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Fujii T, Watanabe S, Uga M, Matsui Y, Sakaki K, Matsukawa N, Machida T, Kurihara M, Tashiro Y, Okamoto E, Yauchi T, Suzuki S, Koyama S. Analysis of lens cloudiness during endoscopic submucosal dissection procedures: Effects of a novel lens cleaner. DEN OPEN 2025; 5:e416. [PMID: 39077550 PMCID: PMC11284122 DOI: 10.1002/deo2.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 07/08/2024] [Accepted: 07/14/2024] [Indexed: 07/31/2024]
Abstract
Objectives We aimed to identify independent factors for intraoperative endoscopic lens cloudiness during gastric and colorectal endoscopic submucosal dissections, investigate the effectiveness of Cleastay, an endoscope anti-fog solution, and examine factors associated with severe submucosal fat deposition. Methods A total of 220 patients who underwent gastric or colorectal endoscopic submucosal dissections in two institutions between January 2022 and October 2023 were included. Significant factors related to cloudiness were determined using univariate and multivariate analyses. Patient background and tumor characteristics related to severe submucosal fat deposition were investigated, and the degree of intraoperative endoscopic lens cloudiness and outcomes were compared between the Cleash and Cleastay groups. Results In the multivariate analysis, factors increasing lens cloudiness included long procedure time (odds ratio [OR], 17.51; 95% confidence interval [CI], 1.52-202.08), stomach (vs. colon; OR, 5.08; 95% CI, 1.99-12.96), and severe submucosal fat deposition (OR, 12.19; 95% CI, 5.02-29.60). Conversely, the use of Cleastay (vs. Cleash; OR, 0.066; 95% CI, 0.021-0.21) was identified as a factor reducing cloudiness. Location analysis revealed that severe submucosal fat deposition was more common in the upper stomach and right colon. Conclusions It was suggested that Cleastay is more useful for endoscopic submucosal dissection of the upper stomach and right colon, where severe submucosal fat deposition is expected.
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Affiliation(s)
- Takashi Fujii
- Department of GastroenterologyTokyo Metropolitan Hiroo HospitalTokyoJapan
| | - Sho Watanabe
- Department of GastroenterologySoka Municipal HospitalSaitamaJapan
| | - Misugi Uga
- Department of GastroenterologySoka Municipal HospitalSaitamaJapan
| | - Yuuki Matsui
- Department of GastroenterologyTokyo Metropolitan Hiroo HospitalTokyoJapan
| | - Kazuomi Sakaki
- Department of GastroenterologyTokyo Metropolitan Hiroo HospitalTokyoJapan
| | - Naoki Matsukawa
- Department of GastroenterologySoka Municipal HospitalSaitamaJapan
| | - Tomoyo Machida
- Department of GastroenterologySoka Municipal HospitalSaitamaJapan
| | | | - Yoshihiro Tashiro
- Department of GastroenterologyTokyo Metropolitan Hiroo HospitalTokyoJapan
| | - Eiko Okamoto
- Department of GastroenterologyTokyo Metropolitan Hiroo HospitalTokyoJapan
| | - Tsunehito Yauchi
- Department of GastroenterologySoka Municipal HospitalSaitamaJapan
| | - Shinji Suzuki
- Department of GastroenterologyTokyo Metropolitan Hiroo HospitalTokyoJapan
| | - Shigeru Koyama
- Department of EndoscopyTokyo Metropolitan Hiroo HospitalTokyoJapan
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Sferrazza S, Maida M, Calabrese G, Fiorentino A, Vieceli F, Facciorusso A, Fuccio L, Maselli R, Repici A, Di Mitri R. Effectiveness and safety of newly introduced endoscopic submucosal dissection in a Western center: a real-life study. Eur J Gastroenterol Hepatol 2024; 36:1281-1287. [PMID: 39012649 DOI: 10.1097/meg.0000000000002829] [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: 07/17/2024]
Abstract
OBJECTIVES Endoscopic submucosal dissection (ESD) is a minimally invasive technique for the resection of superficial gastrointestinal lesions, providing high rates of 'en bloc' and R0 resection. East-West differences in ESD quality indicators have been reported. This study aims to assess feasibility, effectiveness, and safety of ESD for the treatment of superficial gastrointestinal (GI) lesions in a Western cohort. METHODS Consecutive patients undergoing ESD at one Italian endoscopic referral center from September 2018 to March 2020 were included in this prospective study. Primary outcomes were technical success, R0 resection rate, curative resection rate, and adverse events (AEs). RESULTS In total 111 patients (111 lesions) undergoing ESD were included. Anatomic site of the lesions was rectum in 56.8%, colon in 13.5%, stomach in 24.3%, and esophagus in 5.4% of cases, respectively. For upper GI procedures, technical success was 100%, and R0 and curative resection rates were 84.8% and 78.8%, respectively. For colorectal procedures, technical success was 98.7%, R0 and curative resection rates were 88.5% and 84.6%, respectively. Major AEs were reported in 12 cases (10.8%). CONCLUSION The introduction of ESD in a Tertiary Center is feasible, effective, and safe, and should be taken into consideration for the treatment of superficial GI lesions requiring 'en bloc' resection.
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Affiliation(s)
- Sandro Sferrazza
- Gastroenterology and Endoscopy Departiment, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Marcello Maida
- Department of Medicine and Surgery, University of Enna 'Kore', Enna, Italy
| | - Giulio Calabrese
- Gastroenterology and Endoscopy Departiment, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Andrea Fiorentino
- Gastroenterology and Endoscopy Department, Sant'Ottone Frangipane Hospital, Ariano Irpino (AV), Italy
| | - Filippo Vieceli
- Gastroenterology and Endoscopy Department, S. Chiara Hospital, Trento, Italy
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Roberta Maselli
- Endoscopy Department, Humanitas Clinical and Research Hospital, IRCCS, Rozzano (MI), Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Alessandro Repici
- Endoscopy Department, Humanitas Clinical and Research Hospital, IRCCS, Rozzano (MI), Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Roberto Di Mitri
- Gastroenterology and Endoscopy Departiment, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
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Gorgun E, Yilmaz S, Ozgur I, Sommovilla J, Truong A, Maspero M, Bhatt A, Catalano B, Liska D, Steele SR. Predictors of En Bloc, R0 Resection, and Postprocedural Complications After Advanced Endoscopic Resections for Colorectal Neoplasms: Results of 1213 Procedures. Dis Colon Rectum 2024; 67:1185-1193. [PMID: 38889766 DOI: 10.1097/dcr.0000000000003394] [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: 06/20/2024]
Abstract
BACKGROUND Advanced endoscopic resection techniques are used to treat colorectal neoplasms that are not amenable to conventional colonoscopic resection. Literature regarding the predictors of the outcomes of advanced endoscopic resections, especially from a colorectal surgical unit, is limited. OBJECTIVE To determine the predictors of short-term and long-term outcomes after advanced endoscopic resections. DESIGN Retrospective case series. SETTINGS Tertiary care center. PATIENTS Patients who underwent advanced endoscopic resections for colorectal neoplasms from November 2011 to August 2022. INTERVENTIONS Endoscopic mucosal resection, endoscopic submucosal dissection, hybrid endoscopic submucosal dissection, and combined endoscopic laparoscopic surgery. MAIN OUTCOME MEASURES Predictors of en bloc and R0 resection, bleeding, and perforation were determined using univariable and multivariable logistic regression models. Cox regression models were used to determine the predictors of tumor recurrence. RESULTS A total of 1213 colorectal lesions from 1047 patients were resected (median age 66 [interquartile range, 58-72] years, 484 women [46.2%], median BMI 28.6 [interquartile range, 24.8-32.6]). Most neoplasms were in the