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Cocomazzi F, Carparelli S, Labarile N, Capogreco A, Gentile M, Maselli R, Dhar J, Samanta J, Repici A, Hassan C, Perri F, Facciorusso A. Is there a best choice of equipment for colorectal endoscopic submucosal dissection? Expert Rev Med Devices 2024:1-17. [PMID: 38829122 DOI: 10.1080/17434440.2024.2364022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/31/2024] [Indexed: 06/05/2024]
Abstract
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.
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Affiliation(s)
- Francesco Cocomazzi
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
| | - Sonia Carparelli
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
| | - Nunzia Labarile
- Department of Gastroenterology, National Institute of Gastroenterology - IRCCS "Saverio de Bellis" - Castellana Grotte, Bari, Italy
| | - Antonio Capogreco
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
| | - Marco Gentile
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
| | - Roberta Maselli
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University - Rozzano, Foggia, Italy
| | - Jahnvi Dhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University - Rozzano, Foggia, Italy
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University - Rozzano, Foggia, Italy
| | - Francesco Perri
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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Chiba H, Ohata K, Ashikari K, Tachikawa J, Okada N, Hayashi A, Ebisawa Y, Kobayashi M, Arimoto J, Kuwabara H, Nakaoka M. Effectiveness of Strategy-Focused Training in Colorectal Endoscopic Submucosal Dissection: A Retrospective Observational Study. Dig Dis Sci 2024:10.1007/s10620-024-08430-9. [PMID: 38662160 DOI: 10.1007/s10620-024-08430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Colorectal ESD, an advanced minimally invasive treatment, presents technical challenges, with globally varying training methods. We analyzed the learning curve of ESD training, emphasizing preoperative strategies, notably gravity traction, to guide ESD instructors and trainee programs. METHOD This retrospective study included 881 cases guided by an experienced supervisor. Six trainees received "strategy-focused" instruction. To evaluate the number of ESD experiences in steps, the following phases were classified based on ESD experiences of each trainees: Phase 0 (0-50 ESD), Phase 1 (51-100 ESD), Phase 2 (101-150 ESD), and Phase 3 (151-200 ESD). Lesion background, outcomes, and safety were compared across phases. Factors contributing to technical difficulty in early (Phase 0 and 1) and late phases (Phase 2 and 3) were identified, along with the utility of traction ESD with device assistance. RESULT Treatment outcomes were favorable, with 99.8% and 94.7% en bloc resection and curative resection rates, respectively. Approximately 90% self-completion rate could be achieved after experiencing about 50 cases (92.7% in Phase 1), signifying proficiency growth despite increased case difficulty. In early phases, factors such as left-sided colon, LST-NG morphology, and severe fibrosis pose challenges. In late phases, LST-NG morphology, mild and severe fibrosis remained significant. Traction-assisted ESD, utilized in 3% of cases, comprised planned (1.1%) and rescue (1.9%) methods. Planned traction aided specific lesions, while rescue traction was common in the right colon. CONCLUSION "Strategy-focused" ESD training consistently yields successful outcomes, effectively adapting to varying difficulty factors in different proficient stages.
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Affiliation(s)
- Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan.
