Clinical outcomes of endoscopic resection for colorectal laterally spreading tumors with advanced histology

Technical Advances in Endoscopic Resection Techniques for Lower GI Malignancies

Background

The management of bulky neoplastic lesions in the digestive tract has historically been a surgical pursuit. With advancements in endoscopic techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a paradigm shift toward organ preservation has been initiated. These endoscopic methods, developed incrementally since the 1980s, have progressively enabled curative management of lesions with minimal morbidity, challenging the previously unchallenged domain of surgery.

Summary

This review traces the evolution of endoscopic resection from snare polypectomy and EMR to sophisticated ESD, highlighting the technological innovations that have expanded the scope of endoscopic resection. It discusses the intricacies of various EMR techniques like underwater EMR, anchoring EMR, and hybrid EMR, alongside traction-assisted methods and the use of viscous solutions for submucosal injection. Additionally, the manuscript delves into the advancements in ESD, emphasizing traction strategies, knife technology, and the optimization of endoscopes. The benefits of these advancements are weighed against the challenges in anatomopathological interpretation posed by piecemeal resections.

Key Messages

The continuous amelioration of endoscopic resection techniques has significantly improved the outcomes of digestive tract lesion management, particularly in achieving R0 resections and reducing recurrence rates. These advancements represent a monumental step toward minimizing the invasiveness of lesion management. However, despite the progress, the necessity for early follow-up post-EMR remains due to the non-negligible recurrence rates, underscoring the need for a rigorous postoperative surveillance regimen. Furthermore, our review suggests that while ESD has transformed the therapeutic landscape, its widespread adoption hinges on further simplification, safety enhancement, and acceleration of the procedure, possibly through innovations like adaptive traction devices.

Characteristics of factors contributing to follow-up for suspected delayed bleeding after colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Delayed bleeding (DB) is a major adverse event associated with colorectal endoscopic submucosal dissection (ESD) that sometimes causes difficulties in making decisions regarding endoscopic hemostasis. This study identified the factors that contribute to follow-up without endoscopic hemostasis when DB is suspected after colorectal ESD.

METHODS

In total, 583 patients (603 tumors) who underwent ESD or hybrid ESD for colorectal tumors at Chiba University Hospital between June 2009 and January 2022 were retrospectively registered. Of these, 141 cases (141 tumors) with DB, and hematochezia or hemoglobin decrease ≥2 g/dL after colorectal ESD, were analyzed. The DB group was divided into the Hemostasis group (H group; endoscopic hemostasis performed) and no-Hemostasis group (no-H group; no endoscopy performed, or endoscopy performed but no hemostasis performed after hematochezia or hemoglobin decrease). Univariate and multivariate logistic regression analyses were conducted to assess the factors contributing to follow-up.

RESULTS

Thirty-one patients with 31 tumors were categorized into the H group, and 110 patients with 110 tumors were in the no-H group. Multivariate regression analysis revealed that date from ESD to first hematochezia ≤Day 3 (odds ratio, 4.55; 95% confidence interval, 1.44-14.33; P = .010) and bleeding duration ≤1 day (odds ratio, 3.35; 95% confidence interval, 1.35-8.34; P = .009) contributed to follow-up.

CONCLUSIONS

In cases of DB after colorectal ESD, a bleeding duration ≤1 day or date from ESD to first hematochezia ≤Day 3 may contribute to follow-up observation without endoscopic hemostasis.

Comparing endoscopic mucosal resection with endoscopic submucosal dissection in colorectal adenoma and tumors: Meta-analysis and system review

AIMS

This study aimed to evaluate the safety, efficacy, and long-term outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for treating colorectal adenomas and tumors.

METHODS

A systematic literature review was conducted using databases including PubMed, Web of Science, and Embase. Parameters such as number of patients or lesions, histological diagnosis, lesion size, surgery time, en-bloc resection, R0 resection, severe postoperative complications, and local recurrence were extracted and pooled for analysis.