proximal colon (898; 74%). The median lesion size was 30 (interquartile range, 20-40; range, 0-120) mm. Nine hundred eleven lesions (75.1%) underwent previous interventions. The most common Paris and Kudo classifications were 0 to IIa flat elevation (444; 36.6%) and IIIs (301; 24.8%), respectively. En bloc and R0 resection rates were 56.6% and 54.3%, respectively. Smaller lesions, rectal location, and procedure type (endoscopic submucosal dissection) were associated with significantly higher en bloc and R0 resection rates. Bleeding and perforation rates were 5% and 6.6%, respectively. Increased age was a predictor for bleeding (OR 1.06; 95% CI, 1.03-1.09; p < 0.0001). Lesion size was a predictor for perforation (OR 1.02; 95% CI, 1.00-1.03; p = 0.03). The tumor recurrence rate was 6.6%. En bloc (HR 1.41; 95% CI, 1.05-1.93; p = 0.02) and R0 resection (HR 1.49; 95% CI, 1.11-2.06; p = 0.008) were associated with decreased recurrence risk. LIMITATIONS Single-center, retrospective study. CONCLUSIONS Outcomes of advanced endoscopic resections can be predicted by patient-related and lesion-related characteristics. See Video Abstract . PREDICTORES DE LA RESECCION R, EN BLOQUE Y LAS COMPLICACIONES POR RESECCIONES ENDOSCPICAS AVANZADAS EN CASOS DE NEOPLASIA COLORRECTAL RESULTADOS DE PROCEDIMIENTOS ANTECEDENTES:Las técnicas avanzadas de resección endoscópica se utilizan para el tratamiento de neoplasias colorrectales que no son susceptibles de resección colonoscópica convencional. La literatura sobre los predictores de los resultados de las resecciones endoscópicas avanzadas, especialmente en una unidad de cirugía colorrectal, es limitada.OBJETIVO:Determinar los predictores de resultados a corto y largo plazo después de resecciones endoscópicas avanzadas.DISEÑO:Serie de casos retrospectivos.LUGAR:Centro de tercer nivel de atención.PACIENTES:Pacientes sometidos a resecciones endoscópicas avanzadas por neoplasias colorrectales desde noviembre de 2011 hasta agosto de 2022.INTERVENCIÓNES:Resección endoscópica de la mucosa, disección endoscópica submucosa (ESD), ESD híbrida, cirugía laparoscópica endoscópica combinada.PRINCIPALES MEDIDAS DE RESULTADO:Los predictores de resección en bloque y R0, sangrado y perforación se determinaron mediante modelos de regresión logística univariables y multivariables. Se utilizaron modelos de regresión de Cox para determinar los predictores de recurrencia del tumor.RESULTADOS:Se resecaron 1.213 lesiones colorrectales en 1.047 pacientes [edad media 66 (58-72) años, 484 (46,2%) mujeres, índice de masa corporal medio 28,6 (24,8-32,6) kg/m 2 ]. La mayoría de las neoplasias se encontraban en el colon proximal (898, 74%). El tamaño medio de la lesión fue de 30mm (RIC: 20-40, rango: 0-120). 911 (75,1%) lesiones tenían intervenciones previas. Las clasificaciones de París y Kudo más comunes fueron 0-IIa elevación plana (444, 36,6%) y III (301, 24,8%), respectivamente. Las tasas de resección en bloque y R0 fueron del 56,6% y 54,3%, respectivamente. Las lesiones más pequeñas, la ubicación rectal y el tipo de procedimiento (ESD) se asociaron con tasas de resección en bloque y R0 significativamente más altas. Las tasas de sangrado y perforación fueron del 5% y 6,6%, respectivamente. La edad avanzada [1,06 (1,03-1,09), p < 0,0001] fue un predictor de sangrado. El tamaño de la lesión [1,02 (1,00-1,03), p = 0,03] fue un predictor de perforación. La tasa de recurrencia del tumor fue del 6,6%. En bloque [HR 1,41 (IC 95% 1,05-1,93), p = 0,02] y la resección R0 [HR 1,49 (IC 95% 1,11-2,06), p = 0,008] se asociaron con un menor riesgo de recurrencia.LIMITACIONES:Estudio unicéntrico, retrospectivo.CONCLUSIONES:Los resultados de las resecciones endoscópicas avanzadas pueden predecirse según las características del paciente y de la lesión. (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumeyye Yilmaz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ilker Ozgur
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joshua Sommovilla
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adam Truong
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marianna Maspero
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brogan Catalano
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Yilmaz S, Gorgun E. Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Clin Colon Rectal Surg 2024; 37:277-288. [PMID: 39132198 PMCID: PMC11309798 DOI: 10.1055/s-0043-1770941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Up to 15% of colorectal polyps are amenable for conventional polypectomy. Advanced endoscopic resection techniques are introduced for the treatment of those polyps. They provide higher en bloc resection rates compared with conventional techniques, while helping patients to avoid the complications of surgery. Note that 20 mm is considered as the largest size of a polyp that can be resected by polypectomy or endoscopic mucosal resection (EMR) in an en bloc fashion. Endoscopic submucosal dissection (ESD) is recommended for polyps larger than 20 mm. Intramucosal carcinomas and carcinomas with limited submucosal invasion can also be resected with ESD. EMR is snare resection of a polyp following submucosal injection and elevation. ESD involves several steps such as marking, submucosal injection, incision, and dissection. Bleeding and perforation are the most common complications following advanced endoscopic procedures, which can be treated with coagulation and endoscopic clipping. En bloc resection rates range from 44.5 to 63% for EMR and from 87.9 to 96% for ESD. Recurrence rates following EMR and ESD are 7.4 to 17% and 0.9 to 2%, respectively. ESD is considered enough for the treatment of invasive carcinomas in the presence of submucosal invasion less than 1000 μm, absence of lymphovascular invasion, well-moderate histological differentiation, low-grade tumor budding, and negative resection margins.
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Affiliation(s)
- Sumeyye Yilmaz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Gu F, Jiang W, Zhu J, Ma L, He B, Zhai H. Risk factors for unsuccessful colorectal endoscopic submucosal dissection: A systematic review and meta-analysis. Dig Liver Dis 2024; 56:1288-1297. [PMID: 38071178 DOI: 10.1016/j.dld.2023.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/05/2023] [Accepted: 11/21/2023] [Indexed: 07/29/2024]
Abstract
BACKGROUND AND AIMS Despite its growing popularity, endoscopic submucosal dissection (ESD) for colorectal neoplasms is still technically challenging. The factors contributing to the failure of ESD are not yet comprehensively elucidated. Therefore, this systematic review was conducted to explore the potential risk factors associated with unsuccessful colorectal ESD. METHODS A comprehensive search of Medline and Embase databases was conducted to identify relevant publications from inception until March 14, 2023. Unsuccessful ESD was defined as cases involving incomplete resection or the occurrence of adverse events, such as perforation and delayed bleeding. RESULTS Among the 2067 citations initially identified, a total of 23 cohort studies and 16 case-control studies met the inclusion criteria. Following meta-analyses, several significant risk factors for incomplete resection were identified, including lesion diameter ≥40 or 50 mm, right-side colonic location, deeper submucosal invasion, and severe fibrosis. Similarly, lesion diameter ≥40 or 50 mm and severe fibrosis emerged as risk factors for perforation. However, no individual factor was found to be statistically associated with delayed bleeding. CONCLUSIONS This meta-analysis identified risk factors correlated with incomplete resection and adverse events following ESD. The findings provide valuable insights that can guide clinical decision-making, aiding gastroenterologists in accurately identifying high-risk individuals.
