OR: 0.22; 95% CI: 0.05-1.03) or post-ESD coagulation syndrome (pooled OR:0.75; 95% CI: 0.26-2.18) between the closure and non-closure groups.

CONCLUSION

Prophylactic endoscopic closure may reduce the incidence of delayed bleeding following ESD of colorectal lesions. Future studies are needed to further illuminate risk factors and stratify high risk subjects for a cost-effective preventive strategy.

Effect of anticoagulants on the risk of delayed bleeding after colorectal endoscopic submucosal dissection

Background and study aims  In patients receiving antithrombotic therapy, the risks of delayed bleeding after endoscopic procedures for gastrointestinal neoplasms become a major problem. Few reports have shown the effects of delayed bleeding in patients taking anticoagulants after colorectal endoscopic submucosal dissection (ESD). This study aimed to evaluate the delayed bleeding events after colorectal ESD in patients receiving anticoagulant therapy. Patients and methods  We retrospectively analyzed 87 patients taking anticoagulants who underwent colorectal ESD from April 2012 to December 2017 at 13 Japanese institutions participating in the Osaka Gut Forum. Among these patients, warfarin users were managed with heparin bridge therapy (HBT), continued use of warfarin, a temporary switch to direct oral anticoagulation (DOAC), or withdrawal of warfarin, and DOAC users were managed with DOAC discontinuation with or without HBT. We investigated the occurrence rate of delayed bleeding and compared the rates between warfarin and DOAC users. Results  The delayed bleeding rate was 17.2 % among all patients. The delayed bleeding rate was higher in DOAC users than in warfarin users (23.3 % vs. 11.4 %, P  = 0.14), although no statistically significant difference was observed. In DOAC users, the delayed bleeding rates for dabigatran, rivaroxaban, apixaban, and edoxaban users appeared similar (30 %, 18.2 %, 22.2 %, and 25 %, respectively). The onset of delayed bleeding in both warfarin and DOAC users was late, averaging 6.9 and 9.4 days, respectively. Conclusions  Among patients taking anticoagulants, the risk of delayed bleeding after colorectal ESD was relatively high and the onset of delayed bleeding was late.

A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study

BACKGROUND

This study aimed to demonstrate the feasibility of endoscopic hand-suturing (EHS) and attainability of sustained closure after colorectal endoscopic submucosal dissection (ESD).

METHODS

EHS was defined as uninterrupted endoscopic suturing of the mucosal defect after colorectal ESD using an absorbable barbed suture and a through-the-scope needle holder. Following individual EHS training using an ex vivo porcine colonic model, two experienced endoscopists performed EHS. Repeat colonoscopy was performed on the third or fourth day after ESD to examine the EHS site. The primary end point was the complete EHS closure rate, and secondary end points were sustained closure and post-ESD bleeding rates.

RESULTS

11 lesions were included. Median size of the mucosal defect was 38 mm (range 25 - 55 mm) and the lesion characteristics were as follows: lower rectum/upper rectum/ascending colon/cecum = 3/3/2/3, and 0-IIa/0-Is + IIa/others = 5/4/2. EHS was not attempted in two patients owing to difficulty in colonoscope reinsertion after ESD and intraoperative perforation, respectively. EHS was performed for nine lesions, and the complete EHS closure rate was 73 %. Median procedure time for suturing was 56 minutes (range 30 - 120 minutes) and median number of stitches was 8 (range 6 - 12). Sustained closure and post-ESD bleeding rates were 64 % and 9 %, respectively.

CONCLUSIONS

EHS achieved complete and sustained closure in the colorectum. However, EHS is not currently clinically applicable given the long procedure time. Further modifications of the technique and devices are desirable.

Prospective randomized trial comparing the pocket-creation method and conventional method of colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Colorectal endoscopic submucosal dissection (ESD) is recognized as a challenging procedure. Previously, we reported that a new ESD strategy using the pocket-creation method (PCM) is useful for colorectal ESD, but no prospective randomized study has evaluated the efficacy of the PCM. The aim of this study was to evaluate the efficacy and safety of PCM for colorectal ESD compared with the conventional method (CM).

METHODS

This was a prospective randomized controlled trial at 3 institutions in Japan. Patients with superficial colorectal neoplastic lesions >20 mm predicted to be intramucosal were randomly assigned to undergo ESD using the PCM or CM. Primary outcome was the ESD completion rate defined as completion of colorectal ESD with an en bloc resection using the assigned ESD method without changing to other methods or assisted by other devices.