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Keiichi Ashikari
- Ashikari Endoscopy Clinic, 1-12-13 Kamiooka Higashi, Konan-ku, Yokohama, Kanagawa, 233-0001, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan
| | - Naoya Okada
- Department of Gastroenterology, Yokohama Rosai Hospital, 3211 Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, 222-0036, Japan
| | - Akimichi Hayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Yu Ebisawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Mikio Kobayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
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Barbaro F, Papparella LG, Chiappetta MF, Ciuffini C, Fukuchi T, Hamanaka J, Quero G, Pecere S, Gibiino G, Petruzziello L, Maeda S, Hirasawa K, Costamagna G. Endoscopic full-thickness resection vs. endoscopic submucosal dissection of residual/recurrent colonic lesions on scars: a retrospective Italian and Japanese comparative study. Eur J Gastroenterol Hepatol 2024; 36:162-167. [PMID: 38131424 DOI: 10.1097/meg.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIMS Endoscopic treatment of recurrent/residual colonic lesions on scars is a challenging procedure. In this setting, endoscopic submucosal dissection (ESD) is considered the first choice, despite a significant rate of complications. Endoscopic full-thickness resection (eFTR) has been shown to be well-tolerated and effective for these lesions. The aim of this study is to conduct a comparison of outcomes for resection of such lesions between ESD and eFTR in an Italian and a Japanese referral center. METHODS From January 2018 to July 2020, we retrospectively enrolled patients with residual/recurrent colonic lesions, 20 treated by eFTR in Italy and 43 treated by ESD in Japan. The primary outcome was to compare the two techniques in terms of en-bloc and R0-resection rates, whereas complications, time of procedure, and outcomes at 3-month follow-up were evaluated as secondary outcomes. RESULTS R0 resection rate was not significantly different between the two groups [18/20 (90%) and 41/43 (95%); P= 0.66]. En-bloc resection was 100% in both groups. No significant difference was found in the procedure time (54 min vs. 61 min; P= 0.9). There was a higher perforation rate in the ESD group [11/43 (26%) vs. 0/20 (0%); P= 0.01]. At the 3-month follow-up, two lesions relapsed in the eFTR cohort and none in the ESD cohort (P= 0.1). CONCLUSION eFTR is a safer, as effective and equally time-consuming technique compared with ESD for the treatment of residual/recurrent colonic lesions on scars and could become an alternative therapeutic option for such lesions.
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Affiliation(s)
- Federico Barbaro
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Luigi Giovanni Papparella
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Michele Francesco Chiappetta
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Section of Gastroenterology and Hepatology, Promise, Policlinico Universitario Paolo Giaccone, Palermo, Italy
| | - Cristina Ciuffini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Takehide Fukuchi
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Jun Hamanaka
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Università Cattolica del Sacro Cuore, Roma
| | - Silvia Pecere
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Morgagni-Pierantoni, AUSL Romagna, Forlì, Italy
| | - Lucio Petruzziello
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
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Barbaro F, Ciuffini C, Chiappetta MF, Papparella LG, Pecere S, Ricci R, Familiari P, Petruzziello L, Spada C, Costamagna G. Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience. Dig Liver Dis 2023; 55:1391-1396. [PMID: 37316365 DOI: 10.1016/j.dld.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/02/2023] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm. METHODS A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group. RESULTS En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery. CONCLUSIONS ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.
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Affiliation(s)
- Federico Barbaro
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Cristina Ciuffini
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy.
| | - Michele Francesco Chiappetta
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy; Section of Gastroenterology and Hepatology, Promise, Policlinico Universitario Paolo Giaccone, Palermo, Italy
| | - Luigi Giovanni Papparella
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Silvia Pecere
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Riccardo Ricci
- Department of Pathology, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Lucio Petruzziello
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Cristiano Spada
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit - Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Policlinico Universitario Agostino Gemelli IRCCS of Rome, Italy; Università Cattolica del Sacro Cuore, CERTT - Centre for Endoscopic Research, Therapeutics and Training, Rome, Italy