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Affiliation(s)
- Feng Gu
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Wei Jiang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing 100050, China; National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Jingyi Zhu
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Lei Ma
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Boyuan He
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Huihong Zhai
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
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Cecinato P, Sinagra E, Laterza L, Pianigiani F, Grande G, Sassatelli R, Barbara G. Endoscopic removal of gastrointestinal lesions by using third space endoscopy techniques. Best Pract Res Clin Gastroenterol 2024; 71:101931. [PMID: 39209418 DOI: 10.1016/j.bpg.2024.101931] [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: 03/12/2024] [Revised: 05/19/2024] [Accepted: 06/04/2024] [Indexed: 09/04/2024]
Abstract
The concept of submucosal space, or rather the "third space", located between the intact mucosal flap and the muscularis propria layer of the gastrointestinal tract, represents a tunnel that the endoscopist could use to perform interventions in the muscularis propria layer or breech it to enter the mediastinum or the peritoneal cavity without full thickness perforation. The tunnel technique can be used both for the removal of mucosal tumours, called endoscopic submucosal tunnel dissection (ESTD), for the removal of subepithelial tumours (SELs), called submucosal tunnelling endoscopic resection (STER), and for the removal of extra-luminal lesions (for example in the mediastinum or in the rectum), called submucosal tunnelling endoscopic resection for extraluminal tumours (STER-ET). Aim of this updated narrative review, is to summarize the evidences that analyses indications, and outcomes of tunnelling techniques for the treatment of above mentioned lesions.
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Affiliation(s)
- Paolo Cecinato
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto Gemelli-G.Giglio, Cefalù, (Palermo), Italy.
| | - Liboria Laterza
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Federica Pianigiani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Giuseppe Grande
- Gastroenterology and Digestive Endoscopy Unit, Sant'Agostino Estense Hospital, AOU Modena, Italy.
| | - Romano Sassatelli
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Giovanni Barbara
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
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Ulkucu A, Erozkan K, Gorgun E. One step closer to a fully flexible platform: OverStitch and DiLumen C1 systems-A video vignette. Colorectal Dis 2024; 26:1644-1645. [PMID: 38858831 DOI: 10.1111/codi.17061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/26/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Attila Ulkucu
- Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kamil Erozkan
- Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Gauci JL, Whitfield A, Medas R, Kerrison C, Mandarino FV, Gibson D, O'Sullivan T, Cronin O, Gupta S, Lam B, Perananthan V, Hourigan L, Zanati S, Singh R, Raftopoulos S, Moss A, Brown G, Klein A, Desomer L, Tate DJ, Williams SJ, Lee EY, Burgess N, Bourke MJ. Prevalence of Endoscopically Curable Low-Risk Cancer Among Large (≥20 mm) Nonpedunculated Polyps in the Right Colon. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00686-4. [PMID: 39089517 DOI: 10.1016/j.cgh.2024.07.017] [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: 05/12/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection is increasingly promoted for the treatment of all large nonpedunculated colorectal polyps (LNPCPs) to cure potential low-risk cancers (superficial submucosal invasion without additional high-risk histopathologic features). The effect of a universal en bloc strategy on oncologic outcomes for the treatment of LNPCPs in the right colon is unknown. We evaluated this in a large Western population. METHODS A prospective cohort of patients referred for endoscopic resection (ER) of LNPCPs was analyzed. Patients found to have cancer after ER and those referred directly to surgery were included. The primary outcome was to determine the proportion of right colon LNPCPs with low-risk cancer. RESULTS Over 180 months until June 2023, 3294 sporadic right colon LNPCPs in 2956 patients were referred for ER at 7 sites (median size 30 [interquartile range 15] mm). A total of 63 (2.1%) patients were referred directly to surgery, and cancer was proven in 56 (88.9%). A total of 2851 (96.4%) of 2956 LNPCPs underwent ER (median size 35 [interquartile range 20] mm), of which 75 (2.6%) were cancers. The overall prevalence of cancer in the right colon was 4.4% (n = 131 of 2956). Detailed histopathologic analysis was possible in 115 (88%) of 131 cancers (71 after ER, 44 direct to surgery). After excluding missing histopathologic data, 23 (0.78%) of 2940 sporadic right colon LNPCPs were low-risk cancers. CONCLUSIONS The proportion of right colon LNPCPs referred for ER containing low-risk cancer amenable to endoscopic cure was <1%, in a large, multicenter Western cohort. A universal endoscopic submucosal dissection strategy for the management of right colon LNPCPs is unlikely to yield improved patient outcomes given the minimal impact on oncologic outcomes. CLINICALTRIALS gov, Numbers: NCT01368289, NCT02000141.
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Affiliation(s)
- Julia L Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Renato Medas
- Centro Hospitalar e Universitario São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - Clarence Kerrison
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | | | - David Gibson
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Brian Lam
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Varan Perananthan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Luke Hourigan
- Department of Gastroenterology, Princess Alexandra Hospital (Queensland Health), Brisbane, Australia
| | - Simon Zanati
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Amir Klein
- Ambam Heath Care Campus, Technion Institute of Technology, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium; Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Steven J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Eric Y Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia.
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Jiang SX, Shahidi N. Large non-pedunculated colorectal polyp management: The elephant in the room. World J Gastroenterol 2024; 30:3126-3131. [PMID: 39006383 PMCID: PMC11238671 DOI: 10.3748/wjg.v30.i25.3126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/19/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024] Open
Abstract
Minimally invasive innovations have transformed coloproctology. Specific to colorectal cancer (CRC), there has been a shift towards less invasive surgical techniques and use of endoscopic resection as an alternative for low risk T1 CRC. The role of endoscopic resection is however much more extensive: It is now considered the first line management strategy for most large (≥ 20 mm) non-pedunculated colorectal polyps, the majority of which are benign. This is due to the well-established efficacy, safety, and cost-effectiveness of endoscopic techniques compared to surgery. Multiple endoscopic modalities now exist with distinct risk-benefit profiles and their outcomes are further improved by site-specific technical modifications, auxiliary techniques, and adverse event mitigation strategies. Endoscopic capacity continues to evolve with emerging endoscopic techniques and expanding applications, particularly in the confines of a multi-disciplinary setting.
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Affiliation(s)
- Shirley X Jiang
- Department of Medicine, University of British Columbia, Vancouver V6Z 2K5, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 2K5, BC, Canada
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10
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Jung Y. Approaches and considerations in the endoscopic treatment of T1 colorectal cancer. Korean J Intern Med 2024; 39:563-576. [PMID: 38742279 PMCID: PMC11236804 DOI: 10.3904/kjim.2023.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/12/2023] [Accepted: 12/27/2023] [Indexed: 05/16/2024] Open
Abstract
The detection of early colorectal cancer (CRC) is increasing through the implementation of screening programs. This increased detection enhances the likelihood of minimally invasive surgery and significantly lowers the risk of recurrence, thereby improving patient survival and reducing mortality rates. T1 CRC, the earliest stage, is treated endoscopically in cases with a low risk of lymph node metastasis (LNM). The advantages of endoscopic treatment compared with surgery include minimal invasiveness and limited tissue disruption, which reduce morbidity and mortality, preserve bowel function to avoid colectomy, accelerate recovery, and improve cost-effectiveness. However, T1 CRC has a risk of LNM. Thus, selection of the appropriate treatment between endoscopic treatment and surgery, while avoiding overtreatment, is challenging considering the potential for complete resection, LNM, and recurrence risk.