RESULTS

We analyzed 59 patients with 59 colorectal tumors in the PCM group and 55 in the CM group. The ESD completion rate was significantly higher in the PCM group compared with the CM group (93% [55/59] vs 73% [40/55]; P  = .01). En bloc resection rates, R0 resection rates, procedure time, and dissection speed were not significantly different between the 2 groups. The incidence of adverse events was similar in the 2 groups.

CONCLUSIONS

Use of the PCM allows the endoscopist to complete the procedure with the intended method more often than the CM with similar clinical outcomes. (Clinical trial registration number: UMIN 000024394.).

The pocket-creation method may facilitate endoscopic submucosal dissection of large colorectal sessile tumors

Background and study aims  Resecting large colorectal sessile tumors using endoscopic submucosal dissection (ESD) is challenging because of severe submucosal fibrosis. Previously, we reported that ESD strategy using the pocket-creation method (PCM) is useful for large colorectal sessile tumors, but there are no large studies reporting the effectiveness and safety of the PCM for resection of large colorectal sessile tumors. Patients and methods  This was a retrospective review of 90 large colorectal sessile tumors in 89 patients who underwent ESD in our institution. Large colorectal sessile tumors were defined as polypoid lesions 20 mm or more in diameter. We divided them into PCM (n = 40) and conventional method (CM) groups (n = 50). The primary outcome measure was en bloc resection. The inverse-probability-treatment weighting (IPTW) approach was used to adjust for selection bias. Results  Both PCM and CM achieved high en bloc resection (100 % vs. 94 %, non-adjusted P  = 0.25, IPTW-adjusted P  = 0.19) and R0 resection rates (88 % vs. 78 %, non-adjusted P  = 0.28, IPTW-adjusted P  = 0.27). When PCM was used, the rate of pathologically negative vertical margins was significantly greater than with the CM (IPTW-adjusted P  = 0.045). The dissection time was significantly shorter (IPTW-adjusted P  = 0.025) and dissection speed faster (IPTW-adjusted P  = 0.013) using the PCM than when the CM was used. There was no significant difference in the incidence of adverse events (intraprocedural perforation and delayed bleeding, IPTW-adjusted P  = 0.68). Conclusion  Although en bloc resection and R0 resection rates were similar, PCM significantly increased the rate of negative vertical margins with rapid dissection for treatment of large colorectal sessile tumors.

Tip-in endoscopic mucosal resection for large colorectal sessile polyps

BACKGROUND

Tip-in endoscopic mucosal resection (EMR) is a modified EMR technique using which en bloc resection of large colorectal sessile polyps can be performed; however, its usefulness for colorectal sessile polyps of > 20 mm has not been reported. This study examined treatment outcomes of tip-in and conventional EMR for large colorectal sessile polyps of ≥ 20 mm.

METHODS

This was a retrospective case-control study conducted at a single tertiary center in Japan. Subjects included those with large colorectal sessile polyps of ≥ 20 mm, excluding pedunculated-type polyps, who underwent endoscopic resection between January 2010 and January 2019. The primary outcome was endoscopic treatment outcomes when using tip-in and conventional EMR, and the secondary outcome was the local recurrence rate after endoscopic treatment.

RESULTS

Forty-three colorectal lesions were treated using tip-in EMR and 83 using conventional EMR. Tip-in EMR had a significantly higher en bloc resection rate (90.7% vs. 69.8.%), and significantly shorter treatment duration (6.64 ± 0.64 min vs. 10.47 ± 0.81 min) than conventional EMR. However, for lesions > 30 mm, en bloc resection rate was 50.0% and 52.6% for tip-in and conventional EMR, respectively, indicating no significant difference. Perforation rates with tip-in and conventional EMR were 4.6% and 3.6%, respectively, indicating no significant difference. Local recurrence was examined in 80 cases who were followed up for > 6 months after endoscopic resection; recurrence rate was 0% and 7.0% in tip-in and conventional EMR cases, respectively, without significance difference.

CONCLUSIONS

Tip-in EMR showed high en-block resection rate, particularly in polyps of < 30 mm, and no residual tumor was found. This technique is a potential endoscopic treatment alternative for large colorectal sessile polyps of ≥ 20 mm.

