Clinical outcomes for patients with perforations during endoscopic submucosal dissection of laterally spreading tumors of the colorectum. Surg Endosc. 2013;27:487-493. [PMID: 22806523 DOI: 10.1007/s00464-012-2462-6]

A case of disseminated peritoneal metastases after 2-year conservative treatment for intramucosal colon carcinoma due to a perforation during endoscopic submucosal dissection

A 70-year-old man was admitted to our hospital for the treatment of a large granular-type laterally spreading tumor in the splenic flexure of the descending colon. The preoperative diagnosis was intramucosal colon carcinoma and endoscopic submucosal dissection was performed. During treatment, a small perforation occurred accidentally. After conservative treatment with endoscopic suturing, the patient was discharged without additional surgery. The pathological diagnosis was an intramucosal carcinoma. One year after treatment, no local recurrence was observed on endoscopy, and abdominal computed tomography showed no obvious metastasis. Two years later, fluorodeoxyglucose-positron emission tomography/computed tomography, laparoscopic findings, and histopathologic findings by experimental excision of omentum revealed several disseminated peritoneal metastases from previously treated colon carcinoma. To the best of our knowledge, this is the first report of peritoneal dissemination after a small perforation during endoscopic submucosal dissection and conservative therapy for early-stage colon carcinoma. This report suggests the possibility of tumor dissemination in patients with small perforations during endoscopic procedures. Endoscopists should be aware of these rare potential risks and perform later surveillance carefully.

Impact of prophylactic wound closure in colorectal ESD on postoperative wound complications: A meta-analysis

Endoscopic submucosa dissection (ESD) has been applied extensively in the treatment of large intestine tumours due to its high total excision ratio. Nevertheless, there is a high incidence of adverse reactions in colon ESD, and the efficacy of prophylactic ESD following ESD in prevention of postoperative haemorrhage is still disputed. The purpose of this meta-analysis is to evaluate the effectiveness of prophylaxis of wound closure in large intestine ESD after operation. For eligibility, we looked through three databases: PubMed, Embase and Cochrane Library. Heterogenity was measured by means of a chi-square method of Q-statistic and an I2 test. Fixed or random effects models were used for data processing. Based on the retrieval policy, we found a total of 1286 papers, and then we collected nine papers to extract the data. Regarding postoperative haemorrhage, there was a significant reduction in the risk of wound haemorrhage in the wound closure group than in the control group (OR, 0.29; 95% CI, 0.19-0.44 p < 0.0001). No statistical significance was found in the incidence of perforation in the wound closure and the control group (OR, 0.45; 95% CI, 0.19-1.03 p = 0.06). There was a significant reduction in the incidence of postoperation fever among those in the wound closure group than in the control group (OR, 0.37; 95% CI, 0.15-0.93 p = 0.04). Preventive endoscopic closure decreased the rate of ESD in colon disease, but did not significantly decrease the rate of postoperation perforation and postoperative fever. Future research will be required to clarify the risk factors and classify high-risk individuals in order to formulate a cost-effective prevention strategy.

Settings of a novel electrosurgical generator to enable efficient and safe submucosal endoscopic procedures

Background and study aims A novel electrosurgical generator unit (ESU), ConMed Beamer, was recently introduced to facilitate endoscopic submucosal dissection (ESD) by employing Automatic Cutting Effect (ACE) technology. Its use in submucosal endoscopy has yet to be investigated. The aim of this study was to evaluate the feasibility and safety of performing ESD and peroral endoscopic myotomy (POEM) using novel settings generated with ConMed Beamer ESU. Patients and methods This was a single-center prospective study of 59 consecutive patients undergoing ESD/POEM at a tertiary referral center. ESU settings were initially generated by testing in live animal models prior to first in-human study. The primary outcome was technical success. Secondary outcomes were procedure times, rate of en bloc/R0 resection, and rate of adverse events (AEs). Results A total of 44 patients (50 polyps) and 15 patients underwent ESD and POEM, respectively. En bloc resection, R0 resection, and curative resection rates were 90%, 77.1%, and 70.8%, respectively. Mean maximal length of the lesion was 3.07 cm ± 1.43 with an average dissection speed of 14.2 cm 2 /hr ± 11.1. Technical success was achieved in 100% of POEM patients. Mean time (minutes) to complete the POEM procedure was 50.1 min ± 12.4. Two major AEs occurred among all patients (3.4%). All intraprocedural bleeding events were controlled using the ConMed Beamer ESU. Conclusions ConMed Beamer ESU settings generated from this study were proven safe and effective in a prospective cohort of patients who underwent submucosal endoscopic procedures. This novel ESU can be added to the armamentarium of ESD capable generators.

Clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms: A single-center experience in Southern Taiwan

Background and aims

Endoscopic submucosal dissection (ESD) as an advanced endoscopic procedure can be considered for the removal of colorectal lesions with high suspicion of limited submucosal invasion or cannot be optimally removed by snare-based techniques. We aimed to analyze the clinical outcomes of ESD for colorectal neoplasms in our hospital.

Methods

We retrospectively enrolled 230 patients with 244 colorectal neoplasms who received ESD procedures from April 2012 to October 2020 at Kaohsiung Chang Gung Memorial Hospital. Clinicopathological data were collected by chart review. We also recorded ESD-related complications and clinical outcomes.

Results

The average age was 64 years old, with a mean follow-up time of 22.59 months. There was a loss of follow-up in 34 lesions. Most lesions were lateral spreading tumors of the non-granular type. The average ESD time was 51.9 minutes. Nine cases (3.7%) had procedure-related complications, including two intra-procedure perforations (0.8%) and seven delayed bleeding (2.9%) without procedure-related mortality. 241 lesions (98.8%) achieved en-bloc resection, while 207 lesions (84.8%) achieved R0 resection. Most lesions were tubulo-(villous) adenoma. Malignancy included 35 adenocarcinomas and 5 neuroendocrine tumors. No local recurrence was developed during follow-up. Multivariate analysis for long ESD time revealed significance in size ≥ 10 cm² and endoscopist’s experience < 3 years. Pre-ESD endoscopic ultrasound revealed good prediction in discrimination of mucosal (sensitivity: 0.90) and submucosal lesion (specificity: 0.67).

Conclusions

ESD for colorectal neoplasms is an effective and safe technique. Size ≥ 10 cm² and endoscopist’s experience < 3 years were significantly associated with long procedure time. Pre-ESD EUS provided a good prediction for colorectal neoplasms in invasion depth.

Closure of colonic deep mural injury and perforation with endoclips

INTRODUCTION

colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications.

OBJECTIVES

to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection.

METHODS

a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed.

RESULTS

after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm.

CONCLUSION

endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection.

Endoscopic mucosal resection versus endoscopic submucosal dissection for colorectal laterally spreading tumors: a meta-analysis

OBJECTIVE

to assess the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the treatment of colorectal laterally spreading tumors (LSTs).

METHODS

a systematic literature search was performed in PubMed, Embase, the Cochrane Library, CNKI and WANFANG databases. The related references were selected according to certain inclusion and exclusion criteria. The Cochrane Collaboration's Revman 5.3 software was used for data analysis.

RESULTS

a total of 12 studies were included in the analysis. The total number of lesions was 3,062 (EMR: 1,906; ESD: 1,156). The en-bloc resection rate of ESD was 95 % (1,098/1,156), which was significantly higher than that of EMR (42.8 %, 815/1,906) (OR = 0.07, 95 % CI [0.02, 0.07], p < 0.00001). The complete resection rate of ESD was 93.2 % (109/117), which was significantly higher than that of EMR as well (71.9 %, 92/128) (OR = 0.12, 95 % CI [0.05, 0.29], p < 0.00001). The bleeding rate showed no significant difference between EMR and ESD (4.2 % vs 3.5 %) (OR = 1.04, 95 % CI [0.68, 1.60], p = 0.85). The perforation rates of EMR and ESD were 1.8 % and 2.4 %, respectively, which displayed a significant difference (OR = 0.56, 95 % CI [0.32, 0.97], p = 0.04). Nevertheless, the recurrence rate of EMR was significantly higher than that of ESD (15.9 % vs 0.5 %) (OR = 23.06, 95 % CI [11.11, 47.85], p < 0.00001).

