The Feasibility of Performing Colorectal Endoscopic Submucosal Dissection Without Previous Experience in Performing Gastric Endoscopic Submucosal Dissection

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.

Management of complications related to colorectal endoscopic submucosal dissection

Compared to endoscopic mucosal resection (EMR), colonoscopic endoscopic submucosal dissection (C-ESD) has the advantages of higher en bloc resection rates and lower recurrence rates of colorectal neoplasms. Therefore, C-ESD is considered an effective treatment method for laterally spread tumors and early colorectal cancer. However, C-ESD is technically more difficult and requires a longer procedure time than EMR. In addition to therapeutic efficacy and procedural difficulty, safety concerns should always be considered when performing C-ESD in clinical practice. Bleeding and perforation are the main adverse events associated with C-ESD and can occur during C-ESD or after the completion of the procedure. Most bleeding associated with C-ESD can be managed endoscopically, even if it occurs during or after the procedure. More recently, most perforations identified during C-ESD can also be managed endoscopically, unless the mural defect is too large to be sutured with endoscopic devices or the patient is hemodynamically unstable. Delayed perforations are quite rare, but they require surgical treatment more frequently than endoscopically identified intraprocedural perforations or radiologically identified immediate postprocedural perforations. Post-ESD coagulation syndrome is a relatively underestimated adverse event, which can mimic localized peritonitis from perforation. Here, we classify and characterize the complications associated with C-ESD and recommend management options for them.

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

BACKGROUND AND AIMS

As there is still no consensus about the adequate training strategy for ESD in Western countries, we evaluated unsupervised prevalence-based learning curves including detailed organ-specific subgroup analysis.

METHODS

The first 120 ESDs of four operators (n = 480) were divided into three groups (1: ESD 1-40, 2: ESD 41-80, 3: ESD 81-120). Outcome parameters were rates of technical success, en bloc and R0 resection, the resection speed, rates of conversion to EMR, curative resection, adverse events, surgery due to adverse events, and recurrence. In addition, we analyzed the achievement of quality benchmarks indicating levels of expertise.

RESULTS

After exclusion of pretreated lesions, 438 procedures were enrolled in the final analysis. Technical success rates were > 96% with significant improvements regarding rate of en bloc resection (from 82.6 to 91.2%), resection speed (from 4.54 to 7.63 cm²/h), and rate of conversion to EMR (from 22.0 to 8.1%). No significant differences could be observed for rates of R0 resection (65.9 vs. 69.6%), curative resection (55.8 vs. 55.7%), adverse events (16.3 vs. 11.7%), surgery due to adverse events (1.5 vs. 1.3%), and recurrence (12.5 vs. 4.5%). Subgroup and benchmark analysis revealed an improvement in esophageal, gastric, and rectal ESD with achievement of competence levels for the esophagus and stomach within 80 and most of the benchmarks for proficiency level within 120 procedures. Some of the benchmarks could also be achieved in rectal ESD.

CONCLUSIONS

This trial confirms safety and feasibility of unsupervised ESD along the initial learning curve with prevalence-based indication and exclusion of colonic cases.

Decreasing Colectomy Rates in Advanced Adenomas

Advanced colon adenomas are commonly treated with colectomy, which is associated with substantial morbidity and mortality. Novel endoscopic resection techniques have been described, including endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESR), which demonstrate promise in treating these neoplasms without colectomy. We performed a retrospective review of patients with advanced adenomas who were referred to a colorectal surgeon for evaluation for resection over 4 years. 40 of 46 (87%) of these patients underwent a successful endoscopic resection. 10 of 46 (21.6%) patients ultimately underwent an operation for a variety of reasons: inability to resect endoscopically (n = 6), invasive cancer on the excised specimen (n = 2), complication of procedure (n = 1), colectomy after polyp recurrence (n = 1). Our study demonstrates EMR and ESD offers an alternative to colectomy in appropriately selected patients with a high success rate. As more surgeons learn advanced endoscopic techniques, there is potential to decrease colectomy rates in benign disease.

A novel flexible auxiliary single-arm transluminal endoscopic robot facilitates endoscopic submucosal dissection of gastric lesions (with video)

BACKGROUND

Using conventional endoscope to perform endoscopic submucosal dissection (ESD) is difficult because of the one-handed operation and blind dissection caused by gravity. Poor visualization of the submucosal plane causes ESD to be associated with a high risk of bleeding and perforation. This study aimed to develop a novel ESD-assistive robot system and to evaluate its efficacy.

METHODS

A novel flexible auxiliary single-arm transluminal endoscopic robot (FASTER) was developed. A total of 36 artificial lesions in ex vivo porcine stomachs were removed using the FASTER-assisted ESD method (n = 18) and the conventional ESD method (n = 18). Lesions were 2 cm or 4 cm in diameter, located on the anterior and posterior walls of the antrum. Primary outcome measurements were dissection time and dissection speed.

RESULTS

The dissection time in FASTER-assisted ESD was significantly shorter than that in conventional ESD (7 min vs 13 min, p = 0.012), mainly because of the faster dissection speed (148.6 vs 97.0 mm²/min, p = 0.002). The total procedure time in FASTER-assisted ESD was shorter than that in conventional ESD, but the difference was not significant (16 min vs 24 min, p = 0.252). Complete en bloc resection was achieved in all lesions. No perforations were detected. The FASTER exhibited the ability of regrasp, multidirectional traction, and proper tension control during ESD.

CONCLUSION

FASTER significantly increased the dissection speed by providing proper traction and achieving good submucosal vision. This new device is expected to facilitate ESD in clinical practice.

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.

Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice

Endoscopic submucosal dissection (ESD) is a method of en-bloc resection of neoplastic colorectal lesions which is less invasive compared to surgical resection. Lesion stratification, architecture recognition and estimation of depth of invasion are crucial for patient selection. Expert endoscopists have integrated a variety of classification systems including Paris, lateral spreading tumor (LST), narrow band imaging (NBI), international colorectal endoscopic (NICE) and Japanese NBI expert team (JNET) in their day-to-day practice to enhance lesion detection accuracy. Major societies recommend ESD for LST-non granular (NG), Kudo-VI type, large depressed and protruded colonic lesions with shallow submucosal invasion. Chance of submucosal invasion enhances with increased depth as well as tumor location and size. In comparison to endoscopic mucosal resection (EMR), ESD has a lowerl recurrence rate and higher curative resection rate, making it superior for larger colonic lesions management. Major complications such as bleeding and perforation could be seen in up to 11% and 16% of patients, respectively. In major Western countries, performing ESD is challenging due to limited number of expert providers, lack of insurance coverage, and unique patient characteristics such as higher BMI and higher percentage of previously manipulated lesions.

The who, what, where, how, and why of endoscopic submucosal dissection in Canada: A survey among Canadian endoscopists

Background and Aim

Endoscopic submucosal dissection (ESD) is an internationally accepted technique for the resection of superficial gastrointestinal neoplasia. ESD allows for en-bloc removal when endoscopic mucosal resection (EMR) is unsuitable due to the size or depth of the lesion. The aim of this survey was to examine Canadian clinicians' experience and perceptions of ESD as its prevalence increases across the country.

Methods

An electronic survey consisting of 24 multiple-choice questions was distributed via the Canadian Association of Gastroenterology email database and directly to those known to be performing or interested in ESD. The survey covered training, practice, obstacles in implementation, and perceptions of the future of ESD in Canada.

Results

A total of 21 participants completed the survey. ESD was performed primarily in the endoscopy suite exclusively (71%), and most operators (64%) performed it on an outpatient basis. Procedure time was selected as the greatest technical challenge in the performance of ESD by 86% of the participants. Both lack of formalized training and long procedure times were the highest ranked barriers to the adoption of ESD. Over the next 5 years, 95% believed there would be an increase in ESD volume in Canada, and 43% believed ESD was ready for adoption by more therapeutic endoscopists.

Interpretation

In this survey, we explored the current practice, attitude, and challenges of ESD in the Canadian landscape. As the performance of ESD increases and gains more acceptance across Canada, there are opportunities to address technical challenges and barriers through the formalization of training, education, and practice guidelines.

Risk of postpolypectomy bleeding in patients taking direct oral anticoagulants or clopidogrel

The usage of direct oral anticoagulants (DOACs) to prevent and treat thromboembolic events is gradually increasing. We aimed to evaluate the outcomes of patients taking DOACs after polypectomy. We retrospectively reviewed 131 patients taking DOACs and 270 taking clopidogrel who underwent polypectomy between November 2010 and December 2017. The risk of delayed postpolypectomy bleeding (PPB) was evaluated and compared. A total of 989 polyps were removed (320 polyps in the DOAC and 669 polyps in the clopidogrel group). DOACs and clopidogrel were discontinued for 2.8 ± 1.7 days and 5.8 ± 2.5 days before polypectomy, respectively. DOACs and clopidogrel were restarted on 1.6 ± 2.9 days and 1.7 ± 1.1 days after polypectomy, respectively. According to per polyp analysis, delayed PPB rate was 1.6% in both groups (p = 0.924). Logistic regression analysis was performed after propensity score matching and revealed that DOACs did not increase the delayed PPB risk compared to clopidogrel (OR 0.929, 95% CI 0.436–1.975, p = 0.847). With the majority following the antithrombotic discontinuation guidelines, the incidence of delayed PPB was 3.1% in the patients taking DOACs. The delayed PPB risk was not greater in those taking DOACs than in those taking clopidogrel.

Learning curve for endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: use of the cumulative sum method

OBJECTIVE

Although scissor-type knives such as the Stag-Beetle (SB) Knife Jr are expected to result in a safe and easy colorectal endoscopic submucosal dissection (CR-ESD), information regarding the learning curve is lacking. Therefore, this study evaluated the learning curve with using SB Knife Jr.

MATERIALS AND METHODS

We retrospectively reviewed 507 CR-ESD procedures performed in 464 patients using SB Knife Jr. The primary endpoint was a learning curve to achieve a satisfactory complete resection rate. The secondary endpoints were learning curves to achieve a satisfactory en bloc resection rate, curative resection rate, and resection speed.

RESULTS

The complete, en bloc, and curative resection rates were 91.9%, 95.9%, and 84.0%, respectively. Moving average analysis showed that 39 cases were required for a complete resection rate of >80%, 41 for an en bloc resection rate of >90%, and 50 for a curative resection rate of >75%. We divided the procedure into three phases using the cumulative sum method: I, II, and III (cases 1-36, 37-119, and 120-507, respectively). Although we found no significant between-phase differences, the complete resection rate showed an increasing trend in Phase III (83.3 vs. 89.2 vs. 93.3%; p = .099). The en bloc resection rate (91.7 vs. 91.6 vs. 97.2%; p = .047) and resection speed (20.5 vs. 7.2 vs. 6.8 min/cm²; p < .001) were greater in Phase III. Despite the larger specimen size (27.3 vs. 38.2 vs. 40.4 mm; p < .001) and more severe fibrosis (p < .001) in Phase III, the procedure time was shorter (73.8 vs. 57.8 vs. 54.2 min; p = .041). The curative resection rate was not significantly different between phases.

