Optimal surveillance interval after piecemeal endoscopic mucosal resection for large colorectal neoplasia: a multicenter randomized controlled trial

Effectiveness of water pressure method in colorectal endoscopic submucosal dissection by novice endoscopists

Background and study aims Colorectal endoscopic submucosal dissection (ESD) remains challenging for novice endoscopists. Not only the underwater conditions but also active use of water pressure with the water pressure method (WPM) can help widen the submucosal layer. This study aimed to clarify the usefulness of WPM in colorectal ESD, especially for novice endoscopists. Methods This study was ex vivo and enrolled three novices. Each endoscopist performed conventional ESD (C-ESD) and ESD with WPM (WPM-ESD) 10 times on an excised bovine rectum. The treatment outcomes were compared between the two groups. Results Median procedure time was significantly shorter in the WPM-ESD group than in the C-ESD group (54 minutes, interquartile range [IQR] 42-67 vs. 45 minutes, IQR 34-55, P  = 0.035). Although no significant difference in the activation time of electrical surgical unit (ESU) during the procedure was noted, the interval time during the procedure at which the ESU was not activated was significantly shorter in the WPM-ESD group (52 minutes, IQR 40-65 vs. 42 minutes, IQR 32-52, P  = 0.030) than in the C-ESD group. Moreover, the time required for the endoscope to enter the submucosa was significantly shorter in the WPM-ESD group than in the C-ESD group (8.0 minutes, IQR 6.0-10 vs. 5.0 minutes, IQR 3.0-6.0, P  < 0.001). Conclusions The present study reveals that the WPM method significantly shortens the procedure times for novices in colorectal ESD, especially the interval time, which refers to the time spent creating the field of view, and the time required for the endoscope to enter the submucosa.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term Outcomes After Endoscopic Submucosal Dissection for Large Colorectal Epithelial Neoplasms: A Prospective, Multicenter, Cohort Trial From Japan

BACKGROUND & AIMS

To determine the long-term outcomes after colorectal endoscopic submucosal dissection (ESD), we conducted a large, multicenter, prospective cohort trial with a 5-year observation period.

METHODS

Between February 2013 and January 2015, we consecutively enrolled 1740 patients with 1814 colorectal epithelial neoplasms ≥20 mm who underwent ESD. Patients with noncurative resection (non-CR) lesions underwent additional radical surgery, as needed. After the initial treatment, intensive 5-year follow-up with planned multiple colonoscopies was conducted to identify metastatic and/or local recurrences. Primary outcomes were overall survival, disease-specific survival, and intestinal preservation rates. The rates of local recurrence and metachronous invasive cancer were evaluated as the secondary outcomes.

RESULTS

The 5-year overall survival, disease-specific survival, and intestinal preservation rates were 93.6%, 99.6%, and 88.6%, respectively. Patients with CR lesions had no metastatic occurrence, and patients with non-CR lesions had 4 metastatic occurrences. Kaplan-Meier curves revealed that overall survival and disease-specific survival rates were significantly higher in patients with CR lesions than in those with non-CR lesions (P > .001 and P = .009, respectively). Local recurrence occurred in only 8 lesions (0.5%), which were successfully resected by subsequent endoscopic treatment. Multiple logistic regression analyses revealed that piecemeal resection (hazard ratio, 8.19; 95% CI, 1.47-45.7; P = .02) and margin-positive resection (hazard ratio, 8.06; 95% CI, 1.76-37.0; P = .007) were significant independent predictors of local recurrence after colorectal ESD. Fifteen metachronous invasive cancers (1.0%) were identified during surveillance colonoscopy, most of which required surgical resection.

CONCLUSIONS

A favorable long-term prognosis indicates that ESD can be the standard treatment for large colorectal epithelial neoplasms.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000010136.