Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection: When Is Emergency Colonoscopy Needed?

Risk Factors for Post-Colorectal Endoscopic Submucosal Dissection Bleeding and Efficacy of Carbazochrome Sodium Sulfonate: A Multicenter Retrospective Cohort Study

INTRODUCTION

Carbazochrome sodium sulfonate (CSS) is a hemostatic agent that reduces capillary permeability and enhances capillary resistance. However, its specific effects on colorectal endoscopic submucosal dissection (ESD) outcomes remain uncertain. This study aimed to assess the risk factors for post-ESD bleeding and the effect of CSS on colorectal ESD outcomes.

METHODS

First, we retrospectively analyzed the risk factors for post-ESD bleeding using data from 1,315 lesions in 1,223 patients who underwent ESD for superficial colorectal neoplasms at eight institutions. Second, patients were divided into CSS and non-CSS groups using propensity score matching, and their outcomes from colorectal ESD were analyzed.

RESULTS

The risk factors for post-colorectal ESD bleeding were identified as age of ≥70 years, tumor located in the rectum, tumor size of ≥40 mm, and post-ESD defect unclosure in both univariate and multivariate analyses. The CSS and non-CSS groups each consisted of 423 lesions after propensity score matching. The post-colorectal ESD bleeding rate was 3.5% (15/423) and 3.3% (14/423) in the CSS and non-CSS groups, respectively, indicating no significant differences. Among patients with the high-risk factors for post-ESD bleeding, the administration of CSS also did not demonstrate a significant reduction in the post-ESD bleeding rate compared to the non-CSS group.

CONCLUSION

CSS administration is ineffective in preventing post-colorectal ESD bleeding in both the general population and individuals at a high risk for such bleeding. Our results indicate the necessity to reconsider the application of CSS for preventing post-colorectal ESD bleeding.

A strategy combining endoscopic hand-suturing with clips for closure of rectal defects after endoscopic submucosal dissection with or without myectomy (with video)

BACKGROUND AND AIMS

Endoscopic hand-suturing (EHS) has been preliminarily demonstrated to be effective in closing defects after endoscopic submucosal dissection (ESD), but it is not easily performed. We proposed a strategy combining EHS with clips (EHS-Clips) and explored its effectiveness in closing rectal defects after ESD or ESD with myectomy (ESD-ME).

METHODS

In this observational study, data from patients with rectal defects closed using EHS-Clips were reviewed. EHS-Clips refers to a strategy where defects are sutured as much as possible by EHS first, with clips being used to close the remaining parts of defects that cannot be completely sutured. The primary endpoints included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for the sustained closure.

RESULTS

All 49 (100%) defects (42 ESD defects and 7 ESD-ME defects) were completely closed through the strategy of EHS-Clips, with 35 (71.4%) through EHS alone and 14 (28.6%) through EHS and additional clips. No patients experienced DB. Thirty-six (73.5%) defects remained sustained closure on postoperative days 3 to 5 (73.8% for ESD defects vs 71.4% for ESD-ME defects). The multivariate analyses identified a stitch margin of ≥5 mm (hazard ratio, 0.313; 95% confidence interval, 0.023-0.781; P = .009) as the only independent advantage factor for the sustained closure.

CONCLUSIONS

EHS-Clips can be used to effectively close the rectal defects after ESD or ESD-ME and prevent DB. Complete suture with a stitch margin of ≥5 mm may achieve more reliable sustained closure.

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.

The Management of Direct Oral Anticoagulants for Colorectal Endoscopic Submucosal Dissection: A Multicenter Observational Study

BACKGROUND

There is a lack of reports on the use of direct oral anticoagulants (DOACs) during colorectal endoscopic submucosal dissection (ESD).

AIMS

We aimed to assess whether the use of DOACs is associated with a higher incidence of delayed bleeding (DB) after ESD.

METHODS

A total of 4175 colorectal neoplasms in 3515 patients were dissected at our hospitals during study period. We included 3909 lesions in the final analysis. The lesions were divided into two groups: the no-AT group (3668 neoplasms) and the DOAC group (241 neoplasms). We also compared the DOAC withdrawal group (154 neoplasms) and the DOAC continuation group (87 neoplasms).