CONCLUSIONS

endoscopic resection of LSTs is safe and effective. As compared with EMR, ESD has higher en-bloc and complete resection rates but a lower recurrence rate. Therefore, ESD is highly recommended for the treatment of LSTs.

Robotic endoscopic submucosal dissection and full-thickness excision for laterally spreading tumors of the rectum

Endoscopic submucosal dissection (ESD) is technically demanding and time-consuming. Moreover, it bears a high risk of adverse events compared to other endoscopic methods, due to the lack of tissue manipulation. Robotic technology can significantly reduce the time of the procedure and increase the rate of complete resection for ESD. In the case of an unclear deep margin it allows to proceed to the full-thickness excision of the bowel wall. While the gain over transanal endoscopic microsurgery (TEM) is limited today, the longer systems currently under development will allow these complex procedures to be performed at least in the left side of the colon. The Supplementary video shows the application of the Flex Robotic System to perform an ESD and a full-thickness excision.

Predicting and managing complications following colonoscopy: risk factors and management of advanced interventional endoscopy with a focus on colorectal ESD

INTRODUCTION

Colorectal endoscopic submucosal dissection (ESD) has been introduced widely in Western and Asian countries. The management of the perforation during ESD is crucial.

AREAS COVERED

The rate of intraprocedural perforation, risk factors, prevention, and management of perforation during ESD and EMR were discussed in this review. The perforation rate in ESD and EMR depending on the lesion size is also discussed.

EXPERT OPINION

The knowledge regarding the risk factor and techniques to manage perforation is important during colorectal ESD and EMR. The development of novel suturing techniques devices is key for colorectal ESD in the future.

Endoscopic submucosal dissection of colonic lesions: first 50 cases at a local institution

INTRODUCTION

Endoscopic submucosal dissection (ESD) in the colon and rectum has been developed with good reported outcomes. The main advantage of ESD is the ability to perform en bloc resection, which has implications for complete excision and pathological analysis. Locally, the use of ESD in colonic lesions has seen recent traction. Our study aimed to review the outcomes of the first 50 cases of endoscopic excision of advanced colonic lesions using ESD at our institution.

METHODS

This was a retrospective study of all patients who underwent ESD at our institution from September 2010 to October 2016. Data collected included patient demographics, resection technique, conversion rate and morbidity.

RESULTS

51 patients underwent ESD during the study period. All patients were of American Society of Anesthesiologists (ASA) class 1-3. Their median age was 60.0 years and the majority (n = 36) were male. The mean procedure time was 80.9 minutes. 36 (76.6%) of cases underwent en bloc resection. 4 (7.8%) cases required conversion to surgery, mainly due to difficulty in raising the colonic lesions. 3 (5.9%) patients had malignancy as the final histology. 2 (4.3%) patients had recurrence during surveillance scope. No cases of early mortality were reported.

CONCLUSION

Our results suggest that ESD for advanced colonic lesions can be safely performed. Expertise needs to be developed to achieve satisfactory en bloc resection rates.

Effect of prophylactic endoscopic closure for an artificial ulceration after colorectal endoscopic submucosal dissection: a randomized controlled trial

Objective: Endoscopic submucosal dissection (ESD) is now commonly performed as a treatment for not only gastric tumor but also colorectal tumor. However, colorectal ESD has a substantial risk of complications, including post-ESD electrocoagulation syndrome, bowel perforation and bleeding. This study aimed to investigate whether prophylactic endoscopic closure can reduce the occurrence of complications after colorectal ESD.Materials and methods: Patients who underwent colorectal ESD in our unit were randomly assigned to either of two groups. Prophylactic endoscopic closure for an artificial ulceration after ESD was performed in group I but not in group II. After the procedure, the incidence of complications, visual analog scale (VAS) score for abdominal pain, and laboratory findings were investigated.Results: Of the 220 patients (110 per group) enrolled in this study, 137 were men. No significant differences were found in age, sex, comorbidity, medication history, tumor location, size of resected specimen, and pathologic result between the two groups. No significant difference was found in ESD outcomes, including hospitalization period, laboratory findings, VAS score for abdominal pain, incidence of surgical operation, and incidence of post-ESD complications, between the two groups.Conclusions: Contrary to popular belief, prophylactic endoscopic closure after colorectal ESD does not decrease the incidence of complications, and it does not ameliorate inflammatory response and abdominal pain.Clinical trial registration number: KCT0001666.

