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

Efficacy of Two Kinds of Scissor-Type Knives for Colorectal Endoscopic Submucosal Dissection: A Retrospective Comparative Study

INTRODUCTION

Scissor-type knives are spreading as safe devises in endoscopic submucosal dissection (ESD). We evaluated the efficacy of two kinds of scissor-type knives (Clutch Cutter: CC, Fujifilm Co. and SB Knife Jr2: SB, SB-KAWASUMI Laboratories. Inc.) in colorectal ESD.

METHODS

This single-center retrospective study analyzed 178 ESD cases treated with CC from January 2020 to August 2021 and 91 cases with SB from September 2021 to December 2023. The two groups were compared through propensity score matching. Therapeutic results, such as ESD procedure time, en bloc resection rate, perioperative bleeding frequency, and complications, were analyzed in each group. Risk factors for long ESD procedure time (≥ 90 min) were also examined.

RESULTS

After matching, 87 cases in each group were analyzed. There was no significant difference in the ESD procedure time (min, median [interquartile range]) between the CC and SB groups (54.0 [36.0-72.0] vs. 53.0 [39.0-72.0], p = 0.99). Additionally, there were no differences in the en bloc resection (100% vs. 100%, p = 1.00), perioperative perforation (1.1% vs. 1.1%, p = 1.00), or delayed bleeding (1.1% vs. 0.0%, p = 1.00). There was a significant difference in perioperative bleeding frequency (mean ± standard deviation: 1.8 ± 2.6 vs. 3.0 ± 3.5, p < 0.01). The significant risk factors (odds ratio [95% confidence interval]) for long ESD procedure time in patients treated with CC or SB were antiplatelet (7.51 [1.82-31.00]), large lesion size (1.08 [1.05-1.12]), severe fibrosis (24.30 [7.60-77.90]), and perioperative bleeding frequency (1.34 [1.14-1.56]).

CONCLUSIONS

CC and SB in colorectal ESD enabled high en bloc resection and low complication rates. CC showed significantly less perioperative bleeding than SB.

The Key Role of Tumor Budding in Predicting the Status of Lymph Node Involvement in Early Gastric Cancer Patients: A Clinical Multicenter Validation in China

BACKGROUND

Accurate preoperative prediction of lymph node (LN) involvement is essential for the management of early gastric cancer (EGC). Our objective was to formulate a potent nomogram for predicting LN involvement in EGC by leveraging an innovative predictor of tumor budding.

METHODS

We assembled a cohort of EGC patients who underwent radical surgery at two tertiary cancer centers. Tumor budding was stratified by using an optimal cutoff value and integrated with other clinicopathological variables to ascertain the risk factors associated with LN involvement. A nomogram was developed and its predictive performance was assessed by using receiver operating characteristic (ROC) curves and calibration plots. In addition, we conducted decision curve analysis to evaluate its clinical utility. Finally, an external validation was conducted by using an independent cohort.

RESULTS

Finally, 307 eligible patients (215 in the primary cohort and 92 in the validation cohort) were included. Tumor budding, categorized by a count of two, exhibited a robust association with LN involvement (OR 14.12, p = 0.012). Other significant risk factors include lymphovascular invasion, depth of tumor invasion, ulceration, and tumor differentiation. Notably, the nomogram demonstrated exceptional discriminative power (area under the ROC curve, 0.872 in the primary cohort and 0.885 in the validation cohort) and precise predictive capabilities. Furthermore, the nomogram showed notable clinical applicability through decision curve analysis, particularly in endoscopic curability C-2, by mitigating the risk of overtreatment.

CONCLUSIONS

Tumor budding is a robust predictor of LN involvement in EGC. The incorporation of tumor budding into a nomogram is an effective strategy, thereby informing and enhancing clinical decision-making.

Is there a best choice of equipment for colorectal endoscopic submucosal dissection?

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a widely used technique to remove early neoplastic lesions. It was primarily used in the initial days to treat gastric lesions, but recently, the horizon of this endoscopic procedure has expanded, which has allowed us to manage other technically more complex locations, such as the colorectum.

AREAS COVERED

There has been an exponential growth regarding the wide range of devices available in the market for performing colorectal ESD. As a result, the aim of this review is to highlight the indication of this endoscopic technique, which device is best suited for which indication, as well as future trajectories in this field.

EXPERT OPINION

Although some devices have proven to be more advantageous than others in this area, very often the choice is still subjective, which is commonly attributed to individual preferences and experience. However, an accurate knowledge of the available tools and their functioning, with their pros and cons, is fundamental for any endoscopist venturing into the field of third space endoscopy. In this way, one can choose which device best suits a particular situation, along with simultaneously having the wealth of knowledge related to therapeutic armamentarium at our disposal in the endoscopy suite.

Evaluation and Management of Malignant Colorectal Polyps

The detection rate of dysplastic colorectal polyps has significantly increased with improved screening programs. Treatment of dysplastic polyps attempt to limit morbidity of a procedure while also considering the risk of occult lymph node metastasis. Therefore, a variety of methods have been developed to predict the rate of lymph node metastasis to help identify the optimal treatment of patients. These include both the endoscopic and pathologic assessment of the lesion. In order to reduce the morbidity of surgery for patients with low-risk lesions, multiple endoscopic therapies have been developed, including endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic intermuscular dissection, and transanal endoscopic surgery.

AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia

BACKGROUND & AIMS

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia.

METHODS

The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations.

RESULTS

The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics.

CONCLUSIONS

This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.

The diagnostic utility of endocytoscopy for the detection of gastric cancer: a systematic review and meta-analysis

INTRODUCTION

Endocytoscopy (ECS) is an evolving technology that utilizes ultra-high power magnification for real time cellular imaging without the need for physical biopsy. Its application for gastric cancer (GC) detection is not well evaluated at the current time, but there is potential that ECS can make a real time histopathological diagnosis to differentiate neoplastic from benign lesions. We aimed to investigate the diagnostic utility of ECS for GC detection.

EVIDENCE ACQUISITION

Literature searches through multiple databases were performed for studies using ECS for GC detection until November 2021. Measured outcomes included the pooled sensitivity, specificity and accuracy. Quality assessment of diagnostic studies tool was used to assess the risk of bias.

EVIDENCE SYNTHESIS

Four studies (N.=245) were included. The pooled sensitivity was 83.5% (95% CI: 75-89%, I2: 0) and specificity was 91.7% (95% CI: 79-97%, I2: 58%). The pooled accuracy was 89.2% (95% CI: 83-94%, I2: 38%). There was a low risk of bias.

CONCLUSIONS

ECS is an accurate diagnostic modality and has the potential to serve as a complimentary tool in screening for GC. Larger prospective studies are needed to validate these findings before its further widespread use.

The efficacy and safety of snare traction-assisted endoscopic submucosal dissection for circumferential superficial esophageal cancer

OBJECTIVE

This study aims to investigate the efficacy and safety of snare traction-assisted endoscopic submucosal dissection (ESD) for the management of circumferential superficial esophageal cancer.

METHODS

A total of 68 patients who underwent ESD for circumferential superficial esophageal cancer were included in this study. All the patients were divided into two groups based on whether the snare traction was used or not; the snare traction group (S-ESD, group n = 35) and the control group (C-ESD, group n = 33).

RESULTS

There was no significant difference in the size of the resected area between the groups [21.98 (18.30, 27.00) cm2 vs 24.00 (15.28, 30.72) cm2, P = 0.976]. The snare traction group had a shorter dissection time [92.00 (74.00, 121.00) min vs 110.00 (92.50, 137.00) min, P = 0.017] and a faster resection speed [0.28 ± 0.13 cm2/min vs 0.22 ± 0.11cm2/min, P = 0.040] compared to the control group. There were no statistically significant differences between the two groups in terms of hospital stay, cost, en bloc resection rate, R0 resection rate, curative resection rate, bleeding rate, perforation rate, stricture rate, and recurrence rate (P > 0.05).

CONCLUSION

Snare traction-assisted ESD is a safe and efficient approach for the treatment of circumferential superficial esophageal cancer. Its advantages includes shorter procedure so the anesthesia requirement, clear operative filed view, improved mucosal dissection efficiency, simple, and easily accessible equipment.

Additional staining for lymphovascular invasion is associated with increased estimation of lymph node metastasis in patients with T1 colorectal cancer: Systematic review and meta-analysis

OBJECTIVES

Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC.

METHODS

We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding).

RESULTS

Among the 64 studies (18,097 patients) identified, hematoxylin-eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32-0.58) and 0.68 (95% CI 0.44-0.86), specificities of 0.88 (95% CI 0.78-0.94) and 0.76 (95% CI 0.62-0.86), and DORs of 6.26 (95% CI 3.73-10.53) and 6.47 (95% CI 3.40-12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87-12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13-3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22-0.52) and 0.62 (95% CI 0.04-0.99) for HE and additional staining for LVI, respectively.

CONCLUSION

Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists.

