Learning curve of endoscopic submucosal dissection (ESD) with prevalence-based indication in unsupervised Western settings: a retrospective multicenter analysis

Clinical audit of endoscopic sub-mucosal dissection performed for complex lateral spreading colorectal tumors from a region non-endemic for colorectal cancer

BACKGROUND

Endoscopic resection is currently the treatment of choice for laterally spreading tumors (LSTs). Endoscopic sub-mucosal dissection (ESD) can achieve higher enbloc resection and R0 resection, albeit at a slightly higher risk of complications. Given scarce data on ESD from India, we performed a retrospective analysis of our experience with colorectal ESD (CR-ESD) to know its clinical efficacy and complications as well as to assess the learning curve of CR-ESD in non-endemic-areas.

METHODS

Retrospective analysis of prospectively maintained datasheet performed. All patients with large (>2cm), complex or recurrent colorectal LST who underwent ESD at our center between 2012 and 2021 were included in the study. Various baseline lesion-related parameters, procedure-related parameters, enbloc resection (ER) rates, R0 margins and adverse event rates were retrieved. CUSUM analysis was performed to calculate the minimum required procedures to achieve competency in CR-ESD.

RESULTS

Total 149 patients were included in the study; mean patient age was 61.36±18.21 years. Most patients had lesions in rectum (n=102; 68.5%) followed by sigmoid colon (n=25; 16.8%). The mean lesion size was 46.62 ± 25.46 mm and the mean procedure duration for ESD was 219.30 ± 150.05 min. ER was achieved in 94.6% of lesions. R0 resection was achieved in 132 patients (88.6%). Overall, six (4%) adverse events were noted, of which one required surgical intervention. As many as 105 patients (70.5%) had adenomatous lesions on histology. Seventy-four patients underwent follow-up colonoscopy, of which three had a recurrence of adenomatous lesions and five had post-resection stricture requiring endoscopic dilation. CUSUM curve analysis calculated the learning curve for ESD was 47 resections for ER and 55 for the occurrence of AEs, with a composite CUSUM at 47 procedures.

CONCLUSION

CR-ESD even in non-endemic area is associated with high en bloc resection rates, R0 resection rates and acceptable complication profile. Approximately 50 cases of CR-ESD are required to achieve competency.

Endoscopic submucosal dissection for early gastric cancer: A major challenge for the west

Gastric cancer (GC) is the 5th most common cancer and the 3rd most common cause of cancer mortality worldwide. Two main endoscopic resective techniques exist for early GC (EGC): Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). ESD has been widely embraced in the last decade because it allows radical en bloc resections and is associated with better outcomes, as compared to EMR. However, the lack of training opportunities and flat learning curve due to low volume of EGC cases represent major obstacles to obtain proficiency on ESD in the West. As this procedure is highly efficient for the treatment of EGC, dedicated training programs with a stepwise approach and updated guidelines for ESD embracement are needed in Western countries.

Effectiveness and safety of newly introduced endoscopic submucosal dissection in a Western center: a real-life study

OBJECTIVES

Endoscopic submucosal dissection (ESD) is a minimally invasive technique for the resection of superficial gastrointestinal lesions, providing high rates of 'en bloc' and R0 resection. East-West differences in ESD quality indicators have been reported. This study aims to assess feasibility, effectiveness, and safety of ESD for the treatment of superficial gastrointestinal (GI) lesions in a Western cohort.

METHODS

Consecutive patients undergoing ESD at one Italian endoscopic referral center from September 2018 to March 2020 were included in this prospective study. Primary outcomes were technical success, R0 resection rate, curative resection rate, and adverse events (AEs).

RESULTS

In total 111 patients (111 lesions) undergoing ESD were included. Anatomic site of the lesions was rectum in 56.8%, colon in 13.5%, stomach in 24.3%, and esophagus in 5.4% of cases, respectively. For upper GI procedures, technical success was 100%, and R0 and curative resection rates were 84.8% and 78.8%, respectively. For colorectal procedures, technical success was 98.7%, R0 and curative resection rates were 88.5% and 84.6%, respectively. Major AEs were reported in 12 cases (10.8%).

CONCLUSION

The introduction of ESD in a Tertiary Center is feasible, effective, and safe, and should be taken into consideration for the treatment of superficial GI lesions requiring 'en bloc' resection.