Underwater Endoscopic Mucosal Resection

Although an established standard, conventional endoscopic mucosal resection (EMR) has disseminated despite an absence of studies demonstrating the value of submucosal injection. Several consequences of poorly executed submucosal injection may increase the difficulty and risk of EMR. Underwater EMR (UEMR), an alternative resection method for colonic neoplasms, avoids the need for submucosal injections. In comparison with reported outcomes of EMR, UEMR achieves similar rates of complete resection with comparable safety, with lower rates of recurrence and fewer repeat procedures. UEMR also compares favorably with endoscopic submucosal dissection in terms of procedure time and rates of complete resection, recurrence, and complications.

Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities.

METHODS

This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload.

RESULTS

Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P < .0001). The perforation rate was higher in the ESD group (60% vs 30%, P = .18). Total procedure time (34.1 vs 88.6 min, P = .001) and dissection time (27.8 vs 79.4 minutes, P = .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P = .01).

CONCLUSIONS

RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Management of colorectal laterally spreading tumors: a systematic review and meta-analysis

Objective and study aims  To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST). Methods  Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model. Results  Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 - 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 - 92.9 %, I ²  = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 - 95.5 %, vs. 84 % 95 % CI 78.1 - 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 - 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 - 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 - 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 - 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 - 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 - 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 - 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST. Conclusions  EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.

Risk factors for procedure-related complications after endoscopic resection of colorectal laterally spreading tumors

Colorectal laterally spreading tumors (LSTs) are large and flat elevated neoplasms with diameters of at least 10 mm. Endoscopic resection of LSTs, with their large size and broad base, is difficult and dangerous compared with the resection of polypoid neoplasms. This study aimed to determine the risk factors for procedure-related complications including bleeding and perforation after endoscopic resection of LSTs.Patients with colorectal LST undergoing endoscopic resection at 5 university hospitals in Honam Province of South Korea were enrolled, and their records about patients, lesions, and procedure parameters associated with the occurrence of complications were reviewed retrospectively. Logistic regression analysis was performed to identify risk factors for complications.The frequency of comorbidities in bleeding group was significantly higher than in the no bleeding group. The frequency of bleeding was significantly higher in lesions with adenocarcinoma than in lesions with low or high-grade dysplasia. The frequency of bleeding was significantly higher in piecemeal resection than in en bloc resection. The frequency of perforation was significantly higher in endoscopic mucosal resection-precutting (EMR-P) than in endoscopic mucosal resection (EMR) or endoscopic submucosal dissection. The mean procedure duration was significantly longer in the perforation group than in the no perforation group. On multivariate analysis, patient comorbidity and histologic grade of the lesion were significant independent risk factors for bleeding, whereas EMR-P was a significant independent risk factor for perforation after endoscopic resection.This study demonstrated that patient comorbidity and histologic grade of lesion were significant independent risk factors for bleeding, and EMR-P was a significant independent risk factor for perforation after endoscopic resection of colorectal LSTs.

Robotics for Advanced Therapeutic Colonoscopy

Although colonoscopy was originally a diagnostic imaging procedure, it has now expanded to include an increasing range of therapeutic interventions. These procedures require precise maneuvers of instruments, execution of force, efficient transmission of force from the operator to the point of application, and sufficient dexterity in the mobilization of endoscopic surgical instruments. The conventional endoscope is not designed to support technically demanding endoscopic procedures. In case of colonoscopy, the tortuous anatomy of the colon makes inserting, moving, and orientating the endoscope difficult. Exerting excessive pressure can cause looping of the endoscope, pain to the patient, and even perforation of the colon. To mitigate the technical constraints, numerous technically enhanced systems have been developed to enable better control of instruments and precise delivery of force in the execution of surgical tasks such as apposing, grasping, traction, counter-traction, and cutting of tissues. Among the recent developments are highly dexterous robotic master and slave systems, computer-assisted or robotically enhanced conventional endoscopes, and autonomously driven locomotion devices that can effortlessly traverse the colon. Developments in endoscopic instrumentations have overcome technical barriers and opened new horizons for further advancements in therapeutic interventions. This review describes examples of some of these systems in the context of their applications to advanced therapeutic colonoscopy.