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Cecinato P, Lisotti A, Azzolini F, Lucarini M, Bassi F, Fusaroli P, Sassatelli R. Left colonic localization, non-granular morphology, and pit pattern independently predict submucosal fibrosis of naïve colorectal neoplasms before endoscopic submucosal dissection. Surg Endosc 2022; 37:3037-3045. [PMID: 36542136 DOI: 10.1007/s00464-022-09828-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) represents the method of choice for removal of large colorectal neoplasms with suspected submucosal invasion. Presence and degree of submucosal fibrosis increases ESD duration and technical complexity, reduces the rate of curative resection and reduces safety profile. The aim of the study was to identify pre-procedural predictive factors of submucosal fibrosis in naïve colorectal neoplasms and to assess the impact of fibrosis on technical and clinical ESD outcomes. METHODS All consecutive ESD performed between 2014 and 2021 were retrieved from a prospectively collected database. For each patient, pre-procedural, procedural, and post-procedural data were recorded. Logistic regression was used to identify pre-procedural predictive factors for submucosal fibrosis. The study was approved by Institutional Reviewer Board and registered on ClinicalTrials.gov (NCT04780256). RESULTS One hundred-74 neoplasms (46.6% rectum, 21.8% left colon, 31.6% right colon; size 34.9 ± 17.5 mm) from 169 patients (55.0% male; 69.5 ± 10.4-year-old) were included. 106 (60.9%) neoplasms were granular type laterally spreading tumor (LST-G), 42 (24.1%) non-granular (LST-NG), and 26 (14.9%) sessile; invasive pit pattern was observed in 90 (51.7%) lesions. No fibrosis (F0) mild (F1) and severe (F2) were observed in 62 (35.6%), 92 (52.9%), and 20 (11.5%), respectively. Left colonic localization [OR 3.23 (1.1-9.31)], LST-NG morphology [OR 5.84 (2.03-16.77)] and invasive pit pattern [OR 7.11 (3.11-16.23)] were independently correlated to submucosal fibrosis. Lower curative resection rate (59.8% vs. 93.5%, P < 0.001) was observed in case of fibrosis; the incidence of adverse events was higher in case of severe fibrosis (35.5%) compared to no (3.2%) and mild fibrosis (3.3%; P < 0.001). Procedure time was significantly impacted by presence and degree of fibrosis (P < 0.001). CONCLUSIONS Left colonic localization, LST-NG morphology, and invasive pit pattern are independent predictors of fibrosis, affecting technical and clinical ESD outcomes. Pre-procedural stratification is pivotal to estimate procedure time, required operator's experience and advanced dissection techniques. Cecinato P et al. Left colonic localization, non-granular morphology, and pit pattern independently predict submucosal fibrosis of colorectal neoplasms before endoscopic submucosal dissection. Surg Endosc. 2023.
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Affiliation(s)
- Paolo Cecinato
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS Di Reggio Emilia, 42123, Reggio Emilia, Italy.
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Francesco Azzolini
- Unit of Digestive Endoscopy, Vita Salute San Raffaele University, Milan, Italy
| | - Matteo Lucarini
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS Di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Fabio Bassi
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS Di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS Di Reggio Emilia, 42123, Reggio Emilia, Italy
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Abstract
OBJECTIVE An increasing use of endoscopic submucosal dissection (ESD) has been reported in Western countries, although some differences in training schemes and outcomes have been described. We aimed to report the training model, implementation, and outcomes of ESD in Portugal. METHODS All endoscopists trained at our center from our country (n = 9) were invited to a survey regarding: (a) training period; (b) ESD outcomes and (c) implementation of ESD in each respective center. RESULTS All endoscopists completed the survey. Learning ESD was centered on human ESD assistance in a high-volume center during a median time of 6 months and complemented mainly by hands-on courses (89%). During the surveyed period, a total of 1229 ESD were performed, mostly in gastric locations (74%). Median complete R0 and curative resection rate were 92% (IQR, 81-96.8) and 87% (IQR, 74-93.3), respectively, and median perforation rate was 0.89% (IQR, 0.25-6.22). The main limitations encountered during the implementation of ESD were related to the lack of initial mentoring or insufficient expertise to progress to more difficult lesions. CONCLUSION Learning ESD through participation in hands-on courses and visiting high-volume centers seems to be adequate to achieve a good competence at the initial stage of ESD, which in fact is in consonance with the European Society of Gastrointestinal Endoscopy recommendations. However, mentoring is essential for technical progression, and this represents the fundamental barrier during the adoption of ESD, which may be overcome by increasing hands-on training in animal or artificial simulators, but preferably with the implementation of a structured training program.
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De Luca L, Di Berardino M, Mangiavillano B, Repici A. Gastric endoscopic submucosal dissection in Western countries: Indications, applications, efficacy and training perspective. World J Gastrointest Surg 2021; 13:1180-1189. [PMID: 34754386 PMCID: PMC8554716 DOI: 10.4240/wjgs.v13.i10.1180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/02/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection was introduced in Japan for the mini-invasive treatment of early gastric cancer, as part of national screening program considering high prevalence of disease in these latitudes. This technique allows en-bloc curative oncological excision and to obtain in a single step R0-resection, characterization, histological staging and potential cure of the tumor with a very high cost-benefit balance. Over the years, Western endoscopists have adopted endoscopic submucosal dissection, achieving good rates of efficacy, long-term improved outcomes and safety, with low risk of local recurrence comparable to those obtained in Asian institutes. However, according to some authors, the excellent outcomes from East country could not be representative of the Western experience. Despite epidemiological differences of early gastric cancer, scant volume data and limitations in training opportunities between Western and Eastern countries, European Society of Gastrointestinal Endoscopy have adopted Japanese guidelines and developed a European core curriculum for endoscopic submucosal dissection training. Endoscopists should be able to estimate the probability of performing a curative resection by considering the benefit/risk relationship case-by-case in order to implement a correct decision-making process.