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

Background and Aim

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

Methods

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

Results

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

Conclusions

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

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer

The number of deaths from colorectal cancer in Japan continues to increase. Colorectal cancer deaths exceeded 50,000 in 2016. In the 2019 edition, revision of all aspects of treatments was performed, with corrections and additions made based on knowledge acquired since the 2016 version (drug therapy) and the 2014 version (other treatments). The Japanese Society for Cancer of the Colon and Rectum guidelines 2019 for the treatment of colorectal cancer (JSCCR guidelines 2019) have been prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment and to deepen mutual understanding between healthcare professionals and patients by making these guidelines available to the general public. These guidelines have been prepared by consensuses reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. Controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here, we present the English version of the JSCCR guidelines 2019.

Switching from endoscopic submucosal dissection to salvage piecemeal knife-assisted snare resection to remove a lesion: A preoperative risk score from the beginning

BACKGROUND AND AIMS

endoscopic submucosal dissection (ESD) in the Western setting remains a challenge. Therefore, other simplified techniques such as knife-assisted snare resection (KAR) have been reported to overcome this issue.

METHODS

patients who underwent an ESD for the treatment of gastrointestinal neoplasms were included in a retrospective cross-sectional observational study. Factors associated with the end of ESD as a salvage p-KAR were identified and a logistic regression model was developed.

RESULTS

a total of 136 lesions in 133 patients were analyzed. Operator experience of under 50 cases and the combination of lesion size > 30 mm and colorectal location were independent predictive factors for switching to a salvage p-KAR according to the multivariate logistic regression analysis. We developed a risk scoring system based on these four variables (experience, size, location and the combination of size and location) with a receiver operating characteristic curve of 0.81 (95% CI: 0.74-0.89). The diagnostic accuracy of the score for a cut-off point ≥ 5 had a sensitivity of 0.79 (95% CI: 0.66-0.93) and a specificity of 0.71 (95% CI: 0.61-0.80).

CONCLUSION

a simple predictive score system that includes four preoperative factors accurately predicts ESD to finish as a p-KAR. A careful selection of cases considering these variables could be useful to achieve better outcomes in the Western setting.

Feasibility of endoscopic submucosal dissection of lesions at anastomosis site post-colorectal surgery: a case series

Background and study aims  Patients who have undergone colorectal surgery for resection of cancer and benign lesions are at risk for recurrent, residual, or metachronous lesions at the anastomosis site. Surgical resection of such lesions is difficult because of adhesions, and a stoma may be required as there are risks for leakage after resection. The feasibility and safety of endoscopic submucosal dissection (ESD) for these lesions remain unknown. Therefore, this case series aimed to examine the feasibility and safety of ESD by evaluating the clinical outcomes. Patients and methods  We retrospectively investigated five patients who underwent ESD by a single expert for superficial neoplastic lesions at the anastomosis site after previous colorectal surgery. Results  R0 resections were achieved for all lesions. Mean procedure time was 160.6 minutes. Mean dimensions of the resected specimen and tumor were 52.4 mm and 31.8mm, respectively. None of the patients had complications or recurrence after surveillance colonoscopy 1-year post-resection. Conclusions  In an expert's hands, ESD at the anastomosis site might be feasible minimally invasive treatment for superficial neoplastic lesions.

Predictors of invasive cancer of large laterally spreading colorectal tumors: A multicenter study in Japan

Background and Aim

Although colorectal laterally spreading tumors (LSTs) can be classified into four subtypes, the histopathological characteristics are known to differ among these subtypes. We therefore performed a logistic regression analysis to determine whether the risk of pathological T1 cancer of large colorectal LSTs can be predicted based on factors such as endoscopic findings in a large group of patients enrolled in a multicenter study in Japan.

Methods

In the main study, we assessed 1236 colorectal adenomas or early cancers that were classified as LSTs measuring 20 mm or more in diameter and treated endoscopically. Logistic regression analysis was performed to determine whether factors such as the subtype of LST could be used to predict the risk of pathological T1 cancer. A validation study of 356 large colorectal LSTs was conducted to confirm the validity of the results obtained in the main study.