Efficacy and safety of endoscopic submucosal dissection for colorectal dysplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND/AIMS

In this meta-analysis, we studied the safety and efficacy of endoscopic submucosal dissection (ESD) for colorectal dysplasia in patients with inflammatory bowel disease (IBD).

METHODS

Multiple databases were searched, and studies were retrieved based on pre-specified criteria until October 2022. The outcomes assessed were resection rates, procedural complications, local recurrence, metachronous tumors, and the need for surgery after ESD in IBD. Standard meta-analysis methods were followed using the random-effects model, and I2% was used to assess heterogeneity.

RESULTS

Twelve studies comprising 291 dysplastic lesions in 274 patients were included with a median follow-up of 25 months. The pooled en-bloc resection, R0 resection, and curative resection rates were 92.5% (95% confidence interval [CI], 87.9%-95.4%; I2=0%), 81.5% (95% CI, 72.5%-88%; I2=43%), and 48.9% (95% CI, 32.1%-65.9%; I2=87%), respectively. The local recurrence rate was 3.9% (95% CI, 2%-7.5%; I2=0%). The pooled rates of bleeding and perforation were 7.7% (95% CI, 4.5%-13%; I2=10%) and 5.3% (95% CI, 3.1%-8.9%; I2=0%), respectively. The rates of metachronous recurrence and additional surgery following ESD were 10% (95% CI, 5.2%-18.2%; I2=55%) and 13% (95% CI, 8.5%-19.3%; I2=54%), respectively.

CONCLUSIONS

ESD is safe and effective for the resection of dysplastic lesions in IBD with an excellent pooled rate of en-bloc and R0 resection.

Assessment of predictive factors associated with the technical difficulty of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: Japanese multicenter retrospective study

OBJECTIVES

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) is performed for the treatment of lesions with varied backgrounds and factors. However, the predictive factors associated with the technical difficulty of ESD remain unknown in patients with varied lesions. Therefore, this study aimed to identify the predictive factors associated with the technical difficulty of ESD for ESCC using a retrospective cohort.

METHODS

This multicenter, retrospective study was conducted in 10 hospitals in Japan. Consecutive patients who underwent esophageal ESD between January 2013 and December 2019 were enrolled. Lesions of subepithelial tumors, adenocarcinoma, and adenoma were excluded. Difficult lesions were defined as ESD requiring a long procedure time (≥120 min), perforation development, piecemeal resection, or discontinued ESD. In the present study, the clinical factors were assessed to identify the technical difficulty of ESD using univariate and multivariate analyses.

RESULTS

Among 1708 lesions treated with esophageal ESD, eight subepithelial tumors, 44 adenocarcinomas, and two adenomas were excluded. Finally, 1505 patients with 1654 lesions were analyzed, and 217 patients with 217 lesions (13.1%) were classified as patients with difficult lesions. In multivariate analysis, the predictive factors associated with the technical difficulty of ESD were as follows: tumors with varices, tumors with diverticulum, antiplatelet use (discontinued), circumference of tumor (≥1/2), preoperative tumor size ≥30 mm, trainee, and nonhigh-volume center.

CONCLUSION

This multicenter retrospective study identified the predictive factors associated with the technical difficulty of ESD for ESCC with varied backgrounds and factors.

Efficacy, safety, and advantages of magnetic anchor-guided endoscopic submucosal dissection vs conventional endoscopic submucosal dissection: A retrospective paired cohort study

BACKGROUND

Endoscopic submucosal dissection (ESD) has been recommended as the first-line treatment for early gastric cancer (EGC). However, poor visualization of the operative field increases both the procedure time and the risk of complications, especially for large and difficult lesions. We introduced a novel technique, magnetic anchor-guided ESD (MAG-ESD) and compared it with conventional ESD (C-ESD) for the treatment of large EGCs in terms of efficacy, safety, and advantages.

METHODS

Patients with large EGCs who underwent MAG-ESD or C-ESD at the First Affiliated Hospital of Xi'an Jiaotong University from March 2020 to March 2022 were retrospectively enrolled in this study. The patients in the MAG-ESD cohort were matched to those in the C-ESD cohort using propensity score-based matching. The operation time, submucosal dissection time, complete resection status, magnetic anchor, adverse event rate, and tumor recurrence rate were evaluated.

RESULTS

Twenty-two patients who underwent MAG-ESD were ultimately matched to those who underwent C-ESD. The median operation time of MAG-ESD and C-ESD was 43 minutes (IQR, 35.2-49.5) and 50.5 minutes (IQR, 42.0-76.0), respectively, among which the submucosal dissection time was 7.6 minutes (IQR, 5.2-10.4) and 14.8 minutes (IQR, 10.8-19.6), respectively. The operation time of MAG-ESD was shorter than that of C-ESD, especially the submucosal dissection time (P < .05). There was a lower incidence of adverse events associated with MAG-ESD (P < .05) when magnetic anchors were successfully placed and retrieved.

CONCLUSION

MAG-ESD is feasible, effective, safe, and simple for the treatment of large EGCs at different sites and has a high anchor success rate, which could shorten the operation time and reduce the adverse event rate.

Nomogram for predicting electrocoagulation syndrome after endoscopic submucosal dissection of esophageal tumors

BACKGROUND

Endoscopic submucosal dissection (ESD) was widely used for the removal of esophageal tumors, and post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) was one of the postoperative adverse events. The aim of this research was to develop and validate a model to predict electrocoagulation syndrome after endoscopic submucosal dissection of esophageal tumors.

MATERIALS AND METHODS

Patients who underwent esophageal ESD in our hospital were retrospectively included. A predictive nomogram was established based on the results of multivariate logistic regression analysis, and bootstrapping resampling was used for internal validation. Besides, the clinical usefulness of the nomogram was evaluated using decision curve analysis (DCA) and clinical impact curve.

RESULTS

A total of 552 patients who underwent esophageal ESD were included in the study, and the incidence of PPECS was 12.5% (69/552). Risk factors associated with PEECS (p < 0.1) were analyzed by multivariate logistic regression analysis, and the final model included four variables, namely gender, diabetes, tumor size and operation time. The predictive nomogram was constructed based on the above four variables, and the area under the ROC curve (AUC) was 0.811 (95% CI 0.767-0.855). The calibration curve of the nomogram presented good agreement between the predicted and actual probabilities. DCA showed that the model improved patient outcomes by helping to assess the risk of PEECS in patients compared to an all-or-no treatment strategy. In addition, the clinical impact curve of the model also indicates that the nomogram has a high clinical net benefit.

CONCLUSION

In conclusion, we have developed a predictive nomogram for PEECS after ESD for esophageal tumors with good predictive accuracy and discrimination. This predictive nomogram can be effectively used to identify high-risk patients with PEECS, which will help clinicians in clinical decision-making and early intervention.

Validation and update of a clinical score model to predict technical difficulty of colorectal endoscopic submucosal dissection: a multicenter prospective cohort study

BACKGROUND AND AIMS

The Zhongshan colorectal endoscopic submucosal dissection (CR-ESD) score model was proposed to grade the technical difficulty of CR-ESD. The objective of this study was to prospectively validate and update the score model.

METHODS

A multicenter prospective cohort analysis of CR-ESD was conducted. Individual data on patients, lesions, and outcomes of CR-ESD were used to validate the original model and further refine the difficulty of the prediction model. Data were randomly divided into discovery and internal validation cohorts. A multivariate Cox regression analysis was conducted on the discovery cohort to develop an updated risk-scoring system, which was then validated.

RESULTS

Five hundred forty-eight patients with 565 colorectal lesions treated by ESD from 4 hospitals were included. In the prospective validation cohort, the area under the receiver-operating characteristic (ROC) curve for the original model was .707. Six risk factors were identified and assigned point values: tumor size (2 points for 30-50 mm, 3 points for ≥50 mm), at least two-thirds circumference of the lesion (3 points), tumor location in the cecum (2 points) or flexure (2 points), laterally spreading tumor-nongranular lesions (1 point), preceding biopsy sampling (1 point), and NBI International Colorectal Endoscopic type 3 (3 points). The updated model had an area under the ROC curve of .738 in the discovery cohort and of .782 in the validation cohort. Cases were categorized into easy (score = 0-1), intermediate (score = 2-3), difficult (score = 4-6), and very difficult (score ≥7) groups. Satisfactory discrimination and calibration were observed.

CONCLUSIONS

The original model achieved an acceptable level of prediction in the prospective cohort. The updated model exhibited superior performance and can be used in place of the previous version. (Clinical trial registration number: ChiCTR2100047087.).

Planned Hybrid Endoscopic Submucosal Dissection as Alternative for Colorectal Neoplasms: A Propensity Score-Matched Study

BACKGROUND AND AIMS

Hybrid endoscopic submucosal dissection (H-ESD), a modified ESD with a snare, has become increasingly utilized to overcome the limitations of conventional ESD (C-ESD). This study aimed to compare the efficacy and safety of Planned H-ESD and C-ESD for colorectal lesions.