RESULTS

Among the 3909 lesions, DB occurred in a total of 90 cases (2.3%). The rate of DB was 2.2% (82/3668), and 3.3% (8/241), respectively. There were no significant differences in the rate of DB between the no-AT group and the DOAC group. In the DOAC group, there were no significant differences in the rate of DB between the withdrawal group (5.2%, 8/154) and the continuation group (0%, 0/87). The multivariable analysis identified the location of the lesion in the rectum (odds ratio [OR], 4.04; 95% confidence interval [CI], 2.614-6.242; p < 0.001) and lesions ≥ 30 mm in diameter (OR, 4.14; 95% CI, 2.349-7.34; p < 0.001) as independent risk factors for DB.

CONCLUSIONS

Our findings suggest that DOAC use has no significant important on the rate of DB. Prospective studies are warranted to determine whether treatment with DOACs should be interrupted prior to colorectal ESD.

Does Prophylactic Closure Improve Outcomes After Colorectal Endoscopic Submucosal Dissection? A Systematic Review and Meta-analysis

BACKGROUND

Several studies have described prophylactic closure after endoscopic submucosal dissection (ESD) of colorectal lesions for improving postoperative outcomes. We reviewed the evidence on the impact of prophylactic closure after ESD.

METHODS

A literature search was conducted on PubMed, Embase, CENTRAL, and Web of Science by 2 reviewers independently for studies published up to July 9, 2023. All types of comparative studies were eligible.

RESULTS

Ten studies compared 939 patients undergoing prophylactic closure with 1074 controls. Three were randomized controlled trials (RCTs) while the rest were observational. Pooled data from all included studies showed that prophylactic closure resulted in reduced incidence of delayed bleeding after ESD [odds ratio (OR): 0.30; 95% CI: 0.15, 0.72; I2 =0%]. These results were significant only for observational studies but not for RCTs. Meta-analysis showed no significant difference in the risk of delayed perforation (OR: 0.55; 95% CI: 0.18, 1.70; I2 =0%) or post-ESD coagulation syndrome (PECS) (OR: 1.15; 95% CI: 0.41, 3.19; I2 =63%) between closure and nonclosure groups.

CONCLUSIONS

Observational data suggest that prophylactic closure of colorectal mucosal defects after ESD may reduce the risk of delayed bleeding. However, the results are not concurred by RCTs. Furthermore, there seems to be no impact of prophylactic closure on the risk of delayed perforation and PECS.

Onset Time and Characteristics of Postprocedural Bleeding after Endoscopic Resection of Colorectal Lesions: A Multicenter Retrospective Study

INTRODUCTION

Postprocedural bleeding is a major adverse event after endoscopic resection of colorectal lesions, but the optimal surveillance time after endoscopy is unclear. In this study, we determined onset time and characteristics of postprocedural bleeding events.

METHODS

We retrospectively screened patients who underwent endoscopic resection of colorectal lesions at three German hospitals between 2010 and 2019 for postprocedural bleeding events using billing codes. Only patients who required re-endoscopy were included for analysis. For identified patients, we collected demographic data, clinical courses, characteristics of colorectal lesions, and procedure-related variables. Factors associated with late-onset bleeding were determined by univariate and multivariate logistic regression analysis.

RESULTS

From a total of 6,820 patients with eligible billing codes, we identified 113 cases with postprocedural bleeding after endoscopic mucosal (61.9%) or snare resection (38.1%) that required re-endoscopy. The median size of the culprit lesion was 20 mm (interquartile range 14-30 mm). The median onset time of postprocedural bleeding was day 3 (interquartile range: 1-6.5 days), with 48.7% of events occurring within 48 h. Multivariate logistic regression analysis demonstrates that a continued intake of antiplatelet drugs (OR: 3.98, 95% CI: 0.89-10.12, p = 0.025) and a flat morphology of the colorectal lesion (OR: 2.98, 95% CI: 1.08-8.01, p = 0.031) were associated with an increased risk for late postprocedural bleeding (>48 h), whereas intraprocedural bleeding was associated with a decreased risk (OR: 0.12, 95% CI: 0.04-0.50, p = 0.001).

CONCLUSION

Significant postprocedural bleeding can occur up to 18 days after endoscopic resection of colorectal lesions, but was predominantly observed within 48 h. Continued intake of antiplatelet drugs and a flat polyp morphology are associated with risk for late postprocedural bleeding.

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.

A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study

BACKGROUND

Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD.

METHODS

We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a < 5 mm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips.

RESULTS

82 patients with a median defect size of 30 (interquartile range 25-40) mm were included. Technical success was achieved in 92.7 % (n = 76): TTS suturing only in 44 patients (53.7 %) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0 %). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3 % (n = 6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture.

CONCLUSION

The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible.