CONCLUSIONS

SB Knife Jr enables safe and easy CR-ESD during the introductory period compared to the conventional tip-type knife and has an acceptable learning curve. Therefore, using this knife will encourage the widespread adoption of CR-ESD in Asian general hospitals and non-Asian countries.

Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA

Endoscopic submucosal dissection (ESD) is a rigorous and technically sophisticated method for removal of lesions within the gastrointestinal tract. Despite having advantages of en-bloc resection of lesions, regardless of size, and widespread use in Japan and Asia, ESD has not become widely adopted in the USA for a variety of reasons. Based upon Japanese education and the master-apprentice model, modification to the education system and additional techniques designed to facilitate broader adoption are required for trainees in the USA. This article will review the current state of education and training for ESD in the USA.

Learning Curve for Endoscopic Submucosal Dissection With an Untutored, Prevalence-Based Approach in the United States

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) is widely used in Asia to resect early-stage gastrointestinal neoplasms, but use of ESD in Western countries is limited. We collected data on the learning curve for ESD at a high-volume referral center in the United States to guide development of training programs in the Americas and Europe.

METHODS

We performed a retrospective analysis of consecutive ESDs performed by a single operator at a high-volume referral center in the United States from 2009 through 2017. ESD was performed in 540 lesions: 449 mucosal (10% esophageal, 13% gastric, 5% duodenal, 62% colonic, and 10% rectal) and 91 submucosal. We estimated case volumes required to achieve accepted proficiency benchmarks (>90% for en bloc resection and >80% for histologic margin-negative (R0) resection) and resection speeds >9cm²/hr.

RESULTS

Pathology analysis of mucosal lesions identified 95 carcinomas, 346 premalignant lesions, and 8 others; the rate of en bloc resection increased from 76% in block 1 (50 cases) to a plateau of 98% after block 5 (250 cases). The rate of R0 resection improved from 45% in block 1 to >80% after block 5 (250 cases) and ∼95% after block 8 (400 cases). Based on cumulative sum analysis, approximately 170, 150, and 280 ESDs are required to consistently achieve a resection speed >9cm²/hr in esophagus, stomach, and colon, respectively.

CONCLUSIONS

In an analysis of ESDs performed at a large referral center in the United States, we found that an untutored, prevalence-based approach allowed operators to achieve all proficiency benchmarks after ∼250 cases. Compared with Asia, ESD requires more time to learn in the West, where the untutored, prevalence-based approach requires resection of challenging lesions, such as colon lesions and previously manipulated lesions, in early stages of training.

Long-term outcomes of endoscopically resected laterally spreading tumors with a positive histological lateral margin

BACKGROUND

With advances in diagnostic endoscopy, the incidence of superficial colorectal tumors, including laterally spreading tumors (LSTs), has increased. However, little is known about the long-term results of LSTs with positive lateral margin after endoscopic treatment. This study aimed to evaluate the long-term clinical outcomes and risk factors for local recurrence of LSTs with positive lateral margin after initial endoscopic resection.

METHODS

We performed a retrospective analysis of the medical records of 324 patients who had 363 LSTs with positive lateral margin after endoscopic resection at a tertiary academic medical center. The medical records from 2011 to 2015 were analyzed. Local recurrence was confirmed through endoscopic finding and subsequent biopsy analysis. We assessed the local recurrence rate and performed multivariate analyses to identify the factors associated with local recurrence.

RESULTS

Follow-up colonoscopy was performed in 176 of 363 LSTs. The local recurrence rate was 6.3% (11/176), with a median (interquartile range [IQR]) follow-up period of 19.8 (12.4-46.5) months. In multivariate analysis, local recurrence was associated with piecemeal resection (odds ratio [OR] 6.62, 95% confidence interval [CI] 1.28-34.33; p = 0.024) and inversely associated with thermal ablation (OR 0.033, 95% CI 0.00-0.45; p = 0.011). At surveillance colonoscopy, histology of the recurrent tumor was adenoma in 10 (90.9%) of 11; these were treated endoscopically.

CONCLUSIONS

In this retrospective study, we found that endoscopically resected LSTs with positive lateral margin have a low recurrence rate. Piecemeal resection was associated with higher local recurrence, and thermal ablation was inversely associated with local recurrence. Endoscopic resection with positive lateral margin combined with thermal ablation leads to a low recurrence rate.

How to Learn and Perform Endoscopic Submucosal Dissection and Full-Thickness Resection in the Colorectum in the United States

Pioneered in Japan to address the limitations of endoscopic mucosal resection in the stomach, endoscopic submucosal dissection (ESD) has been applied throughout the gastrointestinal tract, including the colorectum. ESD is technically challenging and has been slowly gaining traction in the West. However, for the committed and resourceful endoscopist, proficiency in ESD can still be achieved. Moreover, improvement in techniques and devices are likely to ease the learning curve while improving procedural duration, safety, and efficacy of colorectal ESD. This article reviews challenges and methods in learning ESD in the United States and provides a primer on performing ESD and full-thickness resection in the colorectum.

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.