METHODS

Propensity score matching was performed to control for confounding variables in this retrospective study. Outcomes included en bloc resection and complete resection (R0) rates, procedure time, adverse event rates, and local recurrence rate.

RESULTS

1286 lesions were enrolled in the study. After matching, 263 lesions were assigned to each group. The Planned H-ESD group has lower en bloc rate but similar R0 resection rate compared to the C-ESD group (90.9% vs 98.1%, P = 0.001; 77.2% vs 77.9%, P = 0.917). The median procedure time was shorter in the Planned H-ESD group (27.0 min vs 35.0 min, P = 0.001). There were no significant differences in adverse events rates or local recurrence rate. Subgroup analysis based on lesion size revealed that a significantly lower en bloc resection rate in the Planned H-ESD group compared to the C-ESD group for lesions ≥ 40 mm (71.0% vs 94.3%, P = 0.027), but there was no significant difference for lesions < 40 mm.

CONCLUSION

The Planned H-ESD has a lower en bloc resection rate but a similar R0 resection rate, adverse event rates, local recurrence rate, and shorter procedure duration. Compared to C-ESD, Planned H-ESD presents advantages for managing colorectal neoplasms below 40 mm.

Incidence and risk factors for fever after endoscopic submucosal dissection and its derivative technology for gastric lesions

Introduction

Fever is one of the postoperative complications of endoscopic submucosal dissection (ESD) and its derivative technology. However, there are few studies on risk factors for fever after ESD and its derivative technology. The aim of this study was to determine the incidence and related risk factors after ESD and its derivative technology for gastric lesions.

Materials and methods

A retrospective review of patients with gastric lesions who were treated by ESD and its derivative technology in our hospital from January 2014 to January 2019 was conducted.

Results

A total of 1955 patients were included in the present study. A total of 451 (23.1 %) patients presented with fever after ESD and its derived techniques. The highest fever temperature was 37.6 ± 3.12 °C, and the number of days with fever was 1.48 ± 0.85. Through single factor and multiple factor analysis, age (OR: 1.261, 95% CI: 1.009-1.576, p < 0.05), procedure time (OR: 1.457, 95% CI: 1.053-2.016, p < 0.05), postoperative gastric tube placement (OR: 2.098, 95% CI: 1:616-2.723, p < 0.05), intraoperative hemorrhage (OR: 1.537, 95% CI: 1.196-1.974, p < 0.05) and perforation (OR: 1.970, 95% CI: 1.531-2.535, p < 0.05) were independent risk factors for postoperative fever.

Conclusion

Age ≥56 years old, procedure time ≥60 min, gastric tube placement, intraoperative hemorrhage and perforation were independent risk factors for postoperative fever after gastric ESD and its derivative technology. Attention should be given to such patients to minimize the risk of postoperative fever.

Efficacy and safety of endoscopic submucosal dissection for early gastric cancer and precancerous lesions in elderly patients

BACKGROUND

With advancements in the development of endoscopic technologies, the endoscopic submucosal dissection (ESD) has been one of the gold-standard therapies for early gastric cancer.

AIM

To investigate the efficacy and safety ESD in the treatment of early gastric cancer and precancerous lesions in the elderly patients.

METHODS

Seventy-eight elderly patients with early gastric cancer and precancerous lesions admitted to the Third Affiliated Hospital of Qiqihar Medical University were selected and classified into two groups according to the different surgical therapies they received between January 2021 and June 2022. Among them, 39 patients treated with ESD were included in an experimental group, and 39 patients treated with endoscopic mucosal resection (EMR) were included in a control group. We compared the basic intraoperative conditions, postoperative short-term recovery, long-term recovery effects and functional status of gastric mucosa between the two groups; the basic intraoperative conditions included lesion resection, intraoperative bleeding and operation time; the postoperative short-term recovery assessment indexes were length of hospital stay and incidence of surgical complications; and the long-term recovery assessment indexes were the recurrence rate at 1 year postoperatively and the survival situation at 1 year and 3 years postoperatively; and we compared the preoperative and predischarge serum pepsinogen I (PG I) and PG II levels and PG I/PG II ratio in the two groups before surgery and discharge.

RESULTS

The curative resection rate and the rate of en bloc resection were higher in the experimental group than in the control group. The intraoperative bleeding volume was higher in the experimental group than in the control group. The operation time was longer in the experimental group than that in the control group, and the rate for base residual focus was lower in the experimental group than that of the control group, and the differences were all statistically significant (all P < 0.05). The length of hospital stay was longer in the experimental group than in the control group, and the incidence of surgical complications, 1-year postoperative recurrence rate and 3-year postoperative survival rate were lower in the experimental group than in the control group, and the differences were statistically significant (all P < 0.05). However, the difference in the 1-year postoperative survival rate was not statistically significant between the two groups (P > 0.05). Before discharge, PG I and PG I/PG II ratio were elevated in both groups compared with the preoperative period, and the above indexes were higher in the experimental group than those in the control group, and the differences were statistically significant (both P < 0.05). Moreover, before discharge, PG II level was lower in both groups compared with the preoperative period, and the level was lower in the experimental group than in the control group, and the differences were all statistically significant (all P < 0.05).

CONCLUSION

Compared with EMR, ESD surgery is more thorough. It reduces the rate of base residual focus, recurrence rate, surgical complications, and promotes the recovery of gastric cells and glandular function. It is safe and suitable for clinical application.

Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis

(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.

An Analysis of Delayed Bleeding in Cases of Colorectal Endoscopic Submucosal Dissection Due to Types of Direct Oral Anticoagulants in Japan

BACKGROUND & AIMS

Reported rates of delayed bleeding (DB) after endoscopic resection using direct oral anticoagulants (DOACs) are high and heterogeneous. This large-scale multicenter study analyzed cases of DB after colorectal endoscopic submucosal dissection related to various types of DOACs in Japan (the ABCD-J study) with those associated with warfarin.

METHODS

We retrospectively reviewed 1019 lesions in patients treated with DOACs and 459 lesions in patients treated with warfarin among 34,455 endoscopic submucosal dissection cases from 47 Japanese institutions between 2012 and 2021. The DB rate (DBR) with each DOAC was compared with that with warfarin. Risk factors for DB in patients treated with DOACs or warfarin were also investigated.

RESULTS

The mean tumor sizes in the DOAC and warfarin groups were 29.6 ± 14.0 and 30.3 ± 16.4 mm, respectively. In the DOAC group, the DBR with dabigatran (18.26%) was significantly higher than that with apixaban (10.08%, P = .029), edoxaban (7.73%, P = .001), and rivaroxaban (7.21%, P < .001). Only rivaroxaban showed a significantly lower DBR than warfarin (11.76%, P = .033). In the multivariate analysis, heparin bridging therapy (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.27-3.73, P = .005), rectal location (2.01, 1.28-3.16, P = .002), and procedure time ≥55 minutes (2.43, 1.49-3.95, P < .001) were significant risk factors for DB in the DOAC group. The DB risk in the DOAC group (OR, (95% CI)) was 2.13 (1.30-3.50) and 4.53 (2.52-8.15) for 1 and 2 significant risk factors, respectively.

CONCLUSIONS

Dabigatran was associated with a higher DBR than other DOACs, and only rivaroxaban was associated with a significantly lower DBR than warfarin.

Randomized trial of gastric and colorectal endoscopic submucosal dissection defect closure comparing a novel through-the-scope suturing system with an over-the-scope suturing system (with video)

BACKGROUND AND AIMS

Mucosal closure adds time but reduces adverse events associated with endoscopic submucosal dissection (ESD). We aimed to assess the closure time (CT), technical success, and cost-effectiveness between a novel through-the-scope helix tack suture system (TTSS) and the over-the-scope suturing system (OTSS).

METHODS

In this single-center, prospective, randomized trial, all patients undergoing ESD with anticipated closure were randomized 1:1 to TTSS (study group) or OTSS (control group). Primary outcomes were CT and overall CT (OCT; CT + setup time). Secondary outcomes were rates of technical success, adverse events, and cost-effectiveness.

RESULTS

Forty patients were randomized to OTSS (n = 20) or TTSS (n = 20). OTSS and TTSS groups were similar with respect to age, gender, proportion of colorectal polyps, proximal colon polyps, and mean size of the resected specimen (40.9 mm vs 40.4 mm). The mean CT was 18.4 minutes for OTSS and 23.3 minutes for TTSS (P = .36). The mean OCT was 32 minutes for OTSS and 39.5 minutes for TTSS (P = .36). Closure with a primary device was successful in 17 cases (85%) with OTSS and 18 cases (90%) with TTSS (P = .63). No closure-related intraprocedural adverse events or delayed perforations were noted. Mean cost of closure was significantly lower in the TTSS group for lesions <35 mm (P = .008).

CONCLUSIONS

TTSS was not found to be superior to OTSS with respect to CT and technical and clinical success for closure of gastric and colorectal ESD defects. TTSS is more cost-effective for closure of lesions <35 mm. (Clinical trial registration number: NCT04925271.).

Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasia in close proximity to esophageal varices: a multicenter international experience

BACKGROUND : There are limited data on the feasibility of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasia (SEN) located at or adjacent to esophageal varices. We aimed to evaluate the outcomes of ESD in these patients.

METHODS

 This multicenter retrospective study included cirrhotic patients with a history of esophageal varices with SEN located at or adjacent to the esophageal varices who underwent ESD.

RESULTS

 23 patients with SEN (median lesion size 30 mm; 16 squamous cell neoplasia and seven Barrett's esophagus-related neoplasia) were included. The majority were Child-Pugh B (57 %) and had small esophageal varices (87 %). En bloc, R0, and curative resections were achieved in 22 (96 %), 21 (91 %), and 19 (83 %) of patients, respectively. Severe intraprocedural bleeding (n = 1) and delayed bleeding (n = 1) were successfully treated endoscopically. No delayed perforation, hepatic decompensation, or deaths were observed. During a median (interquartile range) follow-up of 36 (22-55) months, one case of local recurrence occurred after noncurative resection.

CONCLUSION

 ESD is feasible and effective for SEN located at or adjacent to esophageal varices in cirrhotic patients. Albeit, the majority of the esophageal varices in our study were small in size, when expertise is available, ESD should be considered as a viable option for such patients.

Outline of Japanese Guidelines for Colorectal Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection with a Short Reference to the Western Recommendations

The Japan Gastroenterological Endoscopy Society published the latest English versions of the guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for colorectal neoplastic lesions and colorectal cold polypectomy in 2020 and 2022, respectively. In this article, I present a comprehensive overview of these guidelines, including a comparison with the Western recommendations.

A novel entire traction method with clip-anchored nylon ring facilitating endoscopic submucosal dissection (ESD) of early gastric cancer

A 48-year-old woman with a high-grade intraepithelial neoplasia of the gastric antrum was referred for ESD treatment.The difficulty of ESD is to expose the submucosa,especially in difficult sites and lesions with severe fibrosis.Adequate submucosal exposure is the most critical technology to reduce complications and improving efficiency.Here we report a novel entire traction method to facilitate safe and efficient ESD.

Ambulatory Endoscopic Submucosal Dissection for Gastrointestinal Neoplasms: Trends and Associated Factors in the United States

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for superficial gastrointestinal (GI) cancers.1,2 ESD practice is expanding significantly in the United States and Western countries. This is attributed to a shorter hospital stay, better quality of life, and fewer adverse events compared with surgery. In the United States, ESD usually is performed and managed in an outpatient setting (ambulatory ESD) or with an overnight hospital stay. This practice is in contrast to Eastern Asian countries, where 3 to 5 days of hospital stay is a routine process for observation after ESD. A Swedish study showed that patients with well-selected colorectal neoplasms (median tumor size, 37 mm) could be managed safely in an outpatient setting after ESD.3 A North American multicenter ESD study also reported that ambulatory ESD was safe and feasible in selected cases (noninvasive cancers, no adverse events, high-volume endoscopists with short procedure time).4 However, procedural and technical aspects that enable safe outpatient management of patients after ESD need to be investigated.

Bridging polyp in an anastomosis resected by endoscopic submucosal dissection (ESD)

A 60-year-old man was admitted to our hospital for routine postoperative review of colon cancer. He underwent a colonoscopy, which showed a bridge-like polyp located 13 cm from the anal verge, with the base of the polyp located 1.5 cm above the anastomosis and the head of it located on the anastomosis and fusion growth with the anastomosiz. The patient accepted ESD to remove the lesion. During the ESD procedure, the basal of the polyp was incised using an insulated-tip knife, when the polyp tip located at the anastomosis was gradually dissected with a hook knife, severe fibrosis and three staples was found in the submucosal. We carefully separated the scar tissue and pulled out staples with hook knife in electrocision mode. Finally, we removed the lesion completely.

Endoscopic Resection of Early Luminal Cancer

Gastrointestinal cancers can have severe consequences if diagnosed at a late stage but can be cured when detected and resected at an early stage. In recent years, the significance of endoscopic screening for gastrointestinal cancers has been established, leading to the identification of early-stage cancers and precancerous lesions. Consequently, endoscopic removal of gastrointestinal tumors has emerged as an effective means of cancer treatment and prevention. This article delves into the indications, techniques, and safety measures associated with endoscopic resection of early-stage luminal cancer within the gastrointestinal tract.

Comparison of scissor-type knife to non-scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis

BACKGROUND/AIMS

Scissor-type endoscopic submucosal dissection (ST-ESD) knives can reduce the adverse events associated with ESDs. This study aimed to compare ST-ESD and non-scissor-type (NST)-ESD knives.

METHODS

We identified ten studies that compared the performance characteristics and safety profiles of ST-ESD and NST-ESD knives. Fixed- and random-effects models were used to calculate the pooled proportions. Heterogeneity was assessed using the I2 test.

RESULTS

On comparing ST-ESD knives to NST-ESD knives, the weighted odds of en bloc resection was 1.61 (95% confidence interval [CI], 0.90-2.90; p=0.14), R0 resection was 1.10 (95% CI, 0.71-1.71; p=0.73), delayed bleeding was 0.40 (95% CI, 0.17-0.90; p=0.03), perforation was 0.35 (95% CI, 0.18-0.70; p<0.01) and ESD self-completion by non-experts was 1.89 (95% CI, 1.20-2.95; p<0.01). There was no heterogeneity, with an I2 score of 0% (95% CI, 0%-54.40%).

CONCLUSION

The findings of reduced odds of perforation, a trend toward reduced delayed bleeding, and an improvement in the rates of en bloc and R0 resection with ST-ESD knives compared to NST-ESD knives support the use of ST-ESD knives when non-experts perform ESDs or as an adjunct tool for challenging ESD procedures.

Use of artificial intelligence in the management of T1 colorectal cancer: a new tool in the arsenal or is deep learning out of its depth?

The field of artificial intelligence is rapidly evolving, and there has been an interest in its use to predict the risk of lymph node metastasis in T1 colorectal cancer. Accurately predicting lymph node invasion may result in fewer patients undergoing unnecessary surgeries; conversely, inadequate assessments will result in suboptimal oncological outcomes. This narrative review aims to summarize the current literature on deep learning for predicting the probability of lymph node metastasis in T1 colorectal cancer, highlighting areas of potential application and barriers that may limit its generalizability and clinical utility.

Safety and Efficacy of Endoscopic Full Thickness Resection of Upper Gastrointestinal Lesions Using a Full Thickness Resection Device: A Systematic Review and Meta-analysis

INTRODUCTION

Endoscopic full-thickness resection (EFTR) is a promising technique that allows for a minimally invasive resection of mucosal and submucosal lesions in the gastrointestinal (GI) tract. The data regarding the efficacy and safety of performing EFTR of upper GI lesions using a full-thickness resection device (FTRD) is limited. Hence, we performed a systematic review and meta-analysis of the studies that evaluated this technique.

METHODS

We performed a comprehensive systematic search of multiple electronic databases and conference proceedings that reported outcomes of EFTR using the FTRD system. The weighted pooled rates of technical success, complete (R0) resection, adverse events (AE), and residual or recurrent lesions were analyzed with 95% CI using the random effects model.

RESULTS

Eight studies with a total of 139 patients who underwent EFTR of upper GI lesions were included in the study. The pooled, weighted rate of technical success was 88.2% (95% CI: 81.4-92.7%, I2 : 0). The R0 resection rate was 70.7% (95% CI: 62.5-77.8%, I2 : 0). Overall AE rates were 22.1% (95% CI: 15.8-30.1%, I2 : 0), however, most of the AEs were minor. Of the patients who had follow-up endoscopies, the residual and/or recurrent lesion rate was 6.1% (95% CI: 2.4-14.4%, I2 : 0). Heterogeneity in the analysis was low.

CONCLUSIONS

EFTR using the FTRD seems to be effective and safe with acceptable R0 resection rates and low recurrence rates. Further prospective studies are required to validate our results and to compare various modalities of endoscopic resection with this single-step EFTR device.

Esophageal Endoscopic Submucosal Dissection in Older Patients Is Safe and Feasible: A Retrospective Single-Center Cohort Study in the United States

BACKGROUND

Endoscopic submucosal dissection (ESD) is a well-established method for treating early esophageal carcinomas. However, data on the safety and efficacy of esophageal ESD in older patients in the United States are limited.

METHODS

This retrospective study investigated the outcomes of esophageal ESD in patients aged ≥80 years and included those who underwent esophageal ESD between June 2018 and April 2023 at a single center in the United States. Patients were divided into two age groups for comparison: ≥80 and <80 years. Treatment outcomes and complications were evaluated and compared between these groups.