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Affiliation(s)
- Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Riuniti Marche North Hospital, Pesaro 61121, Italy
| | | | | | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Humanitas University, Rozzano 20089, Italy
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Fleischmann C, Probst A, Ebigbo A, Faiss S, Schumacher B, Allgaier HP, Dumoulin FL, Steinbrueck I, Anzinger M, Marienhagen J, Muzalyova A, Messmann H. Endoscopic Submucosal Dissection in Europe: Results of 1000 Neoplastic Lesions From the German Endoscopic Submucosal Dissection Registry. Gastroenterology 2021; 161:1168-1178. [PMID: 34182002 DOI: 10.1053/j.gastro.2021.06.049] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) enables the curative resection of early malignant lesions and is associated with reduced recurrence risk. Due to the lack of comprehensive ESD data in the West, the German ESD registry was set up to evaluate relevant outcomes of ESD. METHODS The German ESD registry is a prospective uncontrolled multicenter study. During a 35-month period, 20 centers included 1000 ESDs of neoplastic lesions. The results were evaluated in terms of en bloc, R0, curative resection rates, and recurrence rate after a 3-month and 12-month follow-up. Additionally, participating centers were grouped into low-volume (≤20 ESDs/y), middle-volume (20-50/y), and high-volume centers (>50/y). A multivariate analysis investigating risk factors for noncurative resection was performed. RESULTS Overall, en bloc, R0, and curative resection rates of 92.4% (95% confidence interval [CI], 0.90-0.94), 78.8% (95% CI, 0.76-0.81), and 72.3% (95% CI, 0.69-0.75) were achieved, respectively. The overall complication rate was 8.3% (95% CI, 0.067-0.102), whereas the recurrence rate after 12 months was 2.1%. High-volume centers had significantly higher en bloc, R0, curative resection rates, and recurrence rates and lower complication rates than middle- or low-volume centers. The lesion size, hybrid ESD, age, stage T1b carcinoma, and treatment outside high-volume centers were identified as risk factors for noncurative ESD. CONCLUSION In Germany, ESD achieves excellent en bloc resection rates but only modest curative resection rates. ESD requires a high level of expertise, and results vary significantly depending on the center's yearly case volume.
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Affiliation(s)
- Carola Fleischmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin, Germany
| | | | - H-P Allgaier
- Medical Department, Evangelisches Diakoniekrankenhaus, Freiburg, Germany
| | - F L Dumoulin
- Department of Medicine/Gastroenterology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Ingo Steinbrueck
- Department of Gastroenterology, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Michael Anzinger
- Department of Gastroenterology, Barmherzige Brüder Krankenhaus München, München, Germany
| | | | - Anna Muzalyova
- Chair of Health Care Operations/ Health Information Management, UNIKA-T, University of Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany.
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Young E, Philpott H, Singh R. Endoscopic diagnosis and treatment of gastric dysplasia and early cancer: Current evidence and what the future may hold. World J Gastroenterol 2021; 27:5126-5151. [PMID: 34497440 PMCID: PMC8384753 DOI: 10.3748/wjg.v27.i31.5126] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/07/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric cancer accounts for a significant proportion of worldwide cancer-related morbidity and mortality. The well documented precancerous cascade provides an opportunity for clinicians to detect and treat gastric cancers at an endoscopically curable stage. In high prevalence regions such as Japan and Korea, this has led to the implementation of population screening programs. However, guidelines remain ambiguous in lower prevalence regions. In recent years, there have been many advances in the endoscopic diagnosis and treatment of early gastric cancer and precancerous lesions. More advanced endoscopic imaging has led to improved detection and characterization of gastric lesions as well as superior accuracy for delineation of margins prior to resection. In addition, promising early data on artificial intelligence in gastroscopy suggests a future role for this technology in maximizing the yield of advanced endoscopic imaging. Data on endoscopic resection (ER) are particularly robust in Japan and Korea, with high rates of curative ER and markedly reduced procedural morbidity. However, there is a shortage of data in other regions to support the applicability of protocols from these high prevalence countries. Future advances in endoscopic therapeutics will likely lead to further expansion of the current indications for ER, as both technology and proceduralist expertise continue to grow.