Colorectal endoscopic submucosal dissection can be efficiently performed by a trainee with use of a simple traction device and expert supervision

Background and study aims  Colorectal endoscopic submucosal dissection (ESD) is technically challenging owing to submucosal fibrosis and difficult endoscope manipulation. Therefore, various traction methods have been reported. We often use a simple looped nylon thread attached to a clip to assist with dissection. We assessed the feasibility of mentor-guided colorectal ESD using this traction device (TD). Patients and methods  From December 2017 to March 2018, we retrospectively reviewed outcomes of 101 colorectal ESDs performed by two groups of endoscopists (A, 5 endoscopists with colorectal ESD experience of < 50 cases; B, 5 endoscopists with experience of > 300 cases). Group A was further divided into two subgroups that performed ESD with or without TD. Results  No significant difference was observed in ESD completion rates (86.1 % [62/72] vs. 96.6 % [28/29]; odds ratio [OR], 0.22; 95 % confidence interval [CI], 0.005 - 1.71; P  = 0.17) or procedure times (52.0 min vs. 40.0 min; P  = 0.27) and adverse event rates between groups A and B. The rate of TD use was significantly higher in group A than in group B (44.4 % [32/72] vs. 20.7 % [6/29]; OR, 3.03; CI, 1.04 - 10.23; P  = 0.03). The completion rate was not different between the two subgroups of group A (with vs. without TD) (81.2 % [26/32] vs. 90.0 % [36/40]; OR, 0.49; CI, 0.09 - 2.29; P  = 0.32); however, the proportion of fibrosis cases was significantly higher in the TD-use group (46.8 % [15/32] vs. 22.5 % [9/40]; OR, 2.99; CI, 0.98 - 9.59; P  = 0.03). Conclusion  Mentor-guided colorectal ESD using TD was performed efficiently, safely, and in a manner comparable to that of experts.

Colorectal endoscopic submucosal dissection in special locations

Colorectal endoscopic submucosal dissection (ESD) is considered one of the most challenging endoscopic procedures for novice endoscopists. When compared with the stomach, the colon and rectum have a narrower tubular lumen, greater angulation at the flexures, and a thinner muscle layer. These factors make endoscopic control and maneuverability difficult. ESD of the colorectum was considered more difficult than gastric and esophageal ESD. However, with learning from the experts, practicing, and selecting an appropriate technique, most of colorectal ESD could be performed successfully. Nevertheless, some colorectal locations are extremely specialized either from unique anatomy or given unstable scope position. Accordingly, the objective of this review was to provide endoscopists with an overview of the techniques and outcomes associated with ESD at these special colorectal locations. ESD at the discussed special locations of the ileo-colo-rectum was found to be feasible, and outcomes were comparable to those of ESD performed in non-special locations of the ileo-colo-rectum. Practice for skill improvement and awareness of the unique characteristics of each special location is the key to performing successful ESD.

Endoscopic Submucosal Dissection for Colitis-Associated Dysplasia

Dysplasia is a precancerous lesion of colorectal cancer in patients with long-standing inflammatory bowel diseases (IBDs), such as ulcerative colitis and Crohn’s disease. Recent guidelines suggest endoscopic resection as a key modality for the treatment of endoscopically resectable dysplasia in patients with colitis. Endoscopic submucosal dissection (ESD) has been suggested as one of the therapeutic options for dysplasia that is potentially resectable but not suitable for the conventional endoscopic mucosal resection technique. Several recent studies supported the feasibility of ESD for the treatment of colitis-associated dysplasia in terms of the en bloc and complete resection rates and the risk of procedure-related complications. However, these studies were performed exclusively in expert centers. Moreover, the local and metachronous recurrence rates were relatively high, and long-term outcome data are still lacking. Endoscopists should be highly skilled in colorectal ESD and have an intensive understanding of not only the lesions but also the conditions of patients with IBDs. Therefore, the decision to perform ESD for colitis-associated dysplasia should be made scrupulously after careful discussion with patients, in collaboration with a multidisciplinary IBD team including physicians, surgeons, and pathologists specialized in IBDs.

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.

Endoscopic resection techniques for colorectal neoplasia: Current developments

Endoscopic polypectomy and endoscopic mucosal resection (EMR) are the established treatment standards for colorectal polyps. Current research aims at the reduction of both complication and recurrence rates as well as on shortening procedure times. Cold snare resection is the emerging standard for the treatment of smaller (< 5mm) polyps and is possibly also suitable for the removal of non-cancerous polyps up to 9 mm. The method avoids thermal damage, has reduced procedure times and probably also a lower risk for delayed bleeding. On the other end of the treatment spectrum, endoscopic submucosal dissection (ESD) offers en bloc resection of larger flat or sessile lesions. The technique has obvious advantages in the treatment of high-grade dysplasia and early cancer. Due to its minimal recurrence rate, it may also be an alternative to fractionated EMR of larger flat or sessile lesions. However, ESD is technically demanding and burdened by longer procedure times and higher costs. It should therefore be restricted to lesions suspicious for high-grade dysplasia or early invasive cancer. The latest addition to endoscopic resection techniques is endoscopic full-thickness resection with specifically developed devices for flexible endoscopy. This method is very useful for the treatment of smaller difficult-to-resect lesions, e.g., recurrence with scar formation after previous endoscopic resections.

AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States

Endoscopic submucosal dissection (ESD) is an established endoscopic resection method in Asian countries, which is increasingly practiced in Europe and by early adopters in the United States for removal of early cancers and large lesions from the luminal gastrointestinal tract. The intent of this expert review is to provide an update regarding the clinical practice of ESD with a particular focus on its use in the United States. This review is framed around the 16 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects our experience as advanced endoscopists with extensive experience in performing and teaching others to perform ESD in the United States. Best Practice Advice 1: Endoscopic submucosal dissection should be recognized as a mature endoscopic technique that enables complete removal of lesions that are too large for en bloc endoscopic mucosal resection or are at increased risk of containing cancer. Best Practice Advice 2: The safety and feasibility of endoscopic submucosal dissection for early gastric cancer is well established. The absolute indications for curative endoscopic resection include moderately and well-differentiated, nonulcerated, mucosal lesions that are ≤2 cm in size. Best Practice Advice 3: Other relative (expanded) indications for gastric endoscopic submucosal dissection include moderately and well-differentiated superficial cancers that are >2 cm, lesions ≤3 cm with ulceration or that contain early submucosal invasion, and poorly differentiated superficial cancers ≤2 cm in size. The risk of lymph node metastasis when endoscopic submucosal dissection is performed for these indications is higher than when it is performed for absolute indications but remains acceptably low. Best Practice Advice 4: Endoscopic submucosal dissection may be considered in selected patients with Barrett's esophagus with the following features: large or bulky area of nodularity, lesions with a high likelihood of superficial submucosal invasion, recurrent dysplasia, endoscopic mucosal resection specimen showing invasive carcinoma with positive margins, equivocal preprocedural histology, and intramucosal carcinoma. Best Practice Advice 5: Endoscopic submucosal dissection is the primary modality for treatment of squamous cell dysplasia and cancer confined to the superficial esophageal mucosa. Any degree of submucosal invasion caries an increased risk of lymph node metastasis and alternative/additional therapy should be considered. Best Practice Advice 6: Duodenal endoscopic submucosal dissection is associated with an increased risk of intraprocedural perforation and delayed adverse events. Duodenal endoscopic submucosal dissection should be limited to endoscopists with extensive experience in performing endoscopic submucosal dissection in other locations. It is strongly suggested that endoscopists in the United States refrain from performing duodenal endoscopic submucosal dissection during the early phase of their endoscopic submucosal dissection practice. Best Practice Advice 7: All colorectal lesions should be evaluated for suitability for endoscopic resection. Accumulating evidence has shown that the majority of colorectal neoplasms without signs of deep submucosal invasion or advanced cancer can be treated by advanced endoscopic resection techniques. Best Practice Advice 8: Colorectal neoplasms containing dysplasia confined to the mucosa have no risk for lymph node metastasis and endoscopic resection should be considered as the criterion standard. Best Practice Advice 9: Large (>2 cm) colorectal lesions frequently (>43%) require piecemeal removal when endoscopic mucosal resection is used, which is associated with increased (up to 20%) rates of recurrent neoplasia. Endoscopic submucosal dissection enables higher rates of en bloc resection and lower recurrence rates for these lesions. Patients with large complex colorectal polyps should be referred to a high-volume, specialized center for endoscopic removal by endoscopic mucosal resection or endoscopic submucosal dissection. Best Practice Advice 10: Endoscopic resection for colorectal lesions offers significant cost benefit compared with surgery, and case-based endoscopic submucosal dissection selection for high-risk lesions could offer cost savings. Best Practice Advice 11: Endoscopists in the United States embarking on performing endoscopic submucosal dissection should be familiar with currently available endoscopic tissue closure devices. Both clip closure and endoscopic suturing techniques have been shown to be effective in managing intraprocedural perforation. Complete closure of a post-endoscopic submucosal dissection site may be considered in certain circumstances based on patient factors, procedural factors, and the location of the lesion. Best Practice Advice 12: Careful coagulation of exposed blood vessels in the resection site may reduce the risk of delayed bleeding after endoscopic submucosal dissection. The use of low-voltage coagulation current is recommended for this technique. Best Practice Advice 13: Endoscopists should affix the endoscopic submucosal dissection specimen to a flat surface (eg, pin the specimen to cork board) and immerse it in formalin. An expert gastrointestinal pathologist should evaluate the specimen for margin involvement, degree of differentiation, presence or absence of lymphovascular invasion, depth of submucosal invasion (if present), and tumor budding. Best Practice Advice 14: Acquiring high-level competency in endoscopic submucosal dissection is achievable in the United States. Alternative educational models should be used in the United States because of the limited number of experts and the differing prevalence of gastrointestinal luminal diseases as compared with Asia. Best Practice Advice 15: The endoscopic submucosal dissection educational model most suited for the current environment in the United States is a stepwise approach consisting of didactic self-study, attending training courses with increasing levels of complexity, self-practice on animal models, and observation of live cases performed by experts. Endoscopists should perform their initial endoscopic submucosal dissections on patients with lesions that have well-established indications for endoscopic submucosal dissection and are of the lowest technical complexity. Best Practice Advice 16: Endoscopists in the United States who perform endoluminal resection should educate referring physicians to avoid practices that may induce submucosal fibrosis hampering future endoscopic mucosal resection or endoscopic submucosal dissection. These practices include tattooing in close proximity to or beneath a lesion for marking and partial snare resection of a portion of a lesion for histopathology.

Safety of simultaneous endoscopic submucosal dissection for two large colorectal neoplasias in the same patient

BACKGROUND/AIMS

Multiple large colorectal lesions requiring endoscopic submucosal dissection (ESD) are sometimes diagnosed during colonoscopy. We evaluated the feasibility and safety of ESD of two colorectal lesions in one session.

MATERIALS AND METHODS

The lesions of 16 patients who underwent two ESD procedures in a single session (double ESD group) from November 2009 to July 2014 were matched with those of 64 patients who underwent a single ESD procedure (single ESD group) based on the size and location of the lesion and presence of submucosal fibrosis.

RESULTS

The net ESD time per patient was longer in double ESD group than in single ESD group (104.0±36.2 vs. 59.1±39.2 min, p<0.001). The net ESD time per lesion tended to be shorter in double ESD group than in single ESD group (49.6±30.0 vs. 59.1±39.2 min, p=0.077). The en bloc resection and curative resection rates did not differ between double ESD and single ESD groups (93.8 % vs. 98.4%, p=0.262; 90.6 % vs. 84.4 %, p=0.534, respectively). The intra- and postprocedural bleeding rates were 12.5% and 0% in double ESD group and 15.6% and 3.1% in single ESD group, respectively. Perforation occurred in two (6.3%) in double ESD group and in six (9.4%) in single ESD group (p=0.715).