RESULTS

A total of 53 cases of esophageal ESD for malignant neoplasms were included, with 12 patients in the ≥80 years age group. No significant differences were observed in the patients' background and characteristics, except for a prior history of interventions (p = 0.04). The en bloc resection rate was 100% in both groups. The R0 resection rate was lower in the ≥80 years age group (75% vs. 88%). There were no complications requiring additional intervention in the ≥80 years age group, such as post-ESD bleeding, perforation, mediastinal emphysema, or pneumonia.

CONCLUSIONS

Esophageal ESD may be a safe and feasible procedure for treating esophageal carcinomas in older patients.

A nomogram for predicting the risk of postoperative fever in elderly patients undergoing endoscopic submucosal dissection of the upper gastrointestinal tract

To explore the risk factors of postoperative fever in elderly patients undergoing endoscopic submucosal dissection (ESD). A total of 439 patients who met the inclusion criteria were enrolled in this study and randomly divided into training (n = 311) and validation (n = 128) cohorts at a ratio of 7:3. Independent risk factors were screened by single-factor and multiple-factor logistic regression analyses, and a nomogram was established using them. The nomogram was evaluated using receiver operating characteristic curve analysis, decision curve analysis, and calibration plot using the "rms" package in R software (R4.2.1). The study included 439 patients. Female (OR = 2.55, 95% CI: 1.5-4.33), diabetes (OR = 2.38, 95% CI: 1.17-4.85), operation time (OR = 1.01, 95% CI: 1-1.02) were lesion located in the esophagus (OR = 2.37, 95% CI: 1.44-3.88), maximum tumor diameter (OR = 1.3, 95% CI: 1.07-1.57), and placement of a urinary catheter (OR = 7.09, 95%CI: 1.43-35.17) were independent risk factors for postoperative fever in elderly ESD patients (P < .05). Female sex, diabetes, lesions located in the esophagus, lesion size, operation time, and placement of a urinary catheter are risk factors for postoperative fever in ESD patients, and patients with these risk factors should be vigilant for postoperative fever and receive appropriate treatment.

Prospective cross-organ analysis for the causes of fever and increased inflammatory response after endoscopic resection

OBJECTIVES

Fever and increased inflammatory responses sometimes occur following endoscopic resection (ER). However, the differences in causes according to the organ are scarcely understood, and several modified ER techniques have been proposed. Therefore, we conducted a comprehensive prospective study to investigate the cause of fever and increased inflammatory response across multiple organs after ER.

METHODS

We included patients who underwent gastrointestinal endoscopic submucosal dissection (ESD) and duodenal endoscopic mucosal resection at our hospital between January 2020 and April 2022. Primary endpoints were fever and increased C-reactive protein (CRP) levels following ER. The secondary endpoints were risk factors for aspiration pneumonia. Blood tests and radiography were performed on the day after ER, and computed tomography was performed if the cause was unknown.

RESULTS

Among the 822 patients included, aspiration pneumonia was the most common cause of fever and increased CRP levels after ER of the upper gastrointestinal tract (esophagus, 53%; stomach, 48%; and duodenum, 71%). Post-ER coagulation syndrome was most common after colorectal ESD (38%). On multivariate logistic regression analysis, lesions located in the esophagus (odds ratio [OR] 3.57; P < 0.001) and an amount of irrigation liquid of ≥1 L (OR 3.71; P = 0.003) were independent risk factors for aspiration pneumonia.

CONCLUSIONS

Aspiration pneumonia was the most common cause of fever after upper gastrointestinal ER and post-ER coagulation syndrome following colorectal ESD. Lesions in the esophagus and an amount of irrigation liquid of ≥1 L were independent risk factors for aspiration pneumonia.

A novel risk score model of esophageal stricture for patients undergoing endoscopic submucosal dissection

BACKGROUND AND PURPOSE

Endoscopic submucosal dissection (ESD) is a promising technique for superficial esophageal lesions. However, stricture is a frequent adverse complication. This study was performed to develop a precise and convenient score prediction model for esophageal strictures after ESD, and compare its efficacy with a previously published predictive model.

METHODS

This study enrolled clinical data of patients who underwent esophageal ESD for superficial esophageal lesions. Possible risk factors for esophageal stricture were identified by univariate and multivariate logistic regression analysis. Then we developed a prediction model according to the Framingham system for the first time and presented a convenient table containing the risk probability for each patient. In addition, we validated our score model and the previously published model in our center.

RESULTS

A total of 838 patients were enrolled in this study and 6 variables, including age, surgery time, location of the lesion, circumference of the lesion, longitudinal resection length, and depth of infiltration were comprised in the score model. The total score ranged from 0 to 16 points and the risk probability was presented in one concise table for each patient. Areas under receiver-operator characteristic curves for the prediction model were 0.715 in derivation group and 0.804 in validation group.

CONCLUSION

We designed and validated a prediction score model for esophageal stricture after ESD, which can be applied conveniently to stratify the stricture risk after esophageal ESD and may facilitate appropriate clinical decision-making for these patients.

Colorectal endoscopic submucosal dissection in the West: A systematic review and meta-analysis

Background and study aims The advantages of endoscopic submucosal dissection (ESD) over endoscopic mucosal resection for large colorectal neoplasms are well established; however, the technical challenges and lack of adequate training in ESD limit its widespread adoption in Western countries. Methods A literature search was performed in Medline, Embase, Web of Science, and the Cochrane Library for studies conducted in non-Asian countries evaluating the effectiveness of colorectal ESD. A random effects model was used to obtain pooled en bloc, R0 resection rates, and adverse events (AEs). Results Thirty-three studies comprising 3,958 ESD procedures met the inclusion criteria. Of the polyps, 96.7% (2,817 of 2913) were ≥ 2 cm. Pooled en bloc resection (31 studies), R0 resection (29 studies), and curative resection rates were 84.6% (95% confidence interval [CI] [83.3%-85.9%]), 75.6% (95% CI [74.1%-77.0%]), and 81.9% (95% CI [78.6%-84.9%]), respectively. Surgery for invasive cancer was performed in 4.8% (23 studies). ESD-related perforation (25 studies) was observed in 5.5% and bleeding in 4.1% (delayed bleeding 3.4%). 1.8% of patients underwent surgery for procedure-related complications. A high degree of heterogeneity was observed for en bloc resection, R0 resection, and curative resection. Heterogeneity for AEs (perforation [I 2 13%], delayed bleeding [I 2 30%], and overall bleeding [I 2 49%]) was low to moderate. Conclusions The effectiveness of colorectal ESD for large colorectal polyps and early colorectal cancers is improving in Western countries, and recent resection rates are comparable to that seen in Asia. Colorectal perforation is still observed in about 5% of ESD; however, < 2% of patients need emergency surgery for AEs.

Development of a hybrid hydrogel for submucosal injection in endoscopic resection of gastrointestinal neoplasm: From laboratory to clinical trial

Background and study aims Submucosal injection solution is essential for successful endoscopic resection of the early gastrointestinal tumor. We evaluated a new endoscopic hydrogel for submucosal injection and its clinical feasibility. Patients and methods A hydrogel (AceGel) containing 0.4% sodium alginate and 2% calcium lactate was developed for ex vivo and animal studies. Subsequently, a prospective, single-arm study was conducted to assess its feasibility and safety in humans. Patients with gastrointestinal neoplasms undergoing endoscopic resection were enrolled. All patients underwent endoscopic surveillance after 4 weeks and outpatient follow-up at week 6. Afterward, they received endoscopic follow-up according to the medical routine. Results In the ex vivo experiments, the submucosal elevation height of AceGel was equivalent to sodium hyaluronate and superior to saline or glycerol. Animal studies showed that the excised wounds healed well without surrounding tissue damage. Twelve patients participated in the clinical trial, including three, two, and seven patients with esophageal, gastric, and colonic lesions, respectively. The mean neoplasm size and submucosal injection volumes were 24.0±8.6 mm and 22.8±19.9 mL, respectively. All patients had adequate wound healing on 4-week surveillance endoscopy, and none had serious adverse events during 6-week follow-up. Moreover, endoscopic follow-up showed complete wound healing after 6 to 46 months without local mucosal inflammation in all patients. Conclusions AceGel is good for endoscopic submucosal injection and demonstrated its usefulness in durable mucosal elevation for endoscopic therapy in preclinical tests. This clinical trial shows its safety and feasibility in all participating patients.

Efficacy and safety of modified endoscopic submucosal tunnel dissection for superficial esophageal circumferential lesions

To evaluate the efficacy and safety of intra-tunnel dissection using hemostatic forceps and needle-type device for patients with esophageal circumferential lesions (ECLs). Patients with ECLs were enrolled in the study and underwent endoscopic submucosal tunnel dissection (ESTD) or hemostatic forceps-based ESTD (ESFTD). All patients were divided into three subgroups according to longitudinal length of the lesions (LLLs): >8 cm, 4-8 cm and < 4 cm. The clinical data such as gender, age, length of lesions and operating time were collected. A total of 152 patients were included in this study and comprised 80 cases of ESFTD and 72 cases of ESTD. The procedure time was markedly shorter in the ESFTD group than in the ESTD group (P < 0.001). Moreover, ESFTD significantly increased the rate of complete resection and reduced specimen injury in LLLs >8 cm and 4-8 cm subgroup compared with ESTD (P < 0.001), but not in <4 cm subgroup (P > 0.05). The perforation and infection rate were similar in ESFTD and ESTD group (P > 0.05). However, ESFTD effectively decreased the muscular injury rate' the duration of chest pain and the time from endoscopic surgery to first occurrence of esophageal stenosis compared with ESTD group (P < 0.01). ESFTD has better efficacy and safety than ESTD in the treatment of ECLs, especially for large lesions. ESFTD could be recommended for patients with ECLs.