Clinicopathological features of laterally spreading colorectal tumors and their association with advanced histology and invasiveness: An experience from Honam province of South Korea: A Honam Association for the Study of Intestinal Diseases (HASID)

Background and aims

Laterally spreading colorectal tumors (LSTs) are divided into four subtypes, including homogenous (HG), nodular mixed (NM), flat elevated (FE), and pseudo-depressed (PD), based on their different endoscopic morphologies. The aim of this study was to investigate the clinicopathological significance of LST subtypes and their association with advanced histology.

Methods

We investigated the medical records of consecutive patients with LST who initially underwent endoscopic resection at five university hospitals in Honam province of South Korea between January 2012 and December 2013. A total of 566LST lesions removed via endoscopic procedures were collected retrospectively for data analysis.

Results

The PD, FE, and NM subtypes were more common in the distal colon and the HG subtype in the proximal colon. The PD subtype had the biggest tumor size, followed by the NM subtype. The frequency of adenomatous pit pattern was significantly higher in the HG, NM, and FE subtypes than in the PD subtype. In contrast, the frequency of cancerous pit pattern was significantly higher in the PD subtype than in the other three subtypes. The rate of advanced histology (high-grade dysplasia or carcinoma) among the LSTs was 36.0%. The risk of advanced histology increased in the distal colon compared with the proximal colon. The PD subtype had the highest incidence of villous component, advanced histology,submucosal invasion, and postprocedure perforation among the four subtypes. The distal colon as tumor site, larger tumor size, PD subtype, and villous component were associated with a statistically significant increased risk of advanced histology.

Conclusion

Our results indicate that the location, size, endoscopic subtype, and histologic component of the LSTs are associated with an increased risk of advanced histology. Therefore, these clinicopathological parameters may be useful in selecting therapeutic strategies in the clinical setting.

A randomized controlled trial of prophylactic antibiotics in the prevention of electrocoagulation syndrome after colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is currently commonly performed, but colorectal ESD has a substantial risk of adverse events, including post-ESD electrocoagulation syndrome (PEECS). We investigated whether the use of prophylactic antibiotics can reduce the occurrence of PEECS.

METHODS

Patients who underwent colorectal ESD were randomly assigned to 1 of 2 treatment regimens. Ampicillin and/or sulbactam mixed with normal saline solution was administered 1 hour before ESD in group 1 then additionally injected every 8 hours twice more. In group 2, normal saline solution without antibiotics was administered following the same schedule. We investigated the characteristics of the patients and tumors, the incidence of PEECS, laboratory findings, and the visual analog scale (VAS) score for abdominal pain measured on the morning after ESD.

RESULTS

A total of 100 cases (50 per group) were finally analyzed, and 97 tumors were successfully resected en bloc. The number of patients having C-reactive protein (CRP) levels ≥1 mg/dL and the number of patients having VAS scores for abdominal pain ≥1 were greater in group 2 than in group 1 (P = .008 and .023, respectively). The incidence of PEECS in group 2 also was higher than that in group 1 (1 and 8 in groups 1 and 2, respectively; P = .031).

CONCLUSIONS

The prophylactic use of ampicillin and/or sulbactam in colorectal ESD is associated with reduced risk of PEECS, decreased CRP levels, and decreased abdominal pain. The use of prophylactic antibiotics in colorectal ESD may be an effective tool for reducing the risk of PEECS. (Clinical trial registration number: KCT0001102.).

Endoscopic and Clinical Factors Affecting the Prognosis of Colorectal Endoscopic Submucosal Dissection-Related Perforation

Background/Aims

Although colorectal endoscopic submucosal dissection (ESD)-related perforation is not uncommon, the factors affecting clinical outcomes after perforation have not been investigated. This study was designed to investigate the factors influencing the clinical course of ESD-related colon perforation.