CONCLUSION

Compared with the single ESD, two simultaneous colorectal ESD procedures in a patient did not increase complications; the en bloc and curative resection rates were similar when performed a single ESD procedure and two simultaneous ESD procedures.

Introduction of endoscopic submucosal dissection in the West

Endoscopic submucosal dissection (ESD) is well established in Asia as a modality for selected advanced lesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence (e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.

Implementation of mentor-assisted colorectal endoscopic submucosal dissection in Sweden; learning curve and clinical outcomes

OBJECTIVE

It's still challenging to introduce colorectal (CR) ESD in Western countries. We assessed the feasibility of introducing and implementing CR-ESD in Sweden with hiring Japanese expert as a supervisor.

METHODS

We analyzed 71 consecutive CR-ESD cases performed by two endoscopists who had no (endoscopist A (E-A)) or 20 cases (endoscopist B (E-B)) of experience in ESD. E-A performed rectal lesions while E-B performed lesions in any locations. Factors associated with failure in en bloc resection and in self-accomplishment were analyzed.

RESULTS

Overall en bloc and R0 resection rates were 80.3% and 70.4%. Adverse event occurred in 7.0% including two perforations, two post-operative hemorrhage and one delayed perforation. Only case with delayed perforation underwent surgical treatment. Total self-accomplishment rate was 50% (10/20) for E-A, and 37.3% (19/51) for E-B. Dividing each performer's cases into three learning phases, self-accomplishment rates increased from 42.9% to 83.3% for E-A, and from 29.4% to 70.6% for E-B, as well as en bloc resection rates from 71.4% to 100% for E-A, and from 52.9% to 94.1% for E-B. Multivariate analysis revealed that location upper than rectum, lesions with formerly taken biopsy and lesions larger than 30mm were significantly associated with en bloc resection failure.

CONCLUSIONS

Implementation of CR-ESD with hiring Japanese supervisor for certain period was safe for patients and effective for good learning curve.

Recurrence rate of lateral margin-positive cases after en bloc endoscopic submucosal dissection of colorectal neoplasia

PURPOSE

We aimed to evaluate the recurrence rate of colorectal neoplasia showing histologic lateral margin involvement after en bloc endoscopic submucosal dissection (ESD).

METHODS

We reviewed 527 colorectal lesions that were removed by en bloc ESD from 2005 to 2013 and followed by endoscopy. Based on the postprocedural pathologic reports, the lesions were categorized as follows: lesions with clear deep and positive lateral margins (n = 63) and lesions with R0 resection (n = 299).

RESULTS

The tumor size was 45.7 ± 21.1 mm in the lateral margin-positive group and 30.6 ± 15.1 in the R0 group (P < 0.001). Procedure time was longer in the lateral margin-positive group than in the R0 group (94.3 ± 75.1 vs. 54.1 ± 48.9 min; P < 0.001). Lateral margin positivity was associated with ESD time ≥ 120 min in the multivariate analysis. Compared with 0-I morphology, LST-G was significantly associated with the lateral margin positivity. The volume of ESD experience in endoscopists may also be associated with the lateral margin positivity. Histologic reassessment of the specimen suggested that 32.2% of lateral margin-positive cases based on the initial pathology report were false-positive lateral margin involvement. The 5-year cumulative recurrence rate was 0.6% in the R0 group and 5% in the margin-positive group (P = 0.198).

CONCLUSIONS

The local recurrence rate was not higher in lateral margin-positive cases than in R0 resection cases if the colorectal epithelial neoplasia was removed in an en bloc manner using ESD. Meticulous pathologic interpretation may reduce unnecessarily frequent surveillance after en bloc ESD.

Clinical outcomes of endoscopic submucosal dissection for colorectal tumors: a large multicenter retrospective study from the Hiroshima GI Endoscopy Research Group

BACKGROUND AND AIMS

Although advanced high-volume centers have reported good outcomes of colorectal endoscopic submucosal dissection (ESD), a limited number of highly skilled experts in specialized institutions performed these procedures. We undertook a retrospective multicenter survey, which included nonspecialized hospitals, to investigate the clinical outcomes of colorectal ESD.

METHODS

We recruited 1233 consecutive patients with 1259 colorectal tumors resected by ESD at 12 institutions. We evaluated the en bloc resection rate, histologic complete resection rate, curative (R0) resection rate, adverse events, and the long-term prognoses, including local recurrence, metachronous tumor development, and survival rate.

RESULTS

The en bloc, histologic complete, and R0 resection rates were 92.6%, 87.4%, and 83.7%, respectively. The delayed bleeding, intraoperative perforation, and delayed perforation rates were 3.7%, 3.4%, and .4%, respectively. The long-term outcomes analysis included 1091 patients (88.4%). Local recurrences occurred in 1.7%, and metachronous tumors (>5 mm) developed in 11.0% of the patients. The 3- and 5-year overall survival rates were 95.1% and 92.3%, respectively. The number of colonic tumors, severe submucosal fibrosis, and en bloc resection rates were significantly higher in the high-volume centers (Group H) than those in the low-volume centers (Group L). The average tumor size in Group H was significantly larger than that in Group L.

CONCLUSIONS

Colorectal ESDs are feasible, have acceptable adverse event risks, and favorable long-term prognoses. (Clinical trial registration number: UMIN000016197.).

Colorectal endoscopic submucosal dissection (ESD) in the West - when can satisfactory results be obtained? A single-operator learning curve analysis

OBJECTIVES

Up to date we lack a detailed description of the colorectal endoscopic submucosal dissection (ESD) learning curve, that would represent the experience of the Western center. The aim of this study was to define the critical points of the learning curve and to draw up lesions qualification guidelines tailored to the endoscopists experience.