Decreasing rates of colectomy for benign neoplasms: A nationwide analysis

BACKGROUND

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms.

METHODS

All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups.

RESULTS

Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001).

CONCLUSIONS

The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

The Learning Curve for Advanced Endoscopy for Colorectal Lesions: A Surgeon's Experience at a High-Volume Center

BACKGROUND

Advanced endoscopy can be used for the complete removal of large colorectal polyps. To date, few surgeons perform advanced endoscopy, and it is unknown how many procedures are needed to reach proficiency.

OBJECTIVE

This study aimed to determine the learning curve for colorectal advanced endoscopy.

DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

We queried a prospectively maintained institutional database of advanced endoscopy performed by a high-volume colorectal surgeon between 2011 and 2018.

MAIN OUTCOME MEASURES

Advanced endoscopy characteristics were compared for 6 chronological intervals. Primary end points were the rates of complications and polyp recurrence. Secondary end point was the change in polyp removal rate (mm/h) over time.

RESULTS

A total of 207 patients underwent advanced endoscopy for a single colorectal polyp. The median polyp size was 30 (4-70) mm, 61.5% were located in the right colon, and 8.8% were malignant. The mean procedure time was 77 (range, 16-320) minutes. Immediate colon resection occurred in 25 patients because of suspicion of cancer or concern for perforation and was excluded from the learning curve analysis. The remaining 182 advanced endoscopy procedures were divided into intervals of 30 procedures. The median removal rate was highest in the last interval and in the endoscopy suite. A removal rate of 30 mm/h was achieved after performing 100 cases. The complication rate (bleeding or return to operating room) was 12.1% and was similar across intervals. The readmission rate was 11.5%, and 6.6% of 6-month follow-up colonoscopies showed polyp recurrence at the resection site.

LIMITATIONS

Retrospective design and single surgeon.

CONCLUSION

The learning curve for achieving proficiency with advanced endoscopy in the colon and rectum required a minimum of 100 cases with a low complication rate, low polyp recurrence rate, high en bloc resection rate, and a polyp removal rate of 30 mm/h. See Video Abstract at http://links.lww.com/DCR/C162 .LA CURVA DE APRENDIZAJE DE LA ENDOSCOPIA AVANZADA PARA LESIONES COLORRECTALES: LA EXPERIENCIA DE UN CIRUJANO EN UN CENTRO DE ALTO VOLUMENANTECEDENTES:La endoscopia avanzada se puede utilizar para la extirpación completa de pólipos colorrectales grandes. Hasta la fecha, pocos cirujanos realizan endoscopia avanzada y se desconoce cuántos procedimientos se necesitan para alcanzar la competencia.OBJETIVO:Determinar la curva de aprendizaje de la endoscopia colorrectal avanzada.DISEÑO:Retrospectivo.AJUSTE:Centro de referencia terciario.PACIENTES:Consultamos una base de datos institucional mantenida prospectivamente de endoscopia avanzada realizada por un cirujano colorrectal de alto volumen entre 2011 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las características de la endoscopia avanzada en seis intervalos cronológicos. Los puntos finales primarios fueron las tasas de complicaciones y recurrencia de pólipos. El criterio de valoración secundario fue el cambio en la tasa de eliminación de pólipos (mm/h) a lo largo del tiempo.RESULTADOS:Un total de 207 pacientes se sometieron a una endoscopia avanzada por un solo pólipo colorrectal. La mediana del tamaño de los pólipos fue de 30 (4-70) mm, el 61,5% se ubicaron en el colon derecho y el 8,8% fueron malignos. El tiempo medio del procedimiento fue de 77 (rango: 16-320) minutos. La resección inmediata del colon ocurrió en 25 pacientes debido a la sospecha de cáncer o preocupación por la perforación y fueron excluidos del análisis de la curva de aprendizaje. Los restantes 182 procedimientos de endoscopia avanzada se dividieron en intervalos de 30 procedimientos. La mediana de la tasa de extirpación fue más alta en el último intervalo y en la sala de endoscopia. Se logró una tasa de extirpación de 30 mm/hr después de realizar 100 casos. La tasa de complicaciones (sangrado o retorno al quirófano) fue del 12,1% y fue similar en todos los intervalos. La tasa de reingreso fue del 11,5% y el 6,6% de las colonoscopias de seguimiento a los 6 meses mostraron recurrencia de pólipos en el sitio de la resección.LIMITACIONES:Diseño retrospectivo, cirujano único.CONCLUSIÓN:La curva de aprendizaje para lograr el dominio de la endoscopia avanzada en el colon y el recto requiere un mínimo de 100 casos con una baja tasa de complicaciones, baja tasa de recurrencia de pólipos, alta tasa de resección en bloque y una tasa de eliminación de pólipos de 30 mm/h. Consulte el Video Resumen en http://links.lww.com/DCR/C162 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Thoracoscopic esophagectomy for thoracic esophageal cancer with right aortic arch and Kommerell diverticulum: a case report and literature review

Background

Esophageal carcinoma accompanied by a right aortic arch (RAA) is very rare. When combined with Kommerell diverticulum (KD), a right aortic arch forms a vascular ring encircling both the esophagus and trachea. Due to abnormal anatomy of the upper mediastinum, it is very difficult to dissociate the esophagus and its surrounding tissues, especially the left recurrent laryngeal nerve. Herein, we report a case of successful thoracoscopic esophagectomy in an esophageal cancer patient concurrent with a RAA and KD.

Case presentation

A 62-year-old male patient was diagnosed with esophageal squamous carcinoma in the middle esophagus at clinical stage I (cT1N0M0) according to UICC-TNM classification 8th edition. Further examinations revealed RAA and KD. Based on the three-dimensional CT (3D-CT) reconstruction, a Mckeown esophagectomy via a left thoracoscopic approach in semi-prone position was performed. During the operation, the left recurrent laryngeal nerve was accurately exposed and well protected. Postoperatively, severe complications, including anastomotic leakage and recurrent laryngeal nerve palsy, were not observed. The patient was discharged 12 days after the surgery.

Conclusion

Preoperative 3D-CT reconstruction is useful to clarify the vascular malformation in esophageal cancer patients with RAA, and helpful to formulate a reasonable surgical approach.

Comparison between ESD and RFA in patients with total or near-total circumferential early esophageal squamous cell neoplasia

BACKGROUND

Patients with early esophageal squamous cell neoplasias (ESCNs) that are totally or nearly totally circumferential face challenges in their clinical work. Endoscopic submucosal dissection (ESD) frequently leads to esophageal strictures. Endoscopic radiofrequency ablation (RFA), which stands out for its simplicity of use and low rate of stenosis, is a rapidly evolving therapeutic strategy for early ESCNs. We contrast ESD with RFA in order to find which method is best for the treatment of a wide range of esophageal diseases.

METHODS

Patients who had flat-type, early, large ESCNs (extending more than 3/4 of the esophageal circumference) treated endoscopically were enrolled retrospectively. The primary outcome measurements were adverse events and local control of the neoplastic lesion.

RESULTS

A total of 105 patients received treatment; 60 had ESD and 45 received RFA. Despite the patients receiving RFA typically having larger tumors (14.27 vs. 5.70 cm, P < 0.05), the local control of the neoplastic lesion and procedure-related complications were comparable between the ESD and RFA groups. A considerably higher risk of esophageal stenosis was observed in patients with extensive lesions in the ESD group compared to the RFA group (60% vs. 31%; P < 0.05), and the rate of refractory stricture is also higher than that of the RFA.

CONCLUSION

Both RFA and ESD are effective in treating large, flat, early ESCNs; however, ESD is more likely to cause side effects, such as esophageal stricture, particularly in lesions that are larger than 3/4 of the diameter. Before RFA, a more precise and thorough pretreatment examination should be performed. A more accurate pretreatment evaluation will be an important development direction for early esophageal cancer in future. After surgery, a strict routine review is crucial.

Safety and efficacy of a novel suturing device for closure of large defects after endoscopic submucosal dissection (with video)

BACKGROUND AND AIMS

Endoscopic suturing enables full closure of large defects after endoscopic submucosal dissection (ESD). However, its use is limited by the need for a double-channel endoscope. A novel closure system, the OverStitch Sx (Apollo Endosurgery, Austin, Tex, USA), compatible with any single-channel endoscope, was introduced to address these shortcomings. The aim of this study was to assess the safety and feasibility of OverStitch Sx for the closure of large defects after ESD.