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Affiliation(s)
- Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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11
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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; 21:561-577. [PMID: 38829122 DOI: 10.1080/17434440.2024.2364022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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12
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van Marle L, Hanevelt J, de Vos Tot Nederveen Cappel WH, van Westreenen HL. Colonoscopic-assisted laparoscopic wedge resection for colonic neoplasms: a systematic review. Scand J Gastroenterol 2024; 59:808-815. [PMID: 38721923 DOI: 10.1080/00365521.2024.2349645] [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: 12/11/2023] [Accepted: 04/23/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES The current literature describes a variety of techniques detailed under the name of combined endoscopic-laparoscopic surgery (CELS) procedures. This systematic review of literature assessed the outcomes of colonoscopic-assisted laparoscopic-wedge resection (CAL-WR) in particular to evaluate its feasibility to remove colonic lesions that do not qualify for endoscopic resection. MATERIALS AND METHODS Electronic databases (PubMed, Embase, and Cochrane) were searched for studies evaluating CAL-WR for the treatment of colonic lesions. Studies with missing full text, language other than English, systematic reviews, and studies with fewer than ten patients were excluded. The quality of the studies was assessed using the Newcastle-Ottawa Scale. RESULTS Out of 68 results, duplicate studies (n = 27) as well as studies that did not meet the inclusion criteria (n = 32) were removed. Nine studies were included, encompassing 326 patients who underwent a CAL-WR of the colon. The technical success rate varied from 93 to 100%, with an R0 resection rate of 91-100%. Morbidity ranged from 6% to 20%. The quality of the included studies was rated as low to moderate and contained heterogeneous terminology, methodology, and outcome measures. CONCLUSIONS There is insufficient high-quality data and substantial variation in outcome measures to draw firm conclusions regarding the value of CAL-WR. Although CAL-WR is a promising local resection technique for endoscopically unremovable neoplasms of the colon, further investigation of this technique in well-designed prospective, multicenter studies with predefined outcome measures is required.Trial registration: A protocol for this systematic review was registered in PROSPERO with the number CRD42023407966.
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Affiliation(s)
| | - Julia Hanevelt
- Department of Gastroenterology & Hepatology, Isala, Zwolle, The Netherlands
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13
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Jiang SX, Zarrin A, Shahidi N. T1 colorectal cancer management in the era of minimally invasive endoscopic resection. World J Gastrointest Oncol 2024; 16:2284-2294. [PMID: 38994167 PMCID: PMC11236244 DOI: 10.4251/wjgo.v16.i6.2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 06/13/2024] Open
Abstract
T1 colorectal cancer (CRC), defined by tumor invasion confined to the submucosa, has historically been managed by surgery. Improved understanding of recurrence and lymph node metastases risk, coupled with advances in endoscopic resection techniques, have led to an increasing capacity for organ-sparing local excision. Minimally invasive management of T1 CRC begins with optical evaluation of the lesion to diagnose invasive disease and quantify depth of invasion, which informs therapeutic decision making. Modality selection between various available endoscopic resection techniques depends upon lesion characteristics, technique risk-benefit profiles, and location-specific implications. Following endoscopic resection, established histopathology features determine the risk of recurrence and subsequent management including surveillance or adjuvant surgical excision. The management of non-operative candidates deviates from conventional recommendations with emerging treatment strategies in select populations.
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Affiliation(s)
- Shirley Xue Jiang
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
| | - Aein Zarrin
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
- Division of Gastroenterology, St. Paul’s Hospital, Vancouver V6Z2K5, British Columbia, Canada
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14
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Du J, Zhang T, Wang L, Zhang H, Yi W. Efficacy and safety of salvage endoscopy in the treatment of residual or recurrent colorectal neoplasia after endoscopic resection: a systematic review and meta-analysis. Surg Endosc 2024; 38:3027-3034. [PMID: 38744694 DOI: 10.1007/s00464-024-10879-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE To systematically review and meta-analyze the efficacy and safety of salvage endoscopy for residual or recurrence of colorectal tumors after endoscopic resection. METHODS Multiple databases including PubMed, EMBASE and the Cochrane Library were searched to screen for eligible studies and perform data extraction and pooled analysis. RESULTS Sixteen studies on salvage endoscopy for residual or recurrent colorectal cancer after endoscopic resection were included, covering approximately 994 patients. The results of the meta-analysis demonstrated that salvage endoscopic therapy for residual or recurrent colorectal tumors following endoscopic resection achieved an en bloc resection rate of 92% (95% CI 0.85-0.97; I2 = 91%) and an R0 resection rate of 82% (95% CI 0.75-0.87; I2 = 78%). The rates of intraoperative or postoperative bleeding and perforation were 10%/1% and 5%/2%, and the recurrence rate was 2%. CONCLUSIONS Salvage endoscopic resection is an effective and safe treatment strategy for residual or recurrent colorectal tumors after endoscopic resection.
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Affiliation(s)
- Juan Du
- Department of Gastroenterology, Meishan City People's Hospital, Meishan, Sichuan, China
| | - Ting Zhang
- Department of Gastroenterology, Meishan City People's Hospital, Meishan, Sichuan, China
| | - Lei Wang
- Department of Gastroenterology, Meishan City People's Hospital, Meishan, Sichuan, China
| | - Hao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Meishan City People's Hospital, Meishan, Sichuan, China
| | - Wenquan Yi
- Department of Gastroenterology, Meishan City People's Hospital, Meishan, Sichuan, China.
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15
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Takahashi K, Iwama T, Tanaka K, Miyazawa Y, Kuroda S, Horiuchi M, Saito S, Muto M, Sakatani A, Ando K, Ueno N, Kashima S, Moriichi K, Tanabe H, Okumura T, Fujiya M. Risk Factors for Post-Colorectal Endoscopic Submucosal Dissection Bleeding and Efficacy of Carbazochrome Sodium Sulfonate: A Multicenter Retrospective Cohort Study. Digestion 2024; 105:310-319. [PMID: 38763127 PMCID: PMC11318496 DOI: 10.1159/000539367] [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: 08/30/2023] [Accepted: 05/12/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Carbazochrome sodium sulfonate (CSS) is a hemostatic agent that reduces capillary permeability and enhances capillary resistance. However, its specific effects on colorectal endoscopic submucosal dissection (ESD) outcomes remain uncertain. This study aimed to assess the risk factors for post-ESD bleeding and the effect of CSS on colorectal ESD outcomes. METHODS First, we retrospectively analyzed the risk factors for post-ESD bleeding using data from 1,315 lesions in 1,223 patients who underwent ESD for superficial colorectal neoplasms at eight institutions. Second, patients were divided into CSS and non-CSS groups using propensity score matching, and their outcomes from colorectal ESD were analyzed. RESULTS The risk factors for post-colorectal ESD bleeding were identified as age of ≥70 years, tumor located in the rectum, tumor size of ≥40 mm, and post-ESD defect unclosure in both univariate and multivariate analyses. The CSS and non-CSS groups each consisted of 423 lesions after propensity score matching. The post-colorectal ESD bleeding rate was 3.5% (15/423) and 3.3% (14/423) in the CSS and non-CSS groups, respectively, indicating no significant differences. Among patients with the high-risk factors for post-ESD bleeding, the administration of CSS also did not demonstrate a significant reduction in the post-ESD bleeding rate compared to the non-CSS group. CONCLUSION CSS administration is ineffective in preventing post-colorectal ESD bleeding in both the general population and individuals at a high risk for such bleeding. Our results indicate the necessity to reconsider the application of CSS for preventing post-colorectal ESD bleeding.