Complications after endoscopic submucosal dissection for early colorectal cancer (Review)

Colorectal cancer (CRC) is a gastrointestinal malignancy that seriously threatens human life and health, resulting in a heavy disease burden. Endoscopic submucosal dissection (ESD) is widely used in clinical practice and is an effective treatment for early CRC (ECC). Colorectal ESD is a challenging operation, and the incidence of postoperative complications is relatively high because of the thin intestinal wall and limited space for endoscopic operations. Systematic reports on the postoperative complications of colorectal ESD, such as fever, bleeding and perforation, from both China and elsewhere are lacking. In the present review, progress in research on postoperative complications after ESD for ECC is summarized.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Continuous use of antithrombotic medications during peri-endoscopic submucosal dissection period for colorectal lesions: A propensity score matched study

BACKGROUND AND AIM

The aim of this study was to elucidate the continuous use of antithrombotic medications during the peri-colorectal endoscopic submucosal dissection (ESD) period.

METHODS

This study included 468 patients with colorectal epithelial neoplasms treated by ESD, consisting of 82 under antithrombotic medications and 386 patients without the medications. Among patients taking antithrombotic medications, antithrombotic agents were continued during the peri-ESD period. Clinical characteristics and adverse events were compared after propensity score matching.

RESULTS

Before and after propensity score matching, post-colorectal ESD bleeding rate was higher in patients continuing antithrombotic medications (19.5% and 21.6%, respectively) than in those not taking antithrombotic medications (2.9% and 5.4%, respectively). In the Cox regression analysis, continuation of antithrombotic medications was associated with post-ESD bleeding risk (hazard ratio, 3.73; 95% confidence interval, 1.2-11.6; P < 0.05) compared with patients without antithrombotic therapy. All patients who experienced post-ESD bleeding were successfully treated by endoscopic hemostasis procedure or conservative therapy.

CONCLUSIONS

Continuation of antithrombotic medications during the peri-colorectal ESD period increases the risk of bleeding. However, the continuation may be acceptable under careful monitoring for post-ESD bleeding.

Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade

Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.

Clip-assisted endoloop ligation of the mucosal defect after resection of colorectal polyps decreased postprocedural delayed bleeding

BACKGROUND

Postprocedural delayed bleeding (PDB) remains the most common major complication of colorectal polypectomy. Incomplete clip closure of mucosal defect and unclosed injured blood vessels in gaps between clips may be the risk factors for PDB.

OBJECTIVES

To observe whether completely no-gap closure of mucosal defect after polypectomy can reduce PDB occurrence.

DESIGN

Single-center, retrospective case-control study.

METHODS

In this study based on historical comparisons of patients in 2 time periods, only the patients with polyps sized between 6 and 15 mm were included. A new clip-assisted endoloop ligation (CAEL, treatment group) method was used between January 2019 and December 2020, and a traditional simple clip closure (SCC, control) was used Between January 2017 and December 2018 to prevent PDB after polypectomy. The rate of PDB of two groups and risk factors for PDB were evaluated.

RESULTS

Totally 4560 patients were included in the study; 2418 patients belong to CAEL group, and 2142 patients belong to SCC group. The overall rate of PDB was significantly lower in CAEL group compared to SCC group (0.6% versus 1.5%, p < 0.00). On multivariate logistic analysis, CAEL was a significant independent preventive factor for PDB (odds ratio (OR), 0.092; 95% confidence interval (CI), 0.029-0.3335; p = 0.000). Polyps located at rectum (colon versus rectum) represented a significant independent risk factor for PDB (OR, 11.888; 95% CI, 3.343-42.269; p = 0.001).

CONCLUSION

Completely no-gap closure of mucosal defect after polypectomy further reduced the rate of PDB for polyps sized between 6 and 15 mm. CAEL may be a significant independent preventive factor for PDB. Polyps located at the rectum may be a significant independent risk factor for PDB.

Indication of emergency colonoscopy after colorectal endoscopic submucosal dissection: A proposal of hematochezia scale

BACKGROUND AND AIM

Hematochezia is a major adverse event associated with colorectal endoscopic submucosal dissection (ESD). This study aimed to distinguish between hematochezia that required endoscopic hemostasis and hematochezia that required no hemostasis.