METHODS

This is a prospective single-center feasibility study of patients who underwent closure of large defects after ESD using the OverStitch Sx system. Main outcomes of the study are technical and clinical success, same-day discharge rate, and adverse event rate.

RESULTS

Thirty-three patients were enrolled. The mean diameter of included lesions was 5.38 ± 2.52 cm. The defect occupied ≥50% of the lumen circumference in 70% of the cases. En-bloc resection, R0 resection, and curative resection were achieved in 97%, 87.5%, and 78.8% of patients, respectively. Technical success and clinical success were seen in 93.9% and 90.9% of the cases, respectively. Same-day hospital discharge was achieved in 77.4% of patients. Total adverse event rate was 35.7%, including delayed bleeding in 1 patient after rectal ESD that was managed conservatively, self-resolving rectal pain in 7 patients, rectal stricture requiring dilation in 1 patient, and temporary dysphagia in 1 patient. No immediate or delayed perforation was reported.

CONCLUSIONS

OverStitch Sx enabled safe and effective closure of large defects after ESD. Future trials are needed to determine its superiority over OverStitch for the closure of defects in challenging locations. (Clinical trial registration number: NCT04361227.).

Reduced DEFA5 Expression and STAT3 Activation Underlie the Submucosal Invasion of Early Gastric Cancers

INTRODUCTION

Submucosal invasion is a core hallmark of early gastric cancer (EGC) with poor prognosis. However, the molecular mechanism of the progression from intramucosal gastric cancer (IMGC) to early submucosal-invasive gastric cancer (SMGC) is not fully understood. The objective of this study was to identify genes and pathways involved in the submucosal invasion in EGC using comprehensive gene expression analysis.

METHODS

Gene expression profiling was performed for eight cases of IMGC and eight cases of early SMGC with submucosal invasion ≥500 μm. To validate the findings of gene expression analysis and to examine the gene expression pattern in tissues, immunohistochemical (IHC) staining was performed for 50 cases of IMGC and SMGC each.

RESULTS

Gene expression analysis demonstrated that the expression levels of small intestine-specific genes were significantly decreased in SMGC. Among them, defensin alpha 5 (DEFA5) was the most downregulated gene in SMGC, which was further validated in SMGC tissues by IHC staining. Gene set enrichment analysis showed a strong association between SMGC, the JAK-STAT signaling pathway, and the upregulation of STAT3-activating cytokines. The expression of phosphorylated STAT3 was significant in the nucleus of tumor cells in SMGC tissues but not in areas expressing DEFA5.

CONCLUSION

The results of this study strongly suggest that the downregulation of DEFA5 and the activation of STAT3 play a significant role in the submucosal invasion of EGC.

Recommendations for Optimal Endoscopic Localization of Colorectal Neoplasms: A Delphi Consensus of National Experts

BACKGROUND

Colonoscopy is the standard of care for diagnosis and evaluation of colorectal cancers before surgery. However, varied practices and heterogenous documentation affects communication between endoscopists and operating surgeons, hampering surgical planning.

OBJECTIVE

This study aimed to develop recommendations for the use of standardized localization and reporting practices for colorectal lesions identified during lower GI endoscopy.

DESIGN

A systematic review of existing endoscopy guidelines and thorough narrative review of the overall endoscopy literature were performed to identify existing practices recommended globally.

SETTING

An online Delphi process was used to establish consensus recommendations based on a literature review.

PATIENTS

Colorectal surgeons and gastroenterologists from across Canada who had previously demonstrated leadership in endoscopy, managed large endoscopy programs, produced high-impact publications in the field of endoscopy, or participated in the development of endoscopy guidelines were selected to participate.

PRIMARY OUTCOME MEASURES

The primary outcomes measured were colorectal lesion localization and documentation practice recommendations important to planning surgical or advanced endoscopic excisions.

RESULTS

A total of 129 of 197 statements achieved consensus after 3 rounds of voting by 23 experts from across Canada. There was more than 90% participation in each round. Recommendations varied according to lesion location in the cecum, colon, or rectum and whether the referral was planned for surgical or advanced endoscopic resection. Recommendations were provided for appropriate documentation, indications, location, and method of tattoo placement, in addition to photograph and real-time 3-dimensional scope configuration device use.

LIMITATIONS

Because of a paucity of evidence, recommendations are based primarily on expert opinion. There may be bias, as all representatives were based in Canada.

CONCLUSIONS

Best practices to optimize endoscopic lesion localization and communication are not addressed in previous guidelines. This consensus involving national experts in colorectal surgery and gastroenterology provides a framework for efficient and effective colorectal lesion localization. See Video Abstract at http://links.lww.com/DCR/C71 .

RECOMENDACIONES PARA LA LOCALIZACIN ENDOSCPICA PTIMA DE LAS NEOPLASIAS COLORRECTALES UN CONSENSO DELPHI DE EXPERTOS NACIONALES

ANTECEDENTES:La colonoscopia es el estándar de atención para el diagnóstico y la evaluación de los cánceres colorrectales antes de la cirugía. Sin embargo, las prácticas variadas y la documentación heterogénea afectan la comunicación entre los endoscopistas y los cirujanos operadores, lo que dificulta la planificación quirúrgica.OBJETIVO:Este estudio tuvo como objetivo desarrollar recomendaciones para el uso de prácticas estandarizadas de localización y notificación de lesiones colorrectales identificadas en la endoscopia gastrointestinal inferior.DISEÑO:Se realizó una revisión sistemática de las pautas de endoscopia existentes y una revisión narrativa exhaustiva de la literatura general sobre endoscopia para identificar las prácticas existentes recomendadas a nivel mundial. Se utilizó un proceso Delphi en línea para establecer recomendaciones de consenso basadas en la revisión de la literatura.PARTICIPANTES:Se seleccionaron para participar cirujanos colorrectales y gastroenterólogos de todo Canadá que previamente habían demostrado liderazgo en endoscopia, manejado grandes programas de endoscopia, producido publicaciones de alto impacto en el campo de la endoscopia o que habían participado en el desarrollo de pautas de endoscopia.RESULTADOS:Localización de lesiones colorrectales y recomendaciones prácticas de documentación importantes para planificar escisiones quirúrgicas o endoscópicas avanzadas.RESULTADOS:129 de 197 declaraciones lograron consenso después de tres rondas de votación de 23 expertos de todo Canadá. Hubo >90% de participación en cada ronda. Las recomendaciones variaron según la ubicación de la lesión en el ciego, colon o recto, y si se planificó la derivación para resección quirúrgica o endoscópica avanzada. Se proporcionaron recomendaciones para la documentación adecuada, las indicaciones, la ubicación y el método de colocación del tatuaje, además de la fotografía y el uso del dispositivo de configuración del alcance 3D en tiempo real.LIMITACIONES:Debido a la escasez de evidencia, las recomendaciones se basan principalmente en la opinión de expertos. Puede haber sesgo, ya que los representantes tenían su sede en Canadá.CONCLUSIONES:Las mejores prácticas para optimizar la localización y comunicación de lesiones endoscópicas no se abordan en las guías anteriores. Este consenso que involucra a expertos nacionales en cirugía colorrectal y gastroenterología proporciona un marco para la localización eficiente y efectiva de lesiones colorrectales. Consulte Video Resumen en http://links.lww.com/DCR/C71 . (Traducción-Dr. Mauricio Santamaria ).

Initial multicenter experience using a novel articulating through-the-scope traction device for endoscopic submucosal dissection

Background and study aims A single-operator, articulating, through-the-scope (TTS) traction device was recently developed to facilitate endoscopic submucosal dissection (ESD). Clinical data on the performance of this device are limited. We report an initial multicenter experience with ESD using this articulating TTS traction device. Patients and methods Retrospective analysis on all consecutive patients who underwent ESD using this traction device (T-ESD) at five centers between August 2021 and December 2022. Endpoints included: rates of en-bloc resection, R0 resection, curative resection, and adverse events. Results Thirty-six patients (median age 64.8 years; 47.2% women) underwent ESD (median lesion size 40 mm; interquartile range [IRQ]: 27.5-67.5) for lesions in the esophagus (n=2), stomach (n=8), sigmoid colon (n=6), and rectum (n=20). Submucosal fibrosis was encountered in one-third of the lesions (33.3%). Median ESD time was 104.6 minutes (IQR: 65-122). En-bloc, R0 and curative resection were achieved in 94.4%, 91.6%, and 97.2%, respectively. The single patient with non-curative resection of an invasive rectal adenocarcinoma underwent surgery. There were no cases of delayed bleeding or perforation. There was no recurrence on surveillance endoscopy (n=20) at a median of 6 months (IQR: 3.75-6). Conclusions This initial multicenter experience demonstrates high resection rates and excellent safety profile when performing ESD with this novel articulating TTS device. Dynamic real-time traction may lower the technical difficulty of ESD. Additional studies are needed to assess its cost-effectiveness and compare its usefulness with other traction devices and techniques during ESD.