Methods

Forty-three patients with colorectal ESD-related perforation were evaluated. The perforations were classified as endoscopic or radiologic perforations. The patients’ medical records and endoscopic pictures were analyzed.

Results

The clinical outcomes were assessed by the duration of nil per os, intravenous antibiotics administration, and hospital stays, which were 2.7±1.5, 4.9±2.3, and 5.1±2.3 days, respectively. Multivariate analyses revealed that a larger tumor size, ESD failure, specific endoscopists, and abdominal pain were independently related to a poorer outcome. The time between perforation and clipping was 15.8±25.4 minutes in the endoscopic perforation group. The multivariate analysis of this group indicated that delayed clipping, specific endoscopists, and abdominal pain were independently associated with poorer outcomes.

Conclusions

Tumor size, ESD failure, abdominal pain, and the endoscopist were factors that affected the clinical outcomes of patients with colorectal ESD-related perforation. The time between the perforation and clipping was an additional factor influencing the clinical course of endoscopic perforation. Decreasing this time period may improve outcomes.

Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection

Endoscopic mucosal resection (EMR) has been used in western countries to remove colonic polyps for at least the last two decades. Significant experience has been accumulated and the efficacy of the method has recently been evaluated in a large meta-analysis. A number of variations to modify the technique, including knife-assisted, cap-assisted, ligation devices, and underwater EMR, have been developed in an attempt to improve outcomes. However, to date there are only limited data comparing these techniques or demonstrating the superiority of any one of them. This article reviews the current evidence on the efficacy of each of these modified techniques.

Feasibility and safety of endoscopic submucosal dissection for lower rectal tumors with hemorrhoids

AIM: To evaluate the feasibility and safety of endoscopic submucosal dissection (ESD) for lower rectal lesions with hemorrhoids.

METHODS: The outcome of ESD for 23 lesions with hemorrhoids (hemorrhoid group) was compared with that of 48 lesions without hemorrhoids extending to the dentate line (non-hemorrhoid group) during the same study period.

RESULTS: Median operation times (ranges) in the hemorrhoid and non-hemorrhoid groups were 121 (51-390) and 130 (28-540) min. The en bloc resection rate and the curative resection rate in the hemorrhoid group were 96% and 83%, and they were 100% and 90% in the non-hemorrhoid group, respectively. In terms of adverse events, perforation and postoperative bleeding did not occur in both groups. In terms of the clinical course of hemorrhoids after ESD, the rate of complete recovery of hemorrhoids after ESD in lesions with resection of more than 90% was significantly higher than that in lesions with resection of less than 90%.

CONCLUSION: ESD on lower rectal lesions with hemorrhoids could be performed safely, similarly to that on rectal lesions extending to the dentate line without hemorrhoids. In addition, all hemorrhoids after ESD improved to various degrees, depending on the resection range.

Colorectal Endoscopic Submucosal Dissection: Past, Present, and Factors Impacting Future Dissemination

First performed in the stomach for removal of localized gastric tumors, endoscopic submucosal dissection (ESD) has evolved into a technique that is increasingly being employed to resect colorectal lesions. As opposed to endoscopic mucosal resection (EMR), ESD allows the endoscopist to remove large specimens en bloc to provide accurate pathologic evaluation and lower local recurrence rates. ESD is an ideal technique for resection of lesions without lymph node metastases and is becoming the standard of care in Japan as outcomes data has proven it to be equally efficacious, less invasive, and inexpensive as compared with surgery; however, potential risk for complications is high and the procedure is currently not widely available in the Western world. As more interest, endoscopist training, and data supporting the technique's use mount, ESD will also likely become the standard of care in the Western world for resection of localized colorectal lesions.

Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand?

BACKGROUND AND AIM

Iatrogenic perforation of the gut during endoscopy remains an uncommon but critical complication with significant morbidity and probable mortality than usual surgical treatment. Some authors have adopted a non-surgical closure method in chosen cases and, since 1993, endoclips have been used to close perforation in the stomach. The endoscopic practice of endoclips has been commonly used in the gut for hemostasis. Currently, the use of endoscopic techniques is increasing for the closure of endoscopic submucosal dissection or endoscopic mucosal resection. Endoscopic perforations that improved with endoscopic closure in the literature prior to 2008 have been previously described. In the present article, we present a descriptive review of cases with iatrogenic perforation in the gut treated with endoclips between 2008 and 2014.