METHODS

This retrospective study included consecutive patients who underwent ESD for colorectal tumors at the Osaka International Cancer Institute between September 2017 and August 2020. The exclusion criteria were as follows: patients with coexisting advanced colorectal cancers or inflammatory bowel diseases, patients who received incomplete ESD or emergency surgery, or patients who underwent ESD for multiple lesions. We evaluated whether the patients had hematochezia and underwent emergency colonoscopy and hemostasis during hospitalization. The degree of hematochezia in the saved photographs was assessed using the hematochezia scale and classified as mild, moderate, or severe. Blood pressure, heart rate, time from ESD to first hematochezia, and total number of hematochezia episodes were also evaluated.

RESULTS

Among the 437 patients who underwent ESD, 44 were excluded, and 393 patients were evaluated. Hematochezia was observed in 100 patients (25%). Emergency colonoscopy was performed in 12 patients (3%), and hemostasis was required in six patients (2%). For patients with hematochezia, only mild hematochezia and hematochezia that developed ≤ 48 h after ESD were significantly associated with no intervention for hemostasis. The positive predictive value for no intervention for hemostasis was 100% (93-100%) for mild hematochezia and 98% (93-100%) for hematochezia ≤ 48 h.

CONCLUSIONS

Mild hematochezia and hematochezia ≤ 48 h were negative predictors of hemostasis, in which emergency colonoscopy may be avoided.

Endoscopic submucosal dissection for removal of large colorectal neoplasias in an outpatient setting: a single-center series of 660 procedures in Sweden

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the removal of large lesions in the GI tract. Because of the complexity of the technique, implementation in Western health care has been slow. An ESD procedure is usually followed by hospital admission. Our aim was to investigate if ESD of colorectal lesions can be performed in an outpatient setting.

METHODS

Six hundred sixty colorectal ESD procedures between 2014 and 2020 were evaluated retrospectively. All patients referred to the unit with an early colorectal neoplasm >20 mm without signs of deep invasion were considered eligible for an ESD procedure.

RESULTS

Of 660 lesions, 323 (48.9%) were localized in the proximal colon, 102 (15.5%) in the distal colon, and 235 (35.6%) in the rectum. Median lesion size was 38 mm (interquartile range, 30-50) and median procedure duration 70 minutes (interquartile range, 45-115). En-bloc resection was achieved in 620 cases (93.9%). R0 resection was achieved in 492 en-bloc resections (79.4%), whereas the number of Rx and R1 resections was 124 (20.0%) and 4 (.6%), respectively. Low-grade dysplasia was found in 473 cases (71.7%), high-grade dysplasia in 144 (21.8%), and adenocarcinoma in 34 (5.1%). Six hundred twelve procedures (92.7%) were scheduled as outpatient, and 33 of these underwent unplanned admission. Forty-eight cases (7.3%) were planned as inpatient procedures. The rate of full wall perforation was 38 (5.8%), in which 35 (92.1%) were managed endoscopically and 3 patients (7.9%) required emergency surgery. Forty-six patients (7.0%) sought medical attention within 30 days because of bleeding (21 [3.2%]), abdominal tenderness (16 [2.4%]), and other reasons (9 [1.4%]). Twenty-four of these patients were admitted for observation for a median of 2 days (range, 1-7). Ten of these patients were treated with antibiotics, and 6 patients required blood transfusion. None required additional surgery.

CONCLUSIONS

ESD of colorectal lesions can be safely performed in an outpatient setting in a well-selected patient.

Propensity score matching analysis to evaluate efficacy of polyethylene oxide adhesive on preventing delayed bleeding after gastric endoscopic submucosal dissection

Regardless of technical advancements, delayed bleeding is still a common adverse event after gastric endoscopic submucosal dissection (ESD), often occurring in the early postoperative phase. This study aimed to evaluate the efficacy of a newly designed polyethylene oxide (PEO) adhesive for preventing delayed gastric bleeding. Patients who underwent gastric ESD between December 2017 and December 2020 at three Chinese institutions were retrospectively reviewed. Patients receiving PEO application on gastric post-ESD ulcers were included in the PEO group, and patients without this procedure were included in the control group. To minimize potential bias, propensity score matching was performed, and sex, age, lesion size, lesion morphology, ulceration, localization, procedure time, frequency of major intraoperative bleeding, resected specimen size, lesion histopathology, submucosal invasion and the taking of antithrombotic drugs were included as matching factors. The incidence of delayed bleeding and time to bleeding were compared between both groups. After propensity score matching, 270 patients (135 per group) were included in the analysis. The delayed bleeding rate in the PEO group was significantly lower than that in the control group (1.5%, 2/135 vs. 8.9%, 12/135, P = 0.006). The median time (range) to bleeding was 4.5 (4–5) days in the PEO group and 2 (1–15) days in the control group, with no significant difference (P = 0. 198). PEO demonstrated a significant effect in reducing the rate of delayed bleeding. Further study is warranted to confirm the efficacy of PEO for bleeding that occurs in the early phase after gastric ESD.