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Affiliation(s)
- Keitaro Takahashi
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takuya Iwama
- Department of Gastroenterology, Asahikawa City Hospital, Asahikawa, Japan
| | - Kazuyuki Tanaka
- Department of Gastroenterology, Asahikawa-Kosei General Hospital, Asahikawa, Japan
| | - Yuki Miyazawa
- Department of Gastroenterology, Nayoro City General Hospital, Nayoro, Japan
| | - Shohei Kuroda
- Department of Gastroenterology, Japanese Red Cross Asahikawa Hospital, Asahikawa, Japan
| | - Masashi Horiuchi
- Department of Gastroenterology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Seisuke Saito
- Department of Gastroenterology, Furano Kyokai Hospital, Furano, Japan
| | - Momotaro Muto
- Department of Internal Medicine, Engaru-Kosei General Hospital, Engaru, Japan
| | - Aki Sakatani
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Katsuyoshi Ando
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Nobuhiro Ueno
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Shin Kashima
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kentaro Moriichi
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroki Tanabe
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Toshikatsu Okumura
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Mikihiro Fujiya
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
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16
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Li S, Li Q, Liu M, Zhan K, Yuan R, Yang Y, Lan X, Deng L. Precutting Endoscopic Band Ligation-Assisted Resection Is Safe and Effective for Treating Gastric Submucosal Tumors from the Muscularis Propria. Dig Dis Sci 2024; 69:1762-1769. [PMID: 38507126 DOI: 10.1007/s10620-024-08381-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 03/04/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND We previously treated small gastric submucosal tumors originating from the muscularis propria layer by precutting endoscopic band ligation but lacked precise pathological results. Then, precutting endoscopic band ligation was modified by additional snare resection after ligation to obtain tumor specimens, termed precutting endoscopic band ligation-assisted resection. AIMS In this study, we aimed to explore the safety, feasibility, and efficacy of precutting endoscopic band ligation-assisted resection. METHODS From 2021 to 2022, a total of 16 consecutive patients underwent precutting endoscopic band ligation-assisted resection to treat small gastric submucosal tumors originating from the muscularis propria. The clinical demography, perioperative data, and follow-up outcomes were retrospectively collected. RESULTS With a mean operative time of 21.3 min, all lesions were successfully and completely resected, and no severe adverse events or local recurrences occurred postoperatively. More importantly, en bloc and R0 resection were achieved in all 16 patients. CONCLUSION Precutting endoscopic band ligation-assisted resection is a safe, effective, and time-saving endoscopic technique for managing gastric small gastric submucosal tumors originating from the muscularis propria for both diagnosis and eradication.
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Affiliation(s)
- Shan Li
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Qingshu Li
- Department of Pathology, College of Basic Medicine, Chongqing Medical University, Chongqing, China
- Diagnostic and Testing Center, Chongqing Medical University, Chongqing, China
- Department of Pathology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingfeng Liu
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ke Zhan
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Rui Yuan
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yichun Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiong Lan
- College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Liang Deng
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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17
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Kimoto Y, Sawada R, Banjoya S, Iida T, Kimura T, Furuta K, Nagae S, Ito Y, Yamazaki H, Takeuchi N, Takayanagi S, Kano Y, Sakuno T, Ono K, Negishi R, Sakai E, Minato Y, Chiba H, Ohata K. Comparison of cold snare polypectomy for sessile serrated lesions ≥10 mm between experienced and trainee endoscopists: A propensity score matching cohort study. DEN OPEN 2024; 4:e328. [PMID: 38188356 PMCID: PMC10771227 DOI: 10.1002/deo2.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/28/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
Objectives Previous studies of cold snare polypectomy (CSP) for sessile serrated lesions (SSLs) ≥10 mm were performed by experienced endoscopists, and therefore their skills might have significantly influenced results. In this study, we compared the efficacy and safety of CSP for SSLs ≥10 mm between experienced and trainee endoscopists. Methods In a 1:1 propensity score matched retrospective cohort study, we compared the complete resection rate, en-bloc resection rate, adverse event rate, and procedure time between experienced and trainee groups. Thirteen endoscopists performed CSP, and we defined the experienced group as endoscopists with board certification from the Japan Gastroenterological Endoscopy Society. Results We examined 616 lesions with SSLs ≥10 mm resected by CSP between February 2018 and May 2022. We excluded 61 lesions from the analysis because they had simultaneously undergone hot snare polypectomy (n = 57) or had been taken over by experienced endoscopists from trainees in the CSP procedure (n = 4). Finally, we identified 217 propensity score-matched pairs (n = 434). Between experienced and trainee groups, the results were complete resection rate (100 vs. 100%; p = 1.00), en-bloc resection rate (73.2 vs. 75.6%; p = 0.24), adverse event rate (3.2 vs. 2.8%; p = 0.77), or procedure time (6.2 vs. 5.9 min; p = 0.64). Conclusions We have demonstrated the safety and efficacy of CSP for SSLs ≥10 mm performed by experienced and trainee endoscopists.
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Affiliation(s)
- Yoshiaki Kimoto
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Rikimaru Sawada
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Susumu Banjoya
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Toshihumi Iida
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Tomoya Kimura
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Koichi Furuta
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Shinya Nagae
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Yohei Ito
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Hiroshi Yamazaki
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Nao Takeuchi
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Syunya Takayanagi
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Yuki Kano
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Takashi Sakuno
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Kohei Ono
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Ryoju Negishi
- Division of GastroenterologyItabashi Chuo Medical CenterTokyoJapan
| | - Eiji Sakai
- Division of GastroenterologyYokohama Sakae Kyosai HospitalKanagawaJapan
| | - Yohei Minato
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
| | - Hideyuki Chiba
- Department of GastroenterologyOmori Red Cross HospitalTokyoJapan
| | - Ken Ohata
- Department of Gastrointestinal EndoscopyNTT Medical Center TokyoTokyoJapan
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18
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Ali S, Khetpal N, Fatima M, Hussain S, Ali A, Khan MA, Childs C, Hasan MK. The Safety of Cold Versus Hot Snare Polypectomy in Polyps 10-20 mm: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58462. [PMID: 38765346 PMCID: PMC11100549 DOI: 10.7759/cureus.58462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.