RESULTS

A total of 12 retrospective studies involving 1289 patients and 1850 lesions were included in the analysis. EMR was found to have a shorter operation time by 53.6 minutes (95% CI: 51.3, 55.9, P<0.001) and fewer incidences of severe postoperative complications such as perforation and delayed bleeding (OR = 0.40, 95%CI: 0.23, 0.71, P<0.001). On the other hand, ESD had higher rates of en-bloc resection (OR = 0.15, 95%CI: 0.07, 0.30, P<0.001) and R0 resection (OR = 0.32, 95%CI: 0.16, 0.65, P<0.001). Recurrence after EMR was found to be significantly higher than that after ESD surgery (OR = 5.88, 95%CI: 2.15, 16.07, P = 0.037).

CONCLUSIONS

The study suggests that the choice of surgical method may have a greater impact on recurrence compared to the pathological type, and that ESD may be more suitable for the treatment of malignant lesions despite its higher rates of severe postoperative complications and longer operation time.

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.

Is underwater endoscopic mucosal resection of colon polyps superior to conventional techniques? A network analysis of endoscopic mucosal resection and submucosal dissection

Background and study aims  Evidence from recent trials comparing conventional endoscopic mucosal resection (EMR) to underwater EMR (UEMR) have matured. However, studies comparing UEMR to endoscopic submucosal dissection (ESD) are lacking. Hence, we sought to conduct a comprehensive network meta-analysis to compare the efficacy of UEMR, ESD, and EMR. Methods  Embase and Medline databases were searched from inception to December 2020 for articles comparing UEMR with EMR and ESD. Outcomes of interest included rates of en bloc and complete polyp resection, risk of perforation and bleeding, and local recurrence. A network meta-analysis comparing all three approaches was conducted. In addition, a conventional comparative meta-analysis comparing UEMR to EMR was performed. Analysis was stratified according to polyp sizes (< 10 mm, ≥ 10 mm, and ≥ 20 mm). Results  Twenty-two articles were included in this study. For polyps ≥ 10 mm, UEMR was inferior to ESD in achieving en bloc resection ( P  = 0.02). However, UEMR had shorter operating time for polyps ≥ 10 mm ( P  < 0.001), and ≥20 mm ( P  = 0.019) with reduced perforation risk for polyps ≥ 10 mm ( P  = 0.05) compared to ESD. In addition, en bloc resection rates were similar between UEMR and EMR, although UEMR had reduced recurrence for polyps ≥ 10 mm ( P  = 0.013) and ≥ 20 mm ( P  = 0.014). UEMR also had shorter mean operating than EMR for polyps ≥ 10 mm ( P  < 0.001) and ≥ 20 mm ( P  < 0.001). Risk of bleeding and perforation with UEMR and EMR were similar for polyp of all sizes. Conclusions  UEMR has demonstrated technical and oncological outcomes comparable to ESD and EMR, along with a desirable safety profile. UEMR appears to be a safe and effective alternative to conventional methods for resection of polyps ≥ 10 mm.

Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions

Endoscopic mucosal resection (EMR) is a technique allowing efficacious and minimally invasive resection of precancerous lesions across the entire gastrointestinal tract. However, conventional EMR, involving injection of fluid into the submucosal space, is imperfect, given the high rate of recurrence of post-endoscopic resection adenoma, especially after piecemeal resection. In light of these observations, modifications of the technique have been proposed to overcome the weakness of conventional EMR. Some of them were designed to maximize the chance of en bloc resection—cap-assisted EMR, underwater EMR, tip-in EMR, precutting, assisted by ligation device—while others were designed to minimize the complications (cold EMR). In this review, we present their modes of action and summarize the evidence regarding their efficacy and safety.

Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal polyps: A meta-analysis and meta-regression with single arm analysis

BACKGROUND

Endoscopic submucosal dissection (ESD) has shown to be effective in management of colorectal neoplasm in the Asian countries, while its implementation in Western countries where endoscopic mucosal resection (EMR) is preferred is still debatable.

AIM

To compare the surgical, histological, and oncological outcomes between ESD and EMR in the treatment of colorectal polyps, with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world.

METHODS

Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc, complete resection, margin involvement, resection time, need for additional surgery, complications, and recurrence rate of ESD with EMR.

RESULTS

Of 281344 colorectal polyps from 21 studies were included. When compared to EMR, the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate, and lower lateral margin involvement and recurrence. ESD led to increased procedural time, need for additional surgery, and perforation risk. No significant difference in bleeding risk was found between the two groups. Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD. Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate, bleeding risk and recurrence. In subgroup analysis, Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4% and 0.0002%, respectively, as compared to perforation risk of 8% and 1%, respectively, in reports coming from rest of the world.