METHODS

Comprehensive literature screening and a systematic review using PubMed and Medline was done for all reports published between January 2008 and December 2014 using the endoclip technique in the closure of iatrogenic perforations.

RESULTS

A total of 47 studies published between 2008 and 2014 using endoclips for the closure of iatrogenic perforations of the gut (nine esophagus, 11 stomach, 15 duodenum, 12 colon and rectum) were found. All studies were explained briefly and summarized in a table.

CONCLUSIONS

There is strong evidence to show the efficacy of endoclips in the management of iatrogenic perforations, especially when recognized early. Limitations of endoclipping such as inefficiency against large perforations may be overcome by improving novel techniques in the future.

Endoscopic management of iatrogenic perforations during endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for colorectal polyps: a case series

BACKGROUND

Iatrogenic perforation during therapeutic colonoscopy, reported in up to 1% of endoscopic mucosal resections (EMRs) and up to 14% of endoscopic submucosal dissections (ESDs), has conventionally been an indication for surgery.

AIMS

We present a case series of successful endoscopic management of iatrogenic colorectal perforation during EMR and ESD, demonstrating the feasibility and safety of the method.

METHODS

Retrospective analysis of a database of patients undergoing EMR and ESD for colorectal polyps in a tertiary referral centre in the United Kingdom.

RESULTS

Four cases of perforation were identified (two EMRs and two ESDs) in a series of 218 procedures (1.8%), all detected at the time of endoscopy and managed with endoscopic clips. Patients were observed in hospital and treated with antibiotics. Their median length of stay was 3 days (range 2-6 days), with no mortality or need for surgery.

CONCLUSION

Surgery is no longer the first choice in the management of iatrogenic perforations during EMR and ESD for colorectal polyps; in selected patients with small perforations and minimal extraluminal contamination, conservative management with application of endoscopic clips, antibiotics and close patient monitoring constitute a safe and effective treatment option, avoiding the morbidity of major surgery.

Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms

BACKGROUND AND OBJECTIVES

There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD.

METHODS

There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS.

RESULTS

There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics.

CONCLUSIONS

The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.

Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms

BACKGROUND AND OBJECTIVES

There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD.

METHODS

There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS.

RESULTS

There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics.

CONCLUSIONS

The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.

Technical difficulty according to location, and risk factors for perforation, in endoscopic submucosal dissection of colorectal tumors

BACKGROUND

Colorectal endoscopic submucosal dissection (ESD) is a widely accepted treatment for colorectal tumors, but is technically more difficult and has a higher risk of complications such as perforation than gastric ESD. Few studies have investigated the factors associated with technical difficulty and perforation in colorectal ESD. This study aimed to evaluate the technical difficulty according to location, and the risk factors for perforation, in colorectal ESD.

METHODS

This retrospective study included 134 consecutive colorectal tumors treated by ESD in 122 patients at the Division of Endoscopy of Hokkaido University Hospital and the Department of Gastroenterology of Kitami Red Cross Hospital from November 2011 to February 2013. To evaluate the technical difficulty of performing ESD for colorectal tumors at specific locations, the en bloc R0 resection rate, specimen diameter, procedure speed, and procedure time were compared among tumor locations using the χ (2) test or analysis of variance. Risk factors for perforation were identified by multiple logistic regression analysis.

RESULTS

The en bloc R0 resection rate was 86.6 % (116/134), the mean tumor diameter was 27.1 mm, and the mean procedure time was 63.5 min. The mean speed of procedures was significantly slower in the sigmoid colon (24.7 min/cm(2)) than in other areas. Perforation occurred in nine cases (6.7 %). Submucosal fibrosis was the only factor independently associated with perforation (odds ratio 5.684, 95 % confidence interval 1.307-24.727).

CONCLUSIONS

ESD was slower for sigmoid colon tumors than for tumors in other areas, suggesting that ESD was technically more difficult in the sigmoid colon than in other colorectal areas. Submucosal fibrosis was independently associated with perforation during colorectal ESD.