Results

The locations and tumor diameter of the LSTs in the main study were found to differ significantly according to the LST subclassification (P < 0.001). The frequency of pathological T1 cancers was the highest at 36% of LST nongranular pseudodepressed type, followed by 14% of LST nongranular flat‐elevated type, 11% of LST granular nodular mixed type, and 3% of LST granular homogenous type lesions. The risk of pathological T1 cancer was significantly associated with LST subclassification and tumor diameter. The area under the curve (AUC) was high (0.743). In the validation study, the AUC was 0.573.

Conclusions

In patients with large colorectal LSTs resected endoscopically, the risk of pathological T1 cancer can be predicted on the basis of the LST subclassification and tumor diameter.

Construction of a preoperative scoring system to predict the difficulty level of colorectal endoscopic submucosal dissection

Background

We attempted to examine the factors contributing to the difficulty in performance of colorectal ESD, with the aim of constructing a scoring system that could help in prediction of the difficulty level of the procedure.

Methods and materials

The data were analyzed from two viewpoints: to determine the factors contributing to 1) non-en bloc resection and the factors contributing to 2) a slow resection speed. Factors falling under these two categories contributing to difficulty in performance of ESD were extracted and used to construct a scoring system. The validity of this scoring system was evaluated by calculating the correlation between the score and the resection speed in a different dataset.

Results

Based on the results of our analysis, we assigned scores for various factors as follows: 4 points for EMR of a scarred lesion, 1 point for tumors with a diameter of ≥ 30 mm, 2 points for lesions located in the liver/splenic flexure, 1 point for lesions located in the transverse colon, 3 points for LST-NG-PD/depressed lesions, 1 point for protruded lesions and LST-NG-F lesions (range 0–10). In the validation study, the rank correlation coefficient between the score according to the scoring system and the resection speed was -0.130, representing a weak and negative correlation (P = 0.03). We defined the difficulty level depending on the sum of the scores: 0–2, low difficulty level; 3–5, intermediate difficulty level; ≥ 6, high difficulty level. The average resection speed was 12.6 mm²/min in the group with scores of 0–2, 8.1 mm²/min in the group with scores of 3–5, and 5.5 mm²/min in the group with scores of ≥ 6 (11.2 mm²/min in all lesions).

Conclusion

Our colorectal ESD scoring system would be useful for selection of operators with the appropriate skill level in the procedure for colorectal ESD cases.

Combination of endoscopic submucosal dissection and transanal minimally invasive surgery for the resection of early rectal cancer with fibrosis after prior partial excision

Endoscopic submucosal dissection is an effective procedure for treating non-invasive colorectal tumors. However, in cases of severe fibrosis, endoscopic submucosal dissection may be technically difficult, leading to incomplete resection. Here, we describe the case of a 74-year-old man who had early rectal cancer along with severe submucosal fibrosis caused by prior local excision. Combination treatment with endoscopic submucosal dissection and transanal minimally invasive surgery successfully enabled complete resection.

Clinical outcomes of colorectal endoscopic submucosal dissection and risk factors associated with piecemeal resection

BACKGROUND/AIMS

We aimed to investigate the factors associated with piecemeal resection of colorectal neoplasia (CRN), in spite of endoscopic submucosal dissection (ESD).

MATERIALS AND METHODS

We analyzed the retrospective data for colorectal ESD cases from January 2005 to April 2014. We also reviewed the piecemeal endoscopic mucosal resection (EMR) for CRNs ≥20 mm, performed over the same period.

RESULTS

En bloc resection was possible in 648 (85.7%) of 756 lesions in 740 patients. Multivariate analysis showed that hybrid ESD (odds ratio (OR), 29.07; 95% confidence interval (CI), 15.46-54.65; p<0.01) and mild or severe submucosal fibrosis (OR, 3.62; 95% CI, 1.94-6.76; p<0.01) were independently associated with piecemeal ESD. The en bloc ESD group showed higher histologic complete resection rate than the piecemeal ESD group (80.4% vs. 56.5%; p<0.01), and the piecemeal ESD group showed higher recurrence rate than in the en bloc ESD group (5.6% [4/72] vs. 0.7% [3/450]; p<0.01). Overall recurrence rate was 1.3% (7/522).

CONCLUSION

Hybrid ESD and submucosal fibrosis are independently associated with piecemeal ESD. Piecemeal ESD cases recurred more frequently than en bloc ESD cases.