Risk factors of delayed post-polypectomy bleeding after treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection

Context

Gastrointestinal polyps are common gastrointestinal diseases that involve localised hyperplastic masses derived from gastrointestinal mucosa.

Aims

To investigate the risk factors of delayed post-polypectomy bleeding (DPPB) after the treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection (ESD) and to construct a nomogram model to predict the risk of DPPB.

Settings and Design

A total of 226 patients who underwent snare-assisted ESD for gastrointestinal polyps from May 2018 to November 2020 were divided into DPPB group (n = 10) and non-DPPB group (n = 216).

Subjects and Methods

The correlations of clinical data and endoscopic data with DPPB were compared. Univariate analysis was performed to screen the influencing factors of DPPB. Multivariate logistic regression analysis was used to screen the risk factors of DPPB, which was employed to construct a nomogram prediction model.

Statistical Analysis Used

SPSS 16.0 software was utilised for statistical analysis. Numerical data were expressed as percentage (n [%]), and Chi-square test was performed for univariate analysis. The significant factors (P < 0.05) in univariate analysis were included in multivariate logistic regression analysis, and the variables with statistical significance (P < 0.05) were considered as independent risk factors. The factors were used to construct a nomogram model for predicting the risk of DPPB. Bootstrap method was employed to perform repeated sampling 1000 times for internal verification. The consistency index (C-index) was used to evaluate the discrimination of the model, and C-index ≥0.70 represented a good discrimination. Two-tailed P < 0.05 indicated that a difference was statistically significant.

Results

Univariate and multivariate logistic regression analyses revealed that hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were the independent risk factors for DPPB (P < 0.05). The C-index of the nomogram model for predicting the risk of DPPB was 0.791, indicating a good discrimination. The calibration curve showed that the mean absolute error between predicted and actual DPPB occurrence risks was 0.014, indicating a high accuracy.

Conclusions

Hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding are the independent risk factors for DPPB, and the nomogram model established based on these factors for prediction has good discrimination and accuracy. Therefore, it is recommended to perform targeted intervention for high-risk groups to reduce the incidence of DPPB.

Risk factors for adverse events of colorectal endoscopic submucosal dissection: a systematic review and meta-analysis

Colorectal endoscopic submucosal dissection (ESD) is already an established treatment for superficial colorectal tumors. However, its technical difficulty and high adverse events rates, compared to endoscopic piecemeal mucosal resection, are a concern to some specialists and have probably contributed to discouragement in its widespread adoption. The debate mentioned above stimulated us to perform a systematic review aiming to identify risk factors for colorectal ESD-related adverse events. We conducted this study following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement and registered in the PROSPERO (University of York) international database (CRD42016042625). We searched MEDLINE, EMBASE, Cochrane Library and LILACS for the publications focused on risk factors for colorectal ESD-related adverse events from inception until April 2020. We included a total of 22 qualified studies in this analysis. We found that fibrosis had an odds ratio (OR) for perforation of 2.90 [95% confidence interval, (1.83-4.59)], right colon location of 2.35 (1.58-3.50), colonic location of 2.20 (1.44-3.35) and larger size of 2.17 (1.47-3.21), as well as one protective factor, the endoscopist experience OR = 0.62 (0.45-0.86). For bleeding, we considered rectal location a risk factor [OR = 3.55 (2.06-6.12)]. Through the several meta-analyses that we performed in this article, we could summarize the main risk factors for perforation and bleeding on colorectal ESD. Therefore, we provide insightful information for clinical judgment on regions where colorectal ESD is already widespread and help in the learning process of this challenging technique.

Evaluation of colorectal endoscopic submucosal dissection using a multifunctional snare: a prospective clinical feasibility study (with videos)

BACKGROUND AND AIMS

The number of colorectal endoscopic submucosal dissections (ESDs) for early colorectal cancer is expected to increase in the future; therefore, cost reduction is a clinically important issue. The SOUTEN snare (Kaneka Medics, Tokyo, Japan) is a novel multifunctional snare developed for hybrid ESD at a low price. If ESD can be performed safely using the SOUTEN snare, the same therapeutic effect can be obtained as with conventional ESD at a lower cost. The aim of this prospective, pilot, clinical feasibility study was to evaluate the safety and efficacy of ESD using the SOUTEN snare (SOUTEN-ESD).