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Affiliation(s)
- Edward Young
- Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale 5112, SA, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, SA, Australia
| | - Hamish Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale 5112, SA, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale 5112, SA, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, SA, Australia
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10
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Bordillon P, Pioche M, Wallenhorst T, Rivory J, Legros R, Albouys J, Lepetit H, Rostain F, Dahan M, Ponchon T, Sautereau D, Loustaud-Ratti V, Geyl S, Jacques J. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021; 94:333-343. [PMID: 33548280 DOI: 10.1016/j.gie.2021.01.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Colonic endoscopic submucosal dissection (ESD) is particularly challenging and limited to a few expert centers. We recently conducted a pilot study on improvement of colonic ESD with systematic use of a countertraction device (double-clip traction with rubber band [DCT-ESD]). METHODS A French prospective multicenter study was conducted between March 2017 and September 2019, including all consecutive cases of naive colonic ESD. Since the first case of DCT-ESD in March 2017, all cases of colonic ESD have been performed using the DCT-ESD strategy in the 3 centers involved in the study. RESULTS Five hundred ninety-nine lesions with a mean size of 53 mm were included in this study, resected by 5 operators in 3 centers. The en bloc, R0, and curative resection rates were 95.7%, 83.5%, and 81.1%, respectively. The adverse event rates were 4.9% for perforation and 4.2% for postprocedure bleeding. Between 2017 and 2019, the rates of R0 and curative resections increased significantly from 74.7% in 2017 to 88.4% in 2019 (P = .003) and from 72.6% in 2017 to 86.3% in 2019 (P = .004), respectively. Procedure duration and speed of resection were 62.4 minutes and 39.4 mm2/minute, respectively. No differences were noted between operators. CONCLUSION DCT-ESD is a safe and reproducible technique, with results comparable with those of the large Japanese teams with speed of resection twice as high as previously reported studies. The DCT strategy is promising, cheap, and seems to be reproducible. Physicians performing colonic ESD should be aware of this promising tool to improve their results in ESD.
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Affiliation(s)
- Pierre Bordillon
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | - Mathieu Pioche
- Service d'Hépato-gastro-entérologie, CHU Edouard Herriot, Lyon, France
| | | | - Jérôme Rivory
- Service d'Hépato-gastro-entérologie, CHU Edouard Herriot, Lyon, France
| | - Romain Legros
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | - Jérémie Albouys
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | - Hugo Lepetit
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | - Florian Rostain
- Service d'Hépato-gastro-entérologie, CHU Edouard Herriot, Lyon, France
| | - Martin Dahan
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | - Thierry Ponchon
- Service d'Hépato-gastro-entérologie, CHU Edouard Herriot, Lyon, France
| | - Denis Sautereau
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | | | - Sophie Geyl
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
| | - Jérémie Jacques
- Service d'Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
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11
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Pih GY, Lee JS, Ahn JY, Kim DH, Na HK, Lee JH, Jung KW, Choi KD, Song HJ, Lee GH, Jung HY. Is Ex Vivo Training before In Vivo Training Effective in Learning Gastric Endoscopic Submucosal Dissection? THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2020.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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12
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Spychalski M, Włodarczyk M, Winter K, Włodarczyk J, Dąbrowski I, Dziki A. Outcomes of 601 Colorectal Endoscopic Submucosal Dissections in a Single Western Center: Is Right Colon Location Still a Major Concern? Surg Laparosc Endosc Percutan Tech 2021; 31:578-583. [PMID: 33935259 DOI: 10.1097/sle.0000000000000940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD), as a minimally invasive procedure for removal of early gastrointestinal neoplasms, is a standard approach in Asian countries. Outcomes of ESD in Western European countries significantly differ, which makes it more difficult to apply this procedure to daily-basis clinical routine. The aim of this study is to analyze the safety and efficiency of colorectal ESD based on a large series of cases performed by a single operator after finishing the learning curve period in a western referral center. MATERIALS AND METHODS We retrospectively studied 601 patients who underwent ESD procedure for colorectal neoplasm from January 2016 to December 2019 in a tertiary colorectal ESD center in Poland. RESULTS The overall en bloc resection was achieved in 88.02%. Complete histologic resection rate (R0) was reported at a level of 86.36%. Lesions located in the right colon were characterized by statistically lower en bloc, R0 resection, and success rate (73.95%, 71.43%, 69.75%, respectively). In 9.82% (n=59) of cases, the ESD procedure-related complications have been observed. Post-ESD bleeding occurred in 23 patients (3.83%) and perforation in 32 patients (5.32%). Twenty-seven patients were treated endoscopically (4.49%) and 5 required surgery (0.83%). Analysis of complications showed that tumors located within the right colon were characterized by the highest perforation rate at 10.92%. Within the rectum there were minimal number of perforations (2.69%), whereas the bleeding rate was 4.48%. CONCLUSIONS Our results represent the largest material concerning ESD of colorectal lesions in the West and show that ESD is characterized by a high rate of successful resections with a low risk of complications. Thus, confirming that it is possible to obtain results similar to Asian centers and that colorectal ESD procedures can be implemented in clinical routine in western countries. Nevertheless, ESD in the right colon is still related with high rate of complications, so qualification for the ESD procedure should be very careful and discussed with the patient and should be performed by an experienced endoscopist after the learning curve.