Effectiveness of Strategy-Focused Training in Colorectal Endoscopic Submucosal Dissection: A Retrospective Observational Study

BACKGROUND

Colorectal ESD, an advanced minimally invasive treatment, presents technical challenges, with globally varying training methods. We analyzed the learning curve of ESD training, emphasizing preoperative strategies, notably gravity traction, to guide ESD instructors and trainee programs.

METHOD

This retrospective study included 881 cases guided by an experienced supervisor. Six trainees received "strategy-focused" instruction. To evaluate the number of ESD experiences in steps, the following phases were classified based on ESD experiences of each trainees: Phase 0 (0-50 ESD), Phase 1 (51-100 ESD), Phase 2 (101-150 ESD), and Phase 3 (151-200 ESD). Lesion background, outcomes, and safety were compared across phases. Factors contributing to technical difficulty in early (Phase 0 and 1) and late phases (Phase 2 and 3) were identified, along with the utility of traction ESD with device assistance.

RESULT

Treatment outcomes were favorable, with 99.8% and 94.7% en bloc resection and curative resection rates, respectively. Approximately 90% self-completion rate could be achieved after experiencing about 50 cases (92.7% in Phase 1), signifying proficiency growth despite increased case difficulty. In early phases, factors such as left-sided colon, LST-NG morphology, and severe fibrosis pose challenges. In late phases, LST-NG morphology, mild and severe fibrosis remained significant. Traction-assisted ESD, utilized in 3% of cases, comprised planned (1.1%) and rescue (1.9%) methods. Planned traction aided specific lesions, while rescue traction was common in the right colon.

CONCLUSION

"Strategy-focused" ESD training consistently yields successful outcomes, effectively adapting to varying difficulty factors in different proficient stages.

Endoscopic Resections for Barrett's Neoplasia: A Long-Term, Single-Center Follow-Up Study

Background and Objectives: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are both well-established and effective treatments for dysplasia and early cancer in Barrett's esophagus (BE). This study aims to compare the short- and long-term outcomes associated with these procedures in treating Barrett's neoplasia. Materials and Methods: This single-center retrospective cohort study included 95 patients, either EMR (n = 67) or ESD (n = 28), treated for Barrett's neoplasia at Sahlgrenska University Hospital between 2004 and 2019. The primary outcome was the complete (en-bloc) R0 resection rate. Secondary outcomes included the curative resection rate, additional endoscopic resections, adverse events, and overall survival. Results: The complete R0 resection rate was 62.5% for ESD compared to 16% for EMR (p < 0.001). The curative resection rate for ESD was 54% versus 16% for EMR (p < 0.001). During the follow-up, 22 out of 50 patients in the EMR group required additional endoscopic resections (AERs) compared to 3 out of 21 patients in the ESD group (p = 0.028). There were few adverse events associated with both EMR and ESD. In both the stratified Kaplan-Meier survival analysis (Log-rank test, Chi-square = 2.190, df = 1, p = 0.139) and the multivariate Cox proportional hazards model (hazard ratio of 0.988; 95% CI: 0.459 to 2.127; p = 0.975), the treatment group (EMR vs. ESD) did not significantly impact the survival outcomes. Conclusions: Both EMR and ESD are effective and safe treatments for BE neoplasia with few adverse events. ESD resulted in higher curative resection rates with fewer AERs, indicating its potential as a primary treatment modality. However, the survival analysis showed no difference between the methods, highlighting their comparable long-term outcomes.

Retrospective Analysis of Rectal Endoscopic Submucosal Dissection at Ordensklinikum Linz and Kepler Universitätsklinikum Linz

Background and study aim: Endoscopic submucosal dissection is a minimally invasive endoscopic procedure for the removal of neoplastic benign and early malignant lesions in the gastrointestinal tract. In this study, we analyse the success and safety of rectal ESD at Linz hospitals, focusing on a specific endoscopist. Additionally, we examine whether there is a learning curve regarding success parameters. Methods: This retrospective study included all 102 patients who underwent endoscopic submucosal dissection of the rectum by a defined endoscopist at Ordensklinikum Hospital and Kepler University Hospital between December 2010 and May 2021. With the collected data, a descriptive statistic was carried out and regression analyses were performed. Results: The en bloc resection rate was 78.4% and the rate of lesions removed in healthy tissue was 55.6%. The average procedure time was 179 min and the complication rate was 7.8%. In total, 26.4% of cases showed carcinoma; in 25.9% of these cases, an oncologically curative resection was achieved with ESD. Follow-up data were available for 61.1% of cases, with recurrence being diagnosed in 3.6% of cases. A learning curve was observed regarding the rate of lesions removed in healthy tissue and the procedure time, but not regarding the en bloc resection rate. Conclusions: Endoscopic submucosal dissection is a safe method for the removal of large rectal adenomas and early carcinomas. The en bloc resection rate of the analysed procedures is within the range of comparable European studies. The rate of lesions removed in healthy tissue is below the R0 resection rate of the comparative literature; however, a learning curve could be observed in this parameter.

Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial

BACKGROUND

Endoscopic resection of adenomas prevents colorectal cancer, but the optimal technique for larger lesions is controversial. Piecemeal endoscopic mucosal resection (EMR) has a low adverse event (AE) rate but a variable recurrence rate necessitating early follow-up. Endoscopic submucosal dissection (ESD) can reduce recurrence but may increase AEs.

OBJECTIVE

To compare ESD and EMR for large colonic adenomas.

DESIGN

Participant-masked, parallel-group, superiority, randomized controlled trial. (ClinicalTrials.gov: NCT03962868).

SETTING

Multicenter study involving 6 French referral centers from November 2019 to February 2021.

PARTICIPANTS

Patients with large (≥25 mm) benign colonic lesions referred for resection.

INTERVENTION

The patients were randomly assigned by computer 1:1 (stratification by lesion location and center) to ESD or EMR.

MEASUREMENTS

The primary end point was 6-month local recurrence (neoplastic tissue on endoscopic assessment and scar biopsy). The secondary end points were technical failure, en bloc R0 resection, and cumulative AEs.

RESULTS

In total, 360 patients were randomly assigned to ESD (n = 178) or EMR (n = 182). In the primary analysis set (n = 318 lesions in 318 patients), recurrence occurred after 1 of 161 ESDs (0.6%) and 8 of 157 EMRs (5.1%) (relative risk, 0.12 [95% CI, 0.01 to 0.96]). No recurrence occurred in R0-resected cases (90%) after ESD. The AEs occurred more often after ESD than EMR (35.6% vs. 24.5%, respectively; relative risk, 1.4 [CI, 1.0 to 2.0]).

LIMITATION

Procedures were performed under general anesthesia during hospitalization in accordance with the French health system.

CONCLUSION

Compared with EMR, ESD reduces the 6-month recurrence rate, obviating the need for systematic early follow-up colonoscopy at the cost of more AEs.

PRIMARY FUNDING SOURCE

French Ministry of Health.

Predictive Factors for the Outcome of Unsupervised Endoscopic Submucosal Dissection During the Initial Learning Curve with Prevalence-Based Indication

BACKGROUND

For an adequate educational strategy of ESD in non-Asian settings with prevalence-based indication it is essential to define adequate lesions, suitable for the beginner without on-site expert-supervision.

AIMS

We analyzed possible predictors for outcome parameters of effectiveness and safety during the initial learning curve.

METHODS

The first 120 ESDs of four operators (n = 480), performed between 2007 and 2020 in four tertiary hospitals, were enrolled. Uni-/multivariable regression analysis was done with sex, age, pretreated lesion, lesion size, organ, and organ-based localization as possible independent predictors for en bloc resection (EBR), complication, and resection speed.

RESULTS

Rates of EBR, complication, and resection speed were 84.5%, 14.2%, and 6.20 (± 4.45) cm2/h. Independent predictors for EBR were pretreated lesion (OR 0.27 [0.13-0.57], p < 0.001) and non-colonic ESD (OR 2.29 [1.26-4.17] (rectum)/5.72 [2.36-13.89] (stomach)/7.80 [2.60-23.42] (esophagus), p < 0.001), for complication pretreated lesion (OR 3.04 [1.46-6.34], p < 0.001) and lesion size (OR 1.02 [1.004-1.04], p = 0.012) and for resection speed pretreated lesion (RC - 3.10 [- 4.39 to - 1.81], p < 0.001), lesion size (RC 0.13 [0.11-0.16], p < 0.001) and male patient (RC - 1.11 [- 1.85 to - 0.37], p < 0.001). We found no significant difference in the incidence of technically unsuccessful resections in esophageal (1/84), gastric (3/113), rectal (7/181), and colonic (3/101) ESDs (p = 0.76). Technical failure was mainly caused by complication and fibrosis/pretreatment.

CONCLUSION

During the initial learning curve of an unsupervised ESD program with prevalence-based indication, pretreated lesions and colonic ESDs should be avoided. In contrast, lesion size and organ-based localizations have less predictive value for the outcome.