METHODS

From October 2018 to January 2019, 119 consecutive patients (121 ESD procedures, 137 colorectal neoplasms) were prospectively enrolled and treated by SOUTEN-ESD at NTT Medical Center Tokyo and Omori Red Cross Hospital. The outcomes of SOUTEN-ESD were evaluated.

RESULTS

Among 137 neoplasms, SOUTEN-ESD was completed in all cases. No cases required conversion to hybrid ESD or to a dedicated ESD device. The mean procedure time was 26.1 ± 14.3 minutes. Both the en-bloc resection rate and R0 resection rate were 100%. The rate of perforation was 0%, the rate of delayed bleeding was 2.2%, and the rate of post-ESD coagulation syndrome was 2.9%.

CONCLUSIONS

SOUTEN-ESD was safe and had good outcomes. Although further studies are required to examine indications for SOUTEN-ESD and confirm the results of this study, effective ESD with this novel knife is feasible. The SOUTEN snare is a realistic option for colorectal ESD. (Clinical trial registration number: UMIN 000034299.).

Impact of obesity in colorectal endoscopic submucosal dissection: single-center retrospective cohort study

BACKGROUND

When performing colorectal endoscopic submucosal dissection (ESD) in obese patients, technically difficult cases are sometimes experienced because of difficulty with the insertion of the colonoscope, poor scope maneuverability, or an abundance of fat tissue in the submucosal layer. Since the association between obesity and colorectal ESD has not been investigated, we evaluated the clinical impact of obesity in patients who underwent colorectal ESD.

METHODS

We retrospectively reviewed 535 patients who underwent colorectal ESD between April 2012 and February 2019. Patients were divided into three groups based on their body mass index (BMI): a control group (BMI < 25 kg/m²), an overweight group (25 kg/m² ≤ BMI < 30 kg/m²), and an obese group (BMI ≥ 30 kg/m²), and the short-term clinical outcomes were analyzed to assess the safety and difficulty of colorectal ESD.

RESULTS

No significant difference in the procedure times, en bloc resection rates, pathological diagnoses, or complications were seen among the groups. While the amount of sedative per body weight was significantly lower in the group with a higher BMI (flunitrazepam: 1.75 × 10^-2 [1.27 × 10^-2-2.34 × 10^-2] mg/kg vs. 1.48 × 10^-2 [1.08 × 10^-2-2.03 × 10^-2] mg/kg vs. 1.16 × 10^-2 [0.98 × 10^-2-1.54 × 10^-2] mg/kg, P < 0.001; pethidine: 0.63 [0.55-0.72] mg/kg vs. 0.50 [0.46-0.56] mg/kg vs. 0.39 [0.32-0.45] mg/kg, P < 0.001), a reduction in percutaneous arterial oxygen saturation occurred significantly more frequently in the group with a higher BMI (123 [30.2%] vs. 43 [43.9%] vs. 10 [55.6%], P = 0.005). When the procedures were performed by trainees, the number of cases that required a procedure time of longer than 90 min was significantly larger in the group with a higher BMI (27 [10.8%] vs. 14 [21.9%] vs. 3 [25.0%], P = 0.033).

CONCLUSIONS

This study showed that colorectal ESD could be performed safely and effectively in obese patients. However, ESD in obese patients requires attention, particularly to changes in respiratory conditions.

Palisade technique as an effective endoscopic submucosal dissection tool for large colorectal tumors

Background and study aims  Endoscopic submucosal dissection (ESD) has become the standard treatment for colorectal ESD, but large colorectal tumors remain difficult to remove. We developed a new method, called the palisade technique, by modifying the multiple tunneling technique. In this method, a palisade of submucosal tissue is left beneath the tumor to anchor a dissected specimen, maintaining effective submucosal traction. Patients and methods  The study included 11 patients with large colorectal tumors that were over half the circumference of the colorectal lumen which were treated using the palisade technique from August 2017 to October 2019. Overall resection outcomes were assessed. Results  All 11 lesions were removed en bloc. The R0 resection rate was 45.6 % because of marginal burning of the specimen, but no local recurrence was found after a median observation period of 31 months. The median submucosal dissection time (SDT) and submucosal dissection speed (SDS) were 170 minutes and 23.1 mm 2 /min, respectively. One case of post-ESD hemorrhage was successfully managed endoscopically, and two cases of post-colorectal ESD coagulation syndrome were managed conservatively. Conclusion  The palisade technique can be an effective and safe technique for treating large colorectal tumors that extend over half the luminal circumference.

Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta-analysis

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large colorectal lesions. However, colorectal ESD is associated with a high frequency of adverse events (AEs), and the efficacy of prophylactic endoscopic closure after ESD for preventing AEs is still controversial. This meta-analysis was conducted to assess the efficacy of closure on AEs following colorectal ESD.

METHODS

We searched PubMed, Embase, and the Cochrane Library for eligible studies. The chi-square-based Q statistics and the I² test were used to test for heterogeneity. Pooling was conducted using a fixed or random effects model.

RESULTS

We identified eight eligible studies that compared the effects of closure vs non-closure with respect to delayed bleeding, delayed perforation, and post-ESD coagulation syndrome. Compared with non-closure (5.2%), closure was associated with a lower incidence (0.9%) of delayed bleeding (pooled odd ratios [ORs]:0.19, 95% CI: 0.08-0.49) following ESD. The pooled ORs showed no significant differences in incidence of delayed perforation (pooled OR: 0.22; 95% CI: 0.05-1.03) or post-ESD coagulation syndrome (pooled OR:0.75; 95% CI: 0.26-2.18) between the closure and non-closure groups.

CONCLUSION

Prophylactic endoscopic closure may reduce the incidence of delayed bleeding following ESD of colorectal lesions. Future studies are needed to further illuminate risk factors and stratify high risk subjects for a cost-effective preventive strategy.

Efficacy and safety of colorectal endoscopic submucosal dissection in patients with sarcopenia

BACKGROUND

Endoscopic submucosal dissection (ESD) for early-stage colorectal cancer (CRC) has become a common and useful treatment. Although sarcopenia has been identified as an independent risk factor for complications after surgery for CRC, whether sarcopenia is also an independent risk factor for complications after colorectal ESD remains to be clarified. The aim of this study was to compare the outcomes of colorectal ESD in patients with and those without sarcopenia.

METHODS

This is a retrospective cohort study. A total of 334 patients underwent colorectal ESD for 361 neoplasms at Hiratsuka City Hospital from March 2012 to October 2018. The neoplasms were divided into two groups depending on the presence or absence of sarcopenia in the patients.

RESULTS

Overall, 334 patients underwent colorectal ESD for 361 neoplasms during the study period. We excluded 90 patients (90 neoplasms), and 244 patients (277 neoplasms) were included in the final analysis (134 from the sarcopenia group, 137 from the non-sarcopenia group). The en-bloc resection rate was high and was not significantly different between the sarcopenia group [126/134 (94.1%)] and the non-sarcopenia group [133/137 (97.1%)], P = 0.1778). The rate of perforation and the rate of delayed bleeding were not significantly different between the sarcopenia group and the non-sarcopenia group [6/134 (4.5%) vs. 9/137 (6.6%), P = 0.314, 4/134 (3%) vs. 6/137 (4.4%), P = 0.3885, respectively].

CONCLUSIONS

The presence of sarcopenia did not influence the rate of complications after ESD. Colorectal ESD is safe and effective even in patients with sarcopenia. Prospective multicenter studies are necessary to confirm our results.

The Efficacy and Safety of a Promising Single-Channel Endoscopic Closure Technique for Endoscopic Treatment-Related Artificial Ulcers: A Pilot Study

Background/Aims

It is important to appropriately manage patients with procedure-related artificial mucosal ulcers or procedure-related complications. Many endoscopic closure techniques have been reported; however, they often require the use of special devices. We developed a single-channel endoscopic closure technique (SCCT) that can be performed with conventional devices. In the present study, we describe the technique and evaluate its efficacy.

Methods

Twenty-five consecutive patients who underwent endoscopic treatment and whose artificial ulcer was closed using the SCCT were enrolled in this study. The technical success rate, number of clips for closure, procedure time, complication rate on the day of the procedure, clinical success rates on days 1 and 5, and incidence of severe stenosis of the gastrointestinal (GI) tract at 2 months after the procedure were evaluated.

Results

The median ulcer diameter was 20 mm. The tumor locations were the stomach (n = 19), jejunum (n = 1), and colon (n = 5). The technical success rate was 100% (25/25), and the rate of incomplete closure was 0% (0/25). Eight clips were needed on average. The median procedure time was 18 min (range 5-49 min). The complication rate was 0% (25/25). The clinical success rates on days 1 and 5 were 100% (19/19) and 100% (9/9), respectively. No patients presented stenosis as a late complication at 2 months after the procedure (0/25).

