Endoscopic submucosal dissection or piecemeal endoscopic mucosal resection for large superficial colorectal lesions: A cost effectiveness study

Impact of Annual Case Volume on Colorectal Endoscopic Submucosal Dissection Outcomes in a Large Prospective Cohort Study

INTRODUCTION

The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort.

METHODS

Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed.

RESULTS

Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers.

DISCUSSION

Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

Traction-Assisted Endoscopic Submucosal Dissection of a Gastric Subepithelial Tumor: A Case Report

Endoscopic submucosal dissection (ESD) is considered curative for patients with early gastrointestinal cancers. However, it is a technically challenging procedure that can be time-consuming and associated with complications such as bleeding and perforation. Traction devices and techniques have been developed to mitigate these risks and reduce procedure times. Most traction devices are unavailable in New Zealand, and traction techniques have not been widely utilized due to the precision required for successful outcomes. We report the first case of traction-assisted ESD performed in New Zealand for a gastric submucosal tumor. The procedure was successfully performed using the clip with rubber band traction technique. The lesion was resected en bloc, and histology confirmed an R0, curative resection. There were no complications, and the total procedure time was 54 minutes. In conclusion, traction techniques can be effectively employed for ESD in lesions with difficult submucosal access. They contribute to safer dissections and reduced procedure times.

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

BACKGROUND

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

OBJECTIVE

To compare ESD and EMR for large colonic adenomas.

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS

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

LIMITATION

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

CONCLUSION

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

PRIMARY FUNDING SOURCE

French Ministry of Health.

Use of endoscopic submucosal dissection or full-thickness resection device to treat residual colorectal neoplasia after endoscopic resection: a multicenter historical cohort study

INTRODUCTION : Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different management techniques are feasible including endoscopic full-thickness resection using the full-thickness resection device (FTRD) system and endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of these two techniques for the treatment of such lesions. METHODS : All consecutive patients with RCN treated either using the FTRD or by ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate, defined as an en bloc resection with histologically tumor-free lateral and deep margins. RESULTS : 275 patients (median age 70 years; 160 men) who underwent 177 ESD and 98 FTRD procedures for RCN were included. R0 resection was achieved in 83.3 % and 77.6 % for ESD and FTRD, respectively (P = 0.25). Lesions treated by ESD were however larger than those treated by FTRD (P < 0.001). The R0 rates for lesions of 20-30 mm were 83.9 % and 57.1 % in the ESD and FTRD groups, respectively, and for lesions of 30-40 mm were 93.6 % and 33.3 %, respectively. On multivariable analysis, ESD procedures were associated with statistically higher en bloc and R0 resection rates after adjustment for lesion size (P = 0.02 and P < 0.001, respectively). The adverse event rate was higher in the ESD group (16.3 % vs. 5.1 %), mostly owing to intraoperative perforations. CONCLUSION:  ESD is effective in achieving R0 resection for RCN whatever the size and location of the lesions. When residual lesions are smaller than 20 mm, the FTRD is an effective alternative.

Endoscopic Submucosal Dissection, Endoscopic Mucosal Resection, and Transanal Minimally Invasive Surgery for the Management of Rectal and Anorectal Lesions: A Narrative Review

Endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and transanal minimally invasive surgery (TAMIS) are modern techniques that now play a crucial role in the treatment of colorectal lesions. ESD is a minimally invasive endoscopic procedure that allows for the resection of lesions of any size in a single piece, with clear advantages regarding oncological outcomes and recurrences. However, it is a complex technique, requiring high endoscopic skills, expertise, and specialized training, with higher rates of adverse events expected compared with EMR. EMR is another endoscopic technique used to remove superficial gastrointestinal tumors, particularly those that are limited to the mucosal layer. It is a faster and more accessible procedure, with fewer adverse events, although it only allows for an en-bloc resection of lesions measuring 15-20 mm. TAMIS is a minimally invasive surgical technique used to remove rectal tumors, involving the insertion of a single-port device through the anus, allowing for a better visualization and removal of the tumor with minimal disruption. This article reviews the current applications and evidence regarding these techniques, in search for the most adequate treatment for the removal of lesions in the rectum and anorectal junction, as these locations possess distinct characteristics that demand a more specific approach.