Factors affecting the technical difficulty and clinical outcome of endoscopic submucosal dissection for colorectal tumors

BACKGROUND

Endoscopic submucosal dissection (ESD) for colorectal tumors is technically difficult due to the anatomy of the large intestine, with its narrow lumen, thin walls, and redundancy. Here, we assessed factors associated with incomplete resection and difficult colorectal ESD.

METHODS

Between November 2009 and April 2013, we performed ESD on 151 consecutive colorectal tumors in 147 patients. We evaluated the clinical outcomes of all cases and conducted multiple logistic regression analysis of the following factors related to incomplete resection and difficult procedure: age, gender, location (right colon, left colon or rectum), tumor size (diameter ≥40 or <40 mm), operation time, morphology [granular-type laterally spreading tumor (LST-G), non-granular-type laterally spreading tumor (LST-NG), or protruded type], fibrosis, and paradoxical movement during the procedure. A procedure that required more than 120 min was defined as a difficult colorectal ESD.

RESULTS

Average tumor size was 32.1 ± 10.7 mm, and the average procedure length was 71.8 ± 49.5 min. The rate of en bloc resection was 94.7%, while that of en bloc curative resection was 86.8%. Perforation occurred in 1.3% of the ESD procedures. Multivariate logistic regression analysis revealed that only severe fibrosis [odds ratio (OR) 4.51; 95% confidence interval (CI) 1.36-14.91, p = 0.014] contributed to incomplete resection and that a tumor size exceeding 40 mm (OR 5.73 [95% CI 1.66-19.74], p = 0.006), severe fibrosis (OR 23.31 [95% CI 6.59-82.54], p < 0.001), and paradoxical movement (OR 4.26 [95% CI 1.11-16.44], p = 0.035) were independent factors exacerbating the difficulty of colorectal ESD.

CONCLUSIONS

Severe fibrosis contributed to both incomplete resection and difficult colorectal ESD. Larger tumor size and paradoxical movement during the procedure were independent factors contributing to the difficulty of colorectal ESD. These factors might enable endoscopists to develop strategies for treating colorectal ESD.

Colonic perforation: can we manage it endoscopically?

Colonic perforation occurs in a variety of clinical scenarios and colonoscopy-associated perforation is one of the important reasons for colonic perforation. Colonoscopy-associated perforation may be diagnosed during colonoscopy procedure by the visualization of evident colonic wall defect or, after the completion of colonoscopy, by the visualization of leaked air in the peritoneal or retroperitoneal space. Recently, the incidence of colonoscopy-associated perforation increased because of the introduction of colorectal endoscopic submucosal dissection. Traditionally, colonoscopy-associated perforation was managed surgically. However, medical management has been introduced widely and endoscopic clipping is the most important component for the medical management of colonoscopy-associated perforation. Timely administration of antibiotics is also important. Large perforations, diagnostic colonoscopy-associated perforations, large amount of pneumoperitoneum, and severe abdominal pain have been reported to be predictive of the necessity of surgery after endoscopic clipping. Surgery should be performed if patients show clinical deterioration even after the initiation of medical management.

Prediction and treatment of difficult cases in colorectal endoscopic submucosal dissection

Purpose. The aim of this study was to examine the characteristics of difficult cases and the learning curve in colorectal endoscopic submucosal dissection (ESD). Methods. We studied 518 colorectal tumors treated by ESD. Patients were divided into 2 groups such as the difficult ESD group and non-difficult ESD group in view of procedure time and procedure speed, respectively. The clinical features in each group were analyzed, and we also examined cases with severe fibrosis. Furthermore, we divided all cases into 5 periods according to experience of ESDs and investigated the rates of difficult and perforation cases. Results. In view of both procedure time and procedure speed, there were significant differences about mean tumor size, rates of severe fibrosis and perforation, and en bloc resection rate between the two groups. Severe fibrosis was detected in protruding tumors >40 mm in diameter. With respect to the learning curve, the rate of difficult and perforation cases decreased significantly in the late periods compared to the first period. Conclusions. Large tumor size, high rates of severe fibrosis and perforation, and low rate of en bloc resection are related with difficult ESD cases. The increasing of experiences can decrease the rate of difficult cases and perforation.