Conclusion

The SCCT could be applied in the treatment of artificial ulcers in several parts of the GI tract with a high clinical success rate and no complications. The SCCT appears to be a good option for closing artificial mucosal ulcers.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect

BACKGROUND

Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD.

METHODS

We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques.

RESULTS

A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed.

CONCLUSIONS

Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Predictive Factors of Mild and Severe Fibrosis in Colorectal Endoscopic Submucosal Dissection

BACKGROUND AND STUDY AIMS

Varying degrees of fibrosis in colorectal endoscopic submucosal dissection (ESD) make the procedure difficult. Consensus on the predictive factors of fibrosis degree (mild or severe) has not been established. We conducted a study to identify the predictive factors and to examine the feasibility of ESD for fibrotic lesions.

PATIENTS AND METHODS

We included 518 patients who had undergone ESD for 558 lesions from April 2012-September 2018. Patients were classified into fibrosis or no-fibrosis groups, and logistic regression analysis was performed to identify predictive factors of fibrosis. Subgroup analyses were performed for fibrosis degree.

RESULTS

The total incidence of fibrosis was 21.1% (mild: 14.1%; severe: 7.1%). Although the curative resection rate (free margin: invasion depth less than 1000 μm: no lymphatic invasion, vascular involvement) was lower in the fibrosis group compared with the control (80.7% vs. 97.6%), neither the en bloc resection rate (99.1% vs. 100%) nor incidence of perforation (0.9% vs. 0.2%) differed between the two groups. Multivariate analysis revealed that a cecal location, preoperative biopsy, straddling fold, laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) type were predictive of mild fibrosis. The presence of a straddling fold and a protruded lesion were independent predictive factors of severe fibrosis.

CONCLUSIONS

We identified the predictive factors of mild and severe fibrosis. It is preferable that a more experienced physician performs ESD for the lesions with F2 fibrosis.

Safety of Cold Snare Polypectomy in Patients Receiving Treatment with Antithrombotic Agents

BACKGROUND

With the aging of the population and rising incidence of thromboembolic events, the clinical use of antithrombotic agents is also increasing. There are few reports yet on the management of antithrombotic agent use in patients undergoing cold snare polypectomy (CSP).

AIMS

The aim of this study was to evaluate whether continued administration of antithrombotic agents in patients undergoing CSP would be associated with an increased rate of delayed post-polypectomy bleeding (DPPB).

METHODS

A total of 1177 colorectal polyps in 501 patients were resected at Omori Red Cross Hospital between October 2017 and March 2018. The polyps were divided into two groups depending on whether the patients received antithrombotic agent treatment or not: the antithrombotic group (911 polyps) and the no-antithrombotic group (266 polyps).

RESULTS

Among the 1177 polyp resections, there was no case of DPPB, including in the antithrombotic group. Immediate bleeding occurred in a total of 63 (5.4%) cases. Polyp location in the rectum (OR (95% CI) 2.64 (1.223-5.679); p = 0.013), polyp size ≥ 6 mm (OR (95% CI) 4.64 (2.719-7.933); p < 0.001), polypoid growth pattern (OR (95% CI) 2.78 (1.607-4.793); p < 0.001), and antithrombotic agent use (OR (95% CI) 2.98 (1.715-5.183); p < 0.001) were identified as significant risk factors of immediate bleeding.

CONCLUSIONS

Continued use of antithrombotic agents does not increase the risk of DPPB, even in those receiving multiple antithrombotic agents. Thus, it is safe to perform CSP even in multiple agent users. Prospective, randomized studies are necessary to confirm our results.

Management of Complications of Colorectal Submucosal Dissection

Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of superficial gastrointestinal neoplasm. Compared with endoscopic mucosal resection (EMR), ESD has several benefits, which include resectability of various difficult lesion, accurate histologic assessment of specimen, and lower recurrence rate. However, the risk of procedure- related complications is higher with ESD than with EMR. Moreover, because the colon has a thin wall and limited endoscopic maneuverability, ESD is considered a more challenging and risky procedure when performed in the colon than in the stomach. ESD-related complications are more likely to occur. The significant complications associated with ESD are bleeding, perforation, coagulation syndrome and stenosis, most of which can be treated and prevented by endoscopic intervention and preparation. Therefore, it is important to know how to occur and manage the ESD related complication.