Endoscopic Resection Techniques for Duodenal and Ampullary Adenomas

Background and Aims

Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary adenomas are even less common. Nonetheless, the incidence continues to rise because of widespread endoscopy use. Duodenal polyps with villous features or those that are larger than 10 mm may raise concern for malignancy and require removal. We demonstrate endoscopic resection of SNDAs and ampullary adenomas using some of our preferred techniques.

Methods

The duodenum has several components that can make EMR of duodenal polyps technically challenging. Not only does the duodenum have a thin muscle layer, but it is also highly mobile and vascular, which may explain higher rates of perforation and bleeding of duodenal EMR reported in the literature compared with colon EMR. A standard adult gastroscope with a distal cap is commonly used for duodenal EMRs. Based on the location, however, side-viewing duodenoscopes or pediatric colonoscopes may be used. To prepare for EMR, a submucosal injection is performed for an adequate lift. The polyp is then resected via stiff monofilament snares and subsequently closed with hemostatic clips if feasible. The ampullectomy technique differs slightly from duodenal EMRs and carries the additional risk of pancreatitis. Submucosal injection in the ampulla may not lift well; thus, its utility is debatable. Biliary sphincterotomy should be performed, and based on endoscopist preference, the pancreatic duct (PD) guidewire can be left during resection to maintain access. After resection, a PD stent is placed to minimize pancreatitis risk.

Results

The video shows the aforementioned duodenal EMR techniques. Two clips of ampullectomy are also shown in the video.

Conclusions

A few common techniques used to perform duodenal EMR and ampullectomy are highlighted in the video. It is important to understand and manage adverse events associated with these procedures and to have established surveillance plans.

Real-world evidence of safety and effectiveness of Barrett's endoscopic therapy

BACKGROUND AND AIMS

Real-world data on the adverse events and the survival benefit of Barrett's endoscopic therapy (BET) are limited. The aim of this study was to examine the safety and effectiveness (survival benefit) of BET in patients with neoplastic Barrett's esophagus (BE).

METHODS

An electronic health record-based database (TriNetX) was used to select patients with BE with dysplasia and esophageal adenocarcinoma (EAC) from 2016 to 2020. Primary outcome was 3-year mortality among patients with high-grade dysplasia (HGD) or EAC who underwent BET versus 2 comparison cohorts: patients with HGD or EAC who had not undergone BET and patients with GERD but no BE/EAC. Secondary outcome was adverse events (esophageal perforation, upper GI bleeding, chest pain, and esophageal stricture) after BET. To control for confounding variables, 1:1 propensity score matching was performed.

RESULTS

We identified 27,556 patients with BE and dysplasia, of whom 5295 underwent BET. After propensity score matching, patients with HGD and EAC who underwent BET had significantly lower 3-year mortality (HGD risk ratio [RR], .59; 95% CI, .49-.71; EAC RR, .53; 95% CI, .44-.65) compared with corresponding cohorts who did not undergo BET (P < .001). There was no difference in median 3-year mortality between control subjects (GERD without BE/EAC) compared with patients with HGD (RR, 1.04; 95% CI, .84-1.27) who underwent BET. Finally, there was no difference in median 3-year mortality between patients who underwent BET compared with patients who underwent esophagectomy among both HGD (RR, .67; 95% CI, .39-1.14; P =.14) and EAC (RR, .73; 95% CI, .47-1.13; P = .14). Esophageal stricture was the most common adverse event (6.5%) after BET.

CONCLUSIONS

Real-world, population-based evidence from this large database shows that endoscopic therapy is safe and effective for patients with BE. Endoscopic therapy is associated with a significantly lower 3-year mortality; however, it leads to esophageal strictures in 6.5% of treated patients.

Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs

Background and study aims Conventional endoscopic mucosal resection (C-EMR) is limited by low en-bloc resection rates, especially for large (> 20 mm) lesions. Underwater EMR (U-EMR) has emerged as an alternative for colorectal polyps and is being shown to improve en-bloc resection rates. We conducted a systematic review and meta-analysis comparing the two techniques. Methods Multiple databases were searched through November 2022 for randomized controlled trials (RCTs) comparing outcomes of U-EMR and C-EMR for colorectal polyps. Meta-analysis was performed to determine pooled proportions and relative risks (RRs) of R0 and en-bloc resection, polyp recurrence, resection time, and adverse events. Results Seven RCTs with 1458 patients (U-EMR: 739, C-EMR: 719) were included. The pooled rate of en-bloc resection was significantly higher with U-EMR vs C-EMR, 70.17% (confidence interval [CI] 46.68-86.34) vs 58.14% (CI 31.59-80.68), respectively, RR 1.21 (CI 1.01-1.44). R0 resection rates were higher with U-EMR vs C-EMR, 58.1% (CI 29.75-81.9) vs 44.6% (CI 17.4-75.4), RR 1.25 (CI 0.99-1.6). For large polyps (> 20 mm), en-bloc resection rates were comparable between the two techniques, RR 1.24 (CI 0.83-1.84). Resection times were comparable between U-EMR and C-EMR, standardized mean difference -1.21 min (CI -2.57 to -0.16). Overall pooled rates of perforation, and immediate and delayed bleeding were comparable between U-EMR and C-EMR. Pooled rate of polyp recurrence at surveillance colonoscopy was significantly lower with U-EMR than with C-EMR, RR 0.62 (CI 0.41-0.94). Conclusions Colorectal U-EMR results in higher en-bloc resection and lower recurrence rates when compared to C-EMR. Both techniques have comparable resection times and safety profiles.

A review of hydrogels used in endoscopic submucosal dissection for intraoperative submucosal cushions and postoperative management

Endoscopic submucosal dissection (ESD) has been clinically proved to have prominent advantages in the treatment of early gastrointestinal cancers over traditional surgery, including less trauma, fewer complications, a quicker recovery and lower costs. During the procedure of ESD, appropriate and multifunctional submucosal injected materials (SIMs) as submucosal cushions play an important role, however, even with many advances in design strategies of SIMs over the past decades, the performance of the submucosal cushions with postoperative management function seems to be still unsatisfactory. In this review, we gave a brief historical recount about the clinical development of SIMs, then some common applications of hydrogels used as SIMs in ESD were summarized, while an account of the universal challenges during ESD procedure was also outlined. Going one step further, some cutting-edge functional strategies of hydrogels for novel applications in ESD were exhibited. Finally, we concluded the advantages of hydrogels as SIMs for ESD as well as the treatment dilemma clinicians faced when it comes to deeply infiltrated lesions, some technical perspectives about linking the clinical demand with commercial supply were also proposed. Encompassing the basic elements of SIMs used in ESD surgery and the corresponding postoperative management requirements, this review could be a good reference for relevant practitioners in expanding the research horizon and improving the well-being index of patients.

Safety and feasibility of same-day discharge after endoscopic submucosal dissection: a Western multicenter prospective cohort study

BACKGROUND AND AIMS

Recent Western studies support the safety and efficacy of endoscopic submucosal dissection (ESD) for lesions throughout the GI tract. Although admission for observation after ESD is standard in Asia, a more selective approach may optimize resource utilization. We aimed to evaluate the safety and feasibility of same-day discharge (SDD) after ESD and factors associated with admission.

METHODS

This was a post hoc analysis of a multicenter, prospective cohort of patients undergoing ESD (2016-2021). The primary end points were safety of SDD and factors associated with post-ESD admission.

RESULTS

Of 831 patients (median age, 67 years; 57% male) undergoing 831 ESDs (240 performed in the esophagus, 126 in the stomach, and 465 in the colorectum; median lesion size, 44 mm), 588 (71%) were SDD versus 243 (29%) admissions. Delayed bleeding and perforation occurred in 12 (2%) and 4 (.7%) of SDD patients, respectively; only 1 (.2%) required surgery. Of the 243 admissions, 223 (92%) were discharged after ≤24 hours of observation. Interestingly, larger lesion size (>44 mm) was not associated with higher admission rate (odds ratio [OR], .5; 95% confidence interval [CI], .3-.8; P = .001). Lesions in the upper GI tract versus colon (OR, 1.7; 95% CI, 1.1-2.6; P = .01), invasive cancer (OR, 1.9; 95% CI, 1.2-3.1; P = .01), and adverse events (OR, 2.7; 95% CI, 1.5-4.8; P = .001) were independent factors for admission. Admissions were more likely performed by endoscopists with ESD volume <50 cases (OR, 2.1; 95% CI, 1.3-3.3; P = .001) with procedure time >75 minutes (OR, 13.5; 95% CI, 8.5-21.3; P < .0001).

CONCLUSIONS

SDD after ESD can be safe and feasible. Patients with invasive cancer, lesions in the upper GI tract, longer procedure times, or procedures performed by low-volume ESD endoscopists are more likely to be admitted postprocedure. Risk stratification of patients for SDD after ESD should help optimize resource utilization and enhance ESD uptake in the West. (Clinical trial registration number: NCT02989818.).