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Affiliation(s)
| | | | - Katarzyna Winter
- Center of Bowel Treatment, Brzeziny
- Digestive Tract Diseases, Medical University of Lodz, Lodz, Poland
| | | | | | - Adam Dziki
- Departments of General and Colorectal Surgery
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13
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Küttner-Magalhães R, Pimentel-Nunes P, Araújo-Martins M, Libânio D, Borges-Canha M, Marcos-Pinto R, Koch AD, Dinis-Ribeiro M. Endoscopic submucosal dissection (ESD): how do Western endoscopists value animal models? Scand J Gastroenterol 2021; 56:492-497. [PMID: 33556257 DOI: 10.1080/00365521.2021.1879251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic Submucosal Dissection (ESD)was introduced in the West later than in the East. Our aim was to assess how Western endoscopists performing ESD have been trained and how they value animal models for training. MATERIAL AND METHODS An online survey regarding training in ESD was sent to Western endoscopists who published articles on advanced resection techniques. RESULTS From 279 endoscopists, 58 (21%) completed the questionnaire, of which 50 confirmed performance of clinical ESD. Endoscopists had a median of 15 years of endoscopic experience (IQR 9.75-20.25) and all of them were performing conventional EMR, before starting ESD. Prior to clinical ESD, 74% (n = 37) underwent training with ex vivo models, 84% (n = 42) with live animal models and 92% (n = 46) with at least, one of the two models. After starting clinical ESD, as trainers, 52% (n = 26) were involved with ex vivo and 60% (n = 30) with live animal models. Personal usefulness of ex vivo and live animal models was rated with a median of 9 (IQR 8-10) and 10 (IQR 8-10), out of 10, respectively. Courses with ex vivo and live animal models were considered a prerequisite before clinical practice by 84% (n = 42) and 78% (n = 39), respectively. CONCLUSIONS Western endoscopists have extensive endoscopic experience before starting ESD. The majority had pre-clinical training with ex vivo and live animal models and more than half are acting as trainers of other endoscopists with these models. Animal models are considered very useful and deemed a prerequisite before clinical practice by the majority of the endoscopists.
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Affiliation(s)
- Ricardo Küttner-Magalhães
- Department of Gastroenterology, Santo António Hospital, Porto University Hospital Center, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.,Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Miguel Araújo-Martins
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.,Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marta Borges-Canha
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Endocrinology, Diabetes and Metabolism, São João University Hospital Center, Porto, Portugal
| | - Ricardo Marcos-Pinto
- Department of Gastroenterology, Santo António Hospital, Porto University Hospital Center, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal.,Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.,Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal
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14
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Arantes VN, Sanna MDGP, Alves JS, Milhomem-Cardoso DM, Maluf-Filho F. IS ENDOSCOPIC SUBMUCOSAL DISSECTION STILL LIMITED TO FEW TERTIARY CENTERS IN THE WEST? RESULTS FROM A NATIONAL SURVEY IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2021; 57:477-483. [PMID: 33331480 DOI: 10.1590/s0004-2803.202000000-84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers. OBJECTIVE This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED). METHODS In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided. RESULTS A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers. CONCLUSION ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.