MATERIALS AND METHODS

We have carried out a single center prospective study. Between June 2013 and December 2016, 228 primary colorectal lesions were managed by ESD procedure. In order to create a learning curve model and to carry out the analysis the cases were divided into six periods, each consisting of 38 cases.

RESULTS

The overall en bloc resection rate was 79.39%. The lowest en bloc resection rate (52.36%) was observed in the first period. After completing 76 procedures, the resection rate surged to 86% and it was accompanied by the significant increase in the mean procedure speed of ≥9 cm²/h. Lesions localization and diameter had a signification impact on the outcomes. After 76 procedures, en bloc resection rate of 90.9 and 90.67% were achieved for the left side of colon and rectum, respectively. In the right side of colon statistically significant lower resection rate of 67.57% was observed.

CONCLUSION

We have proved that in the setting of the Western center, colorectal ESD can yield excellent results. It seems that the key to the success during the learning period is 'tailoring' lesions qualification guidelines to the experience of the endoscopist, as lesions diameter and localization highly influence the outcomes.

Local recurrence and subsequent endoscopic treatment after endoscopic piecemeal mucosal resection with or without precutting in the colorectum

Background/Aims

Precutting before endoscopic piecemeal mucosal resection (EPMR) may increase colorectal polyp resection effectiveness. We aimed to identify risk factors for recurrence after conventional EPMR (CEPMR) and precut EPMR (PEPMR) and investigated endoscopic treatment outcomes for recurrent cases.

Methods

The medical records of patients with colorectal polyps treated by EPMR were analyzed. Patients without follow-up surveillance colonoscopies were excluded.

Results

Among 359 lesions, the local recurrence rate on the first surveillance colonoscopy was 5.8% (18/312) and 6.4% (3/47) after CEPMR and PEPMR, respectively. Among lesions without recurrence at the first surveillance colonoscopy, the rates of late recurrence on subsequent surveillance colonoscopy were 3.9% (6/152) and 0% after CEPMR and PEPMR, respectively. Larger tumor size was the only independent risk factor for recurrence (odds ratio, 7.93; 95% confidence interval, 1.95–32.30; P<0.001). Endoscopic treatment was performed for all 27 recurrences. A combination of ≥2 endoscopic treatment modalities was used in 19 of 27 recurrences (70.4%). Surveillance colonoscopies were performed in 20 of 27 recurrences after endoscopic treatment. One (5.0%) had a re-recurrence and was treated by surgical resection because recurrence occurred at the appendiceal orifice. Nineteen of 20 lesions (95.0%) could be cured endoscopically, although 3 of the 19 showed second or third recurrences and were treated by repeat endoscopic resection.

Conclusions

The local recurrence rates after CEPMR and PEPMR were similar. Larger tumor size was an independent risk factor for local recurrence after EPMR. Endoscopic treatment of recurrences resulted in high cure rates, although combination methods were necessary in many cases.

Colorectal endoscopic submucosal dissection (ESD)

Endoscopic submucosal dissection (ESD) is an interventional procedure for en-bloc resection of gastrointestinal lesions. ESD is a challenging and can involve a reasonable degree of risk, therefore case selection is of crucial importance, especially in the colo-rectum. This procedure should be mainly used for dissection of lesions when there is a high suspicion of superficial malignant invasion; several classifications have been proposed in order to better identify lesions suitable for ESD. However, case selection is still an issue, since only about 8-10% of dissected lesions are superficially invading cancer and most of cases involve benign or massively invading cancer. In addition, significant differences have been reported between Asian and Western countries in regard to main outcomes, and therefore measures should be adopted as soon as possible to reduce this discrepancy.

Colorectal endoscopic submucosal dissection: patient selection and special considerations

Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered.

Feasibility of colorectal endoscopic submucosal dissection (ESD) carried out by endoscopists with no or little experience in gastric ESD

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) is recommended to be carried out only by endoscopists with sufficient experience in gastric ESD. However, early gastric carcinoma is less common in Western countries than in Japan, and endoscopic maneuverability differs between the stomach and colorectum. We assessed the feasibility of colorectal ESD carried out by endoscopists with no or little experience in gastric ESD.

METHODS

We analyzed en bloc resection, R0 resection and perforation rates in 180 consecutive colorectal ESD carried out by three endoscopists who had no or <5 cases of experience in gastric ESD. We also identified factors associated with R0 resection failure.

RESULTS

Overall en bloc and R0 resection rates were 93.3% (168/180) and 82.2% (148/180), respectively. All 11 cases with perforation were treated endoscopically. Dividing 180 cases into three learning phases (early, middle, or late phases), the en bloc and R0 resection rates increased from 88.3% and 75.0% in the early phase to 98.3% and 88.3% in the late phase, respectively. Perforation rate also improved from 10.0% to 3.3%. Factors associated with R0 resection failure were location at junctions (odds ratio: 6.8, 95% CI: 1.9-27.5), preoperative factors reflecting fibrosis (5.8, 1.9-19.0), and late phase (0.2, 0.1-0.7).

CONCLUSION

Endoscopists without experience in gastric ESD carried out colorectal ESD safely. In the early and middle phases (≤40 cases), they should treat mainly rectal lesions but may also resect lesions in the colon avoiding flexures. Lesions located at junctions and those with preoperative factors reflecting fibrosis should be resected after completing 40 procedures.