CONCLUSION

ESD resulted in better resection outcomes and lower recurrence compared to EMR. With appropriate training, ESD is preferred over EMR as the first-line therapy for resection of colorectal polyps, without restricting to lesions greater than 20 mm and those with high suspicion of submucosal invasion.

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.

Blue laser imaging combined with JNET (Japan NBI Expert Team) classification for pathological prediction of colorectal laterally spreading tumors

BACKGROUND

Blue laser imaging (BLI) can provide useful information on colorectal laterally spreading tumors (LSTs) by visualizing the surface and vessel patterns in detail. The present research aimed to evaluate the diagnostic performance of BLI-combined JNET (Japan NBI Expert Team) classification for identifying LSTs.

METHODS

This retrospective, multicenter study included 172 LSTs consisted of 6 hyperplastic polyps/sessile serrated polyps, 94 low-grade dysplasias (LGD), 60 high-grade dysplasias (HGD), 6 superficial submucosal invasive (m-SMs) carcinomas, and 4 deep submucosal invasive carcinomas. The relationship between the JNET classification and the histologic findings of these lesions were then analyzed.

RESULTS

For all LSTs, non-experts and experts had a 79.7% and 90.7% accuracy for Type 2A (P = 0.004), a sensitivity of 94.7% and 96.8% (P = 0.718), and a specificity of 61.5% and 83.3% (P = 0.002) for prediction of LGD, respectively. The results also demonstrated 80.8% and 91.3% accuracy for Type 2B (P = 0.005), a sensitivity of 65.2% and 83.3% (P = 0.017), and a specificity of 90.6% and 96.2% (P = 0.097) for predicting HGD or m-SMs. For LST-granular (LST-G) lesions, Type 2A in experts had higher specificity (65.6% vs. 83.6%, P = 0.022) and accuracy (81.8% vs. 91.2%, P = 0.022). Type 2B in experts only had higher accuracy (82.5% vs. 92.0%, P = 0.019). However, no significant differences were noted for any comparisons between non-experts and experts for LST-non-granular (LST-NG) lesions.

CONCLUSIONS

BLI combined with JNET classification was an effective method for the precise prediction of pathological diagnosis in patients with LSTs. Diagnostic performance of JNET classification by experts was better than that by non-experts for all examined LST or LST-G lesions when delineating between Type 2A and 2B, but there was no difference for the identification of LST-NG lesions by these two groups.

The Coexistence of Colorectal Polyps in the Right Colon Increases the Malignant Risk of Laterally Spreading Tumors

Background

The coexistence of colorectal polyps with laterally spreading tumors (LSTs) is commonly observed during colonoscopy. However, there are rare studies that assess the malignant risks for LSTs with colorectal polyps, which might largely contribute to further strategies of treatment and follow-up plans in LSTs.

Methods

We conducted a retrospective cohort study that enrolled 206 patients with LSTs in the Endoscopy Center and Endoscopy Research Institute, Renji Hospital, Shanghai Jiao Tong University, China. The subjects with LSTs were divided into two groups: the nonpolyp group with 89 patients and the polyp group with 117 patients. Binary logistic regression was used to identify the independent predictors of outcomes of interest.

Results

The risk of the polyps' coexistence phenomenon increased in males compared with females (OR = 2.138, p = 0.047), especially in those between 50 and 75 years old (OR = 7.074, p = 0.036). Tumor size (3–4 cm), LSTs with tubulovillous types, and history of polyps statistically increased the risk of the polyp coexistence phenomenon (OR = 5.768, p = 0.003; OR = 36.345, p = 0.024; OR = 13.245, p < 0.0001, respectively). LST-NG-PD (OR = 20.982, p = 0.017) and LSTs ≥ 5 cm (OR = 37.604, p = 0.038) notably increased the malignant risk of LSTs. When the simultaneous polyps are located in the right colon, the risk of malignant LSTs (OR = 58.540, p = 0.013) positively increased.

Conclusion

The simultaneous colorectal polyps in the right colon were the most important risk factor to predict the malignant risk of LSTs.