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Affiliation(s)
- Vitor N Arantes
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Instituto Alfa de Gastroenterologia, Unidade de Endoscopia, Belo Horizonte, MG, Brasil.,Hospital Mater Dei Contorno, Unidade de Endoscopia, Belo Horizonte, MG, Brasil
| | - Maria das Graças Pimenta Sanna
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Instituto Alfa de Gastroenterologia, Unidade de Endoscopia, Belo Horizonte, MG, Brasil
| | - Jairo Silva Alves
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Instituto Alfa de Gastroenterologia, Unidade de Endoscopia, Belo Horizonte, MG, Brasil
| | | | - Fauze Maluf-Filho
- Instituto do Câncer do Estado de São Paulo (ICESP), Unidade de Endoscopia, SP, Brasil
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15
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Manta R, Galloro G, Pugliese F, Angeletti S, Caruso A, Zito FP, Mangiafico S, Marmo R, Zullo A, Esposito G, Annibale B, Mutignani M, Conigliaro R. Endoscopic Submucosal Dissection of Gastric Neoplastic Lesions: An Italian, Multicenter Study. J Clin Med 2020; 9:jcm9030737. [PMID: 32182894 PMCID: PMC7141243 DOI: 10.3390/jcm9030737] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) allows removing neoplastic lesions on gastric mucosa, including early gastric cancer (EGC) and dysplasia. Data on ESD from Western countries are still scanty. We report results of ESD procedures performed in Italy. Data of consecutive patients who underwent ESD for gastric neoplastic removal were analyzed. The en bloc resection rate and the R0 resection rates for all neoplastic lesions were calculated, as well as the curative rate (i.e., no need for surgical treatment) for EGC. The incidence of complications, the one-month mortality, and the recurrence rate at one-year follow-up were computed. A total of 296 patients with 299 gastric lesions (80 EGC) were treated. The en bloc resection was successful for 292 (97.6%) and the R0 was achieved in 266 (89%) out of all lesions. In the EGC group, the ESD was eventually curative in 72.5% (58/80) following procedure. A complication occurred in 30 (10.1%) patients. Endoscopic treatment was successful in all 3 perforations, whereas it failed in 2 out of 27 bleeding patients who were treated with radiological embolization (1 case) or surgery (1 case). No procedure-related deaths at one-month follow-up were observed. Lesion recurrence occurred in 16 (6.2%) patients (6 EGC and 10 dysplasia). In conclusion, the rate of both en bloc and R0 gastric lesions removal was very high in Italy. However, the curative rate for EGC needs to be improved. Complications were acceptably low and amenable at endoscopy.
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Affiliation(s)
- Raffaele Manta
- Gastroenterology and Digestive Endoscopy, General Hospital, 06129 Perugia, Italy
- Correspondence: ; Tel.: +39-075-5784480; Fax: +39-075-5784479
| | - Giuseppe Galloro
- Surgical Digestive Endoscopy, Department of Clinical Medicine and Surgery, Federico II University, 80055 Naples, Italy;
| | - Francesco Pugliese
- Digestive Endoscopy Unit, Niguarda Hospital, 20162 Milan, Italy; (F.P.); (M.M.)
| | - Stefano Angeletti
- Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University. 00189 Rome, Italy; (S.A.); (G.E.); (B.A.)
| | - Angelo Caruso
- Digestive Endoscopy Unit, S. Agostino-Estense Hospital, 41126 Modena, Italy; (A.C.); (F.P.Z.); (S.M.); (R.C.)
| | - Francesco P. Zito
- Digestive Endoscopy Unit, S. Agostino-Estense Hospital, 41126 Modena, Italy; (A.C.); (F.P.Z.); (S.M.); (R.C.)
| | - Santi Mangiafico
- Digestive Endoscopy Unit, S. Agostino-Estense Hospital, 41126 Modena, Italy; (A.C.); (F.P.Z.); (S.M.); (R.C.)
| | - Riccardo Marmo
- Gastroenterology and Digestive Endoscopy, L. Curto Hospital, Polla, 84036 Salerno, Italy;
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, 00153 Rome, Italy;
| | - Gianluca Esposito
- Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University. 00189 Rome, Italy; (S.A.); (G.E.); (B.A.)
| | - Bruno Annibale
- Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University. 00189 Rome, Italy; (S.A.); (G.E.); (B.A.)
| | | | - Rita Conigliaro
- Digestive Endoscopy Unit, S. Agostino-Estense Hospital, 41126 Modena, Italy; (A.C.); (F.P.Z.); (S.M.); (R.C.)
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