Endoscopic Mucosal Resection with Circumferential Mucosal Incision for Colorectal Neoplasms: Comparison with Endoscopic Submucosal Dissection and between Two Endoscopists with Different Experiences

Background/Aims

Endoscopic mucosal resection with circumferential mucosal incision (CMI-EMR) may offer benefits comparable to those of endoscopic submucosal dissection (ESD), while requiring less technical proficiency than ESD.

Methods

We retrospectively compared the outcomes of CMI-EMR (n=34) and size-matched ESD (n=102), which were performed by a Korean endoscopist for colorectal epithelial lesions of 20–35 mm. Procedural parameters of CMI-EMRs performed by an American ESD novice (n=30) were compared with those performed by the Korean endoscopist.

Results

The lesion size was 22.3±3.9 mm and 22.9±2.4 mm in the CMI-EMR and size-matched ESD groups, respectively (p=0.730). The resection time was 12.7±7.0 minutes in the CMI-EMR group and 45.6±30.1 minutes in the ESD group (p<0.001). The en bloc resection rate was 94.1% in the CMI-EMR group and 100% in the ESD group (p=0.061). There were no differences in the en bloc resection and complication rates of CMI-EMRs between a Korean and an American endoscopist.

Conclusions

For the treatment of moderate-size colorectal lesions, CMI-EMR showed a trend toward lower en bloc resection rate, but required shorter procedure time than ESD. CMI-EMR outcomes were similar when performed by a Korean ESD expert and an American ESD novice.

Management of early colonic neoplasia: where are we now and where are we heading?

There have been considerable advances in the endoscopic treatment of colorectal neoplasia. The development of endoscopic submucosal dissection and full thickness resection techniques is changing the way benign disease and early cancers are managed. This article reviews the evidence behind these new techniques and discusses where this field is likely to move in the future. Areas covered: A PubMed literature review of resection techniques for colonic neoplasia was performed. The clinical and cost effectiveness of endoscopic mucosal resection (EMR) is examined. The development of endoscopic submucosal dissection (ESD) and knife assisted resection is described and issues around training reviewed. Efficacy is compared to both EMR and transanal endoscopic microsurgery. The future is considered, including full thickness resection techniques and robotic endoscopy. Expert commentary: The perceived barriers to ESD are falling, and views that such techniques are only possible in Japan are disappearing. The key barriers to uptake will be training, and the development of educational programmes should be seen as a priority. The debate between TEMS and ESD will continue, but ESD is more flexible and cheaper. This will become less significant as the number of endoscopists trained in ESD grows and some TEMS surgeons may shift across towards ESD.

Endoscopic submucosal dissection for flat or sessile colorectal neoplasia > 20 mm: A European single-center series of 182 cases

BACKGROUND AND STUDY AIMS

Colorectal endoscopic submucosal dissection (ESD) is an attractive method for en bloc resection of larger flat neoplastic lesions. Experience with this method is limited in the Western World.

PATIENTS AND METHODS

A total of 182 consecutive flat or sessile colorectal lesions (cecum n = 43; right-sided colon n = 65; left-sided colon n = 11, rectum: n = 63) with a size > 20 mm (mean 41.0 ± 17.4 mm) were resected in 178 patients. The data were recorded prospectively.

RESULTS

ESD was technically feasible in 85.2 % of patients with a mean procedure time of 127.5 min (± 99.8) min and a complication rate of 11.5 % (microperforation 9.3 %, delayed bleeding 2.7 %, no case of emergency surgery, 30-day mortality rate 0 %). For 155 successfully completed procedures the en bloc and R0 resection rates were 88.4 and 62.6 %. Efficacy was better for smaller lesions (20 mm to 49 mm; n = 131) than for larger lesions (50 mm to 140 mm; n = 51) with R0 rates of 70.8 vs. 40.5 % (P < 0.001) and procedure times of 92.7 ± 62.4 minutes vs. 217.0 ± 120.9 minutes (P < 0,001).

CONCLUSIONS

This series confirms the efficacy of ESD for en bloc resection of colorectal lesions > 20 mm. RESULTS are satisfactory for lesions up to 50 mm. ESD for larger lesions was associated with low R0 resection rates and very long procedure times. The clinical consequences of microperforations were minor and do not argue against the spread of ESD in the West. Meeting presentations: The data were presented in part at DDW 2014, Chicago IL, USA (Gastrointest Endosc 2014; 79: AB536).

Cap-assisted EMR for rectal neuroendocrine tumors: comparisons with conventional EMR and endoscopic submucosal dissection (with videos)

BACKGROUND AND AIMS

The incidence of rectal neuroendocrine tumors (NETs) is increasing, and most small rectal NETs can be treated endoscopically. Cap-assisted EMR (EMR-C) was suggested as an effective treatment for rectal NETs in a few studies. We aimed to compare the outcomes of conventional EMR, EMR-C, and endoscopic submucosal dissection (ESD) for the treatment of rectal NETs.

METHODS

A total of 138 rectal NETs were treated endoscopically by a single endoscopist at Asan Medical Center. We analyzed 122 rectal NETs that had been removed by using EMR (n = 56), EMR-C (n = 34), or ESD (n = 32).

RESULTS

The histologic complete resection rate was higher in the EMR-C group than in the EMR group (94.1% vs 76.8%, P = .032). Intraprocedural bleeding tended to be more frequent in the EMR-C group than in the EMR group (8.8% vs 0%, P = .051). No differences in the rates of adverse events or histologic complete resections were observed between the EMR-C group and the ESD group for 6-mm to 8-mm NETs; however, the procedure time was significantly shorter in the EMR-C group (3.9 ± 1.1 minutes) than in the ESD group (19.0 ± 12.1 minutes) (P < .001). There was no recurrence in any of the 3 groups.

CONCLUSIONS

EMR-C is the preferable technique for endoscopic resection of small rectal NETs.