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Affiliation(s)
- Saeed Ali
- Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, USA
| | - Neelam Khetpal
- Department of Hospital Medicine, Hartford Hospital, Hartford, USA
| | - Munazza Fatima
- Department of Anesthesiology, State University of New York (SUNY) Upstate Medical University Hospital, Syracuse, USA
| | - Sana Hussain
- Department of Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | - Asad Ali
- Department of Gastroenterology and Hepatology, State University of New York (SUNY) Upstate Medical University Hospital, Syracuse, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christopher Childs
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, USA
| | - Muhammad K Hasan
- Department of Gastroenterology, Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, USA
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19
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Ding C, Yang JF, Wang X, Zhou YF, Khizar H, Jin Z, Zhang XF. Cold EMR vs. Hot EMR for the removal of sessile serrated polyps larger than 10 mm: a systematic review and meta-analysis. BMC Surg 2024; 24:93. [PMID: 38509508 PMCID: PMC10953062 DOI: 10.1186/s12893-024-02325-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/16/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) appears to be a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. To assess the effectiveness and safety of EMR for removing SSPs ≥ 10 mm, we conducted this systematic review and meta-analysis. METHODS We conducted a thorough search of Embase, PubMed, Cochrane, and Web of Science databases for relevant studies reporting on EMR of SSPs ≥ 10 mm, up until December 2023. Our primary endpoints of interest were rates of technical success, residual SSPs, and adverse events (AE). RESULTS Our search identified 426 articles, of which 14 studies with 2262 SSPs were included for analysis. The rates of technical success, AEs, and residual SSPs were 100%, 2.0%, and 3.1%, respectively. Subgroup analysis showed that the technical success rates were the same for polyps 10-19 and 20 mm, and en-bloc and piecemeal resection. Residual SSPs rates were similar in en-bloc and piecemeal resection, but much lower in cold EMR (1.0% vs. 4.2%, P = 0.034). AEs rates were reduced in cold EMR compared to hot EMR (0% vs. 2.9%, P = 0.168), in polyps 10-19 mm compared to 20 mm (0% vs. 4.1%, P = 0.255), and in piecemeal resection compared to en-bloc (0% vs. 0.7%, P = 0.169). CONCLUSIONS EMR is an effective and safe technique for removing SSPs ≥ 10 mm. The therapeutic effect of cold EMR is superior to that of hot EMR, with a lower incidence of adverse effects. PROSPERO REGISTRATION NUMBER CRD42023388959.
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Affiliation(s)
- Cong Ding
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Jian-Feng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Xia Wang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Yi-Feng Zhou
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Hayat Khizar
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Zheng Jin
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China.
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang Province, China.
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Haghbin H, Zakirkhodjaev N, Fatima R, Kamal F, Aziz M. Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis. J Clin Med 2024; 13:1298. [PMID: 38592137 PMCID: PMC10932371 DOI: 10.3390/jcm13051298] [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: 01/07/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(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.
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Affiliation(s)
- Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Hospital, Southfield, MI 48075, USA
| | - Nuruddinkhodja Zakirkhodjaev
- Division of Occupational and Environmental Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77021, USA;
| | - Rawish Fatima
- Division of Rheumatology, University of Toledo, Toledo, OH 43606, USA;
| | - Faisal Kamal
- Division of Gastroenterology, Thomas Jefferson University, Philadelphia, PA 19144, USA;
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, OH 43608, USA;
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21
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Choi HS, Hwang JH. Endoscopic Resection of Early Luminal Cancer. Gastrointest Endosc Clin N Am 2024; 34:51-78. [PMID: 37973231 DOI: 10.1016/j.giec.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Hyuk Soon Choi
- Korea University College of Medicine, Stanford University Medicine, Korea University Anam Hospital, Goryeodae-ro 73, Seongbuk-gu, Seoul 02841, South Korea
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medicine, Stanford Hospital, 300 Pasteur Drive, H0268, MC: 5244, Stanford, CA 94305, USA.
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22
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Jacques J, Schaefer M, Wallenhorst T, Rösch T, Lépilliez V, Chaussade S, Rivory J, Legros R, Chevaux JB, Leblanc S, Rostain F, Barret M, Albouys J, Belle A, Labrunie A, Preux PM, Lepetit H, Dahan M, Ponchon T, Crépin S, Marais L, Magne J, Pioche M. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial. Ann Intern Med 2024; 177:29-38. [PMID: 38079634 DOI: 10.7326/m23-1812] [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: 01/17/2024] Open
Abstract
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.
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Affiliation(s)
- Jérémie Jacques
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Marion Schaefer
- Hépato-Gastro-Entérologie, CHRU de Nancy, Nancy, France (M.S., J.-B.C.)
| | | | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital, Hamburg-Eppendorf, Hamburg, Germany (T.R.)
| | - Vincent Lépilliez
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | | | - Jérôme Rivory
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Romain Legros
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | | | - Sarah Leblanc
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | - Florian Rostain
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Maximilien Barret
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Jérémie Albouys
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Arthur Belle
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Anaïs Labrunie
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Pierre-Marie Preux
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Hugo Lepetit
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Martin Dahan
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Thierry Ponchon
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Sabrina Crépin
- Service de Pharmacologie-Toxicologie et Pharmacovigilfance-Unité de Vigilance des Essais Cliniques, CHU de Limoges, Limoges, France (S.C.)
| | - Loïc Marais
- Direction de la Recherche et de l'Innovation, CHU de Limoges, Limoges, France (L.M.)
| | - Julien Magne
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Mathieu Pioche
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
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Chen X, Peng D, Liu D, Li R. The feasibility of endoscopic resection for colorectal laterally spreading tumors. Updates Surg 2023; 75:2235-2243. [PMID: 37812317 DOI: 10.1007/s13304-023-01650-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/23/2023] [Indexed: 10/10/2023]
Abstract
The present study aimed to investigate the feasibility and safety of endoscopic resection for colorectal laterally spreading tumors (LSTs) in different size groups. This retrospective study included 2699 patients with LSTs who underwent endoscopic treatment at the Second Xiangya Hospital of Central South University from May 2012 to February 2022. The patient baseline and procedure outcomes were compared between the < 5 cm group, 5-10 cm group, and ≥ 10 cm group. Meanwhile, lesions larger than 5 cm in diameter were longitudinally compared for endoscopic safety using ESD with surgical operation outcomes. There were 2105 patients in the < 5 cm group, 547 patients in the 5-10 cm group, and 47 patients in the ≥ 10 cm group. En bloc resection and R0 resection rates, the incidence of adverse events, length of stay (LOS), and medical costs significantly differed between the groups (P < 0.01). Comorbidity of diabetes or hypertension, history of antithrombotic drug use, lesion size, location, gross type, endoscopic procedures selection, and circumferential extent of the mucosal defect were independent risk factors for delayed bleeding (P < 0.05). En bloc resection, R0 resection, and lesion canceration were associated with local recurrence. For lesions larger than 5 cm in diameter, ESD had similar R0 resection and local recurrence rates compared with a surgical operation but a lower en bloc rate, LOS, and medical costs. Expert endoscopists can significantly increase en bloc and R0 resection rates and reduce the incidence of adverse events. Endoscopic resection results distinguish in different size groups of colorectal LSTs, yet its safety and feasibility are not inferior to a surgical operation.
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Affiliation(s)
- Xingcen Chen
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Dongzi Peng
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Rong Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China.
- Research Center of Digestive Diseases, Central South University, No. 139 Middle Renmin Road, Changsha, 410011, Hunan Province, China.
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China.
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24
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Baik SM, Lee RA. Weighing the benefits of lymphadenectomy in early-stage colorectal cancer. Ann Surg Treat Res 2023; 105:245-251. [PMID: 38023437 PMCID: PMC10648610 DOI: 10.4174/astr.2023.105.5.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023] Open
Abstract
Recent advancements in endoscopic procedures have resulted in a growing diagnosis of early colorectal cancer (CRC) cases, where classical en bloc lymph node (LN) dissection is not performed and treatment is terminated with the removal of the main cancer lesion by endoscopy without pathologic LN staging. Although many studies report noninferior outcomes of endoscopic resection in comparison to surgical resection, a cautious approach to completing treatment with endoscopic resection alone is recommended because LN metastases may be present even in early-stage CRC. In most countries, including the United States, Europe, and South Korea, the guidelines for additional surgery after endoscopic resection are very similar. If LN metastasis is suspected, even in T1 stage or lower lesions, further surgery is an essential treatment modality, but confirmation of the presence of LN metastasis is perhaps the most difficult part of this process. Another paradoxical recent trend is the expansion of more extensive and complete surgical lymphadenectomy for CRC. The success rate of surgery has improved dramatically over the past decade with the introduction of surgical devices and minimally invasive surgery, and the associated risks have been significantly reduced. While the burden of surgery on patients is understandable, the indications for surgery in early colon cancer need to be carefully reviewed to improve cure rates. In this process, we believe that an integrated decision-making process with surgeons, radiologists, and pathologists, in addition to the opinions of endoscopists, will be an important process to improve the cure rate.
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Affiliation(s)
- Seung Min Baik
- Division of Critical Care Medicine, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ryung-Ah Lee
- Division of Colorectal Surgery, Department of Surgery, Ewha Womans University College of Medicine, Seoul, Korea
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25
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Yamaguchi H, Fukuzawa M, Kawai T, Muramatsu T, Matsumoto T, Uchida K, Koyama Y, Madarame A, Morise T, Kono S, Naito S, Nagata N, Sugimoto M, Itoi T. Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases. Clin Endosc 2023; 56:778-789. [PMID: 37491992 PMCID: PMC10665627 DOI: 10.5946/ce.2022.268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/09/2023] [Accepted: 03/13/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND/AIMS Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD). METHODS We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes. RESULTS Resection time was significantly shorter in the following order: RH-ESD (149 [90-197] minutes) >C-ESD (90 [60-140] minutes) >SH-ESD (52 [29-80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%-30%]) than in the en bloc resection group (40% [20%-60%]). CONCLUSION RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.
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Affiliation(s)
- Hayato Yamaguchi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Kawai
- Endoscopy Center, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takahiro Muramatsu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Taisuke Matsumoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kumiko Uchida
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yohei Koyama
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Akira Madarame
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Morise
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shin Kono
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Sakiko Naito
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naoyoshi Nagata
- Endoscopy Center, Tokyo Medical University Hospital, Tokyo, Japan
| | | | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Sakowitz S, Bakhtiyar SS, Mallick S, Khoraminejad B, Olmedo M, Croman M, Benharash P, Lee H. Decreasing rates of colectomy for benign neoplasms: A nationwide analysis. PLoS One 2023; 18:e0293389. [PMID: 37878628 PMCID: PMC10599571 DOI: 10.1371/journal.pone.0293389] [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: 05/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
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.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Manuel Olmedo
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Millicent Croman
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Hanjoo Lee
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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Brunori A, Daca-Alvarez M, Pellisé M. pT1 colorectal cancer: A treatment dilemma. Best Pract Res Clin Gastroenterol 2023; 66:101854. [PMID: 37852711 DOI: 10.1016/j.bpg.2023.101854] [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: 05/17/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 10/20/2023]
Abstract
The implementation of population screening programs for colorectal cancer (CRC) has led to a considerable increase in the prevalence pT1-CRC originating on polyps amenable by local treatments. However, a high proportion of patients are referred for unnecessary oncological surgeries without a clear benefit in terms of survival. Selecting the appropriate endoscopic resection technique in the moment of diagnosis becomes crucial to provide the best treatment alternative to each individual polyp and patient. For this, it is imperative to increase the optical diagnostic skill for differentiating pT1-CRCs and decide the appropriate initial therapy. En bloc resection is crucial to obtain an adequate histological specimen that might allow organ preserving therapeutic management. In this review, we address key challenges in T1 CRC management, explore the efficacy and safety of the available diagnostic and therapeutic approaches, and shed light on upcoming advances in the field.
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Affiliation(s)
- Angelo Brunori
- Gastroenterology and Digestive Endoscopy, Università degli Studi di Perugia, Italy
| | - Maria Daca-Alvarez
- Department of Gastroenterology Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Centro de Investigación Biomédica en Red de EnfermedadesHepáticas y Digestivas (CIBERehd), Spain
| | - Maria Pellisé
- Department of Gastroenterology Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Centro de InvestigaciónBiomé, dica en Red de EnfermedadesHepáticas y Digestivas (CIBERehd), Universitat de Barcelona, Barcelona, Spain.
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Kuo LJ, Fang CY, Su RY, Lin YK, Wei PL, Kung CH, Chen CL. Tn as a potential predictor for regional lymph node metastasis in T1 colorectal cancer. Asian J Surg 2023; 46:4302-4307. [PMID: 37173248 DOI: 10.1016/j.asjsur.2023.04.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/14/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Approximately 10 percent of T1 colorectal cancer (CRC) has lymph node metastasis. In this study, we aimed to determine possible predictors for nodal involvement in order to aid selection of appropriate patients for organ-preserving strategies. METHODS We retrospectively reviewed CRC patients underwent radical surgery from January 2009 to December 2016, with final pathology report disclosed as T1 lesion. The paraffin-embedded samples were achieved for glycosylated proteins expression analysis by immunohistochemistry. RESULTS Totally, 111 CRC patients with T1 lesion were enrolled in this study. Of these patients, seventeen patients had nodal metastases, with the lymph node positive rate of 15.3%. Semiquantitative analysis of immunohistochemical results indicated that mean value of Tn protein expression in T1 CRC specimens was significantly different between patients with and without lymph node metastasis (63.6 vs. 27.4; p = 0.018). CONCLUSIONS Our data shown that Tn expression may be applied as a molecular predictor for regional lymph node metastasis in T1 CRC. Moreover, the organ-preserving strategy could be improved by proper classification of patients. The mechanism involved in expression of Tn glycosylation protein and CRC metastasis need further investigation.
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Affiliation(s)
- Li-Jen Kuo
- Division of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Yeu Fang
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan Town, Taiwan
| | - Ruei-Yu Su
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Pathology and Laboratory Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yen-Kuang Lin
- Graduate Institute of Athletics and Coaching Science, National Taiwan Sport University, Taoyuan, 33301, Taiwan
| | - Po-Li Wei
- Division of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ching-Huei Kung
- Department of Diagnostic Radiology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chi-Long Chen
- Department of Pathology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Santos-Antunes J, Pioche M, Ramos-Zabala F, Cecinato P, Gallego F, Barreiro P, Mascarenhas A, Sferrazza S, Berr F, Wagner A, Lemmers A, Ferreira MF, Albéniz E, Uchima H, Küttner-Magalhães R, Fernandes C, Morais R, Gupta S, Martinho-Dias D, Faria-Ramos I, Marques M, Bourke MJ, Macedo G. Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study. J Clin Med 2023; 12:5356. [PMID: 37629398 PMCID: PMC10455482 DOI: 10.3390/jcm12165356] [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: 06/30/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) in colorectal lesions is demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a piecemeal ESD resection, or after an en bloc resection but with positive horizontal margins (local-risk resection-LocRR), for colorectal benign neoplasia. A retrospective multicenter analysis of consecutive colorectal ESDs was performed. Patients with LocRR ESDs for the treatment of benign colorectal lesions with at least one follow-up endoscopy were included. A cohort of en bloc resected lesions, with negative margins, was used as the control. A total of 2255 colorectal ESDs were reviewed; 352 of the ESDs were "non-curative". Among them, 209 were LocRR: 133 high-grade dysplasia and 76 low-grade dysplasia. Ten cases were excluded due to missing data. A total of 146 consecutive curative resections were retrieved for comparison. Compared to the "curative group", LocRRs were observed in lengthier procedures, with larger lesions, and in non-granular LSTs. Recurrence was higher in the LocRR group (16/199, 8% vs. 1/146, 0.7%; p = 0.002). However, statistical significance was lost when considering only en bloc resections with positive horizontal margins (p = 0.068). In conclusion, a higher rate of residual lesion was found after a piecemeal ESD resection, but not after an en bloc resection with positive horizontal margins.
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Affiliation(s)
- João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, 4200-319 Porto, Portugal
- Ipatimup/i3S (Instituto de Investigação e Inovação em Saúde da Universidade do Porto), 4200-135 Porto, Portugal
| | - Mathieu Pioche
- Department of Hepatology and Gastroenterology, Edouard Herriot Hospital, 69003 Lyon, France
| | - Felipe Ramos-Zabala
- Servicio de Gastroenterología, Departamento de Ciencias Médicas Clínicas, Hospital Universitario HM Montepríncipe, HM Hospitales, 28660 Madrid, Spain
| | - Paolo Cecinato
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Francisco Gallego
- Gastroenterology Department, Hospital de Poniente, 04700 Almería, Spain
| | - Pedro Barreiro
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental EPE, 1169-050 Lisbon, Portugal
- Lisbon Advanced Endoscopic Center, Hospital Lusíadas, 2724-002 Lisbon, Portugal
| | - André Mascarenhas
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental EPE, 1169-050 Lisbon, Portugal
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, 38123 Trento, Italy
| | - Frieder Berr
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Andrej Wagner
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1000 Brussels, Belgium
| | - Mariana Figueiredo Ferreira
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1000 Brussels, Belgium
| | - Eduardo Albéniz
- Complejo Hospitalario de Navarra, Navarrabiomed Research Institute, Public University of Navarra, IdiSNA, 31006 Pamplona, Spain
| | - Hugo Uchima
- Servicio de Endoscopia Digestiva Centro Médico Teknon, 08022 Barcelona, Spain
- Servicio de Gastroenterología Hospital Universitario Germans Trias i Pujol, 08916 Barcelona, Spain
| | - Ricardo Küttner-Magalhães
- Gastroenterology Department, Hospital Santo António, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal
| | - Carlos Fernandes
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, 4400-129 Vila Nova de Gaia, Portugal
| | - Rui Morais
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, 4200-319 Porto, Portugal
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney 2145, Australia
| | - Daniel Martinho-Dias
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, 4169-007 Porto, Portugal
| | - Isabel Faria-Ramos
- Ipatimup/i3S (Instituto de Investigação e Inovação em Saúde da Universidade do Porto), 4200-135 Porto, Portugal
| | - Margarida Marques
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, 4200-319 Porto, Portugal
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney 2145, Australia
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, 4200-319 Porto, Portugal
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Jung Y, Hwangbo Y, Cho YS, Choi SW, Jeon SR, Kim HG, Ko BM, Kim JO. Is colorectal endoscopic submucosal dissection safe and effective for 15-19-mm tumors? Int J Colorectal Dis 2023; 38:206. [PMID: 37540284 DOI: 10.1007/s00384-023-04498-3] [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] [Accepted: 07/29/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The outcomes of colorectal endoscopic submucosal dissection (ESD) in 15-19-mm tumors are unclear. This study compared the effectiveness and safety of colorectal ESD for 15-19-mm tumors and tumors exceeding that size. METHODS From August 2018 to December 2020, 213 cases of colorectal tumors removed by colorectal ESD at a tertiary hospital were enrolled in this study. The cases were divided into two groups according to the pathologically measured size of the resected lesion: an intermediate group (15-19 mm, n = 62) and a large group (≥ 20 mm, n = 151). The en bloc resection rate, complete resection rate, and complications were investigated retrospectively. RESULTS The en bloc resection rate was significantly higher in the intermediate than large group (100% vs. 94%, p = 0.049), and the mean total procedure time was shorter in the intermediate than large group (29.2 [Formula: see text] 12.6 vs. 48.4 [Formula: see text] 28.8 min, p < 0.001). However, the mean procedure speed was significantly lower in the intermediate than large group (0.25 [Formula: see text] 0.10 vs. 0.28 [Formula: see text] 0.11 cm2/min, p = 0.031). The complete resection rate, post-procedural bleeding, and perforation rate were not significantly different between the two groups. In multivariate analyses, the total procedure time and mean procedure speed were significantly associated with lesion size. CONCLUSION Colorectal ESD of 15-19-mm lesions is effective, and has a shorter procedure time and higher en bloc resection rate than the same procedure for larger lesions.
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Affiliation(s)
- Yunho Jung
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, 23-20 Bongmyung-dong, Dongnam-gu, Cheonan-si, Chungcheongnam-do, South Korea.
| | - Young Hwangbo
- Department of Preventive Medicine, Soonchunhyang University College of Medicine, Cheonan-si, Republic of Korea
| | - Young Sin Cho
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, 23-20 Bongmyung-dong, Dongnam-gu, Cheonan-si, Chungcheongnam-do, South Korea
| | - Seong Woo Choi
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, 23-20 Bongmyung-dong, Dongnam-gu, Cheonan-si, Chungcheongnam-do, South Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Hyun Gun Kim
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Bong Min Ko
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Jin-O Kim
- Department of Internal Medicine, Division of Gastroenterology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
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Dang H, Dekkers N, Steyerberg EW, Baldaque-Silva F, Omae M, Haasnoot KJ, van Tilburg L, Nobbenhuis K, van der Kraan J, Langers AM, van Hooft JE, de Graaf W, Koch AD, Didden P, Moons LM, Hardwick JC, Boonstra JJ. Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers. Endosc Int Open 2023; 11:E724-E732. [PMID: 37941732 PMCID: PMC10629487 DOI: 10.1055/a-2122-0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 06/27/2023] [Indexed: 11/10/2023] Open
Abstract
Background and study aims Overcoming logistical obstacles for the implementation of colorectal endoscopic submucosal dissection (ESD) requires accurate prediction of procedure times. We aimed to evaluate existing and new prediction models for ESD duration. Patients and methods Records of all consecutive patients who underwent single, non-hybrid colorectal ESDs before 2020 at three Dutch centers were reviewed. The performance of an Eastern prediction model [GIE 2021;94(1):133-144] was assessed in the Dutch cohort. A prediction model for procedure duration was built using multivariable linear regression. The model's performance was validated using internal validation by bootstrap resampling, internal-external cross-validation and external validation in an independent Swedish ESD cohort. Results A total of 435 colorectal ESDs were analyzed (92% en bloc resections, mean duration 139 minutes, mean tumor size 39 mm). The performance of current unstandardized time scheduling practice was suboptimal (explained variance: R 2 =27%). We successfully validated the Eastern prediction model for colorectal ESD duration <60 minutes (c-statistic 0.70, 95% CI 0.62-0.77), but this model was limited due to dichotomization of the outcome and a relatively low frequency (14%) of ESDs completed <60 minutes in the Dutch centers. The model was more useful with a dichotomization cut-off of 120 minutes (c-statistic: 0.75; 88% and 17% of "easy" and "very difficult" ESDs completed <120 minutes, respectively). To predict ESD duration as continuous outcome, we developed and validated the six-variable cESD-TIME formula ( https://cesdtimeformula.shinyapps.io/calculator/ ; optimism-corrected R 2 =61%; R 2 =66% after recalibration of the slope). Conclusions We provided two useful tools for predicting colorectal ESD duration at Western centers. Further improvements and validations are encouraged with potential local adaptation to optimize time planning.
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Affiliation(s)
- Hao Dang
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Nik Dekkers
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Ewout W. Steyerberg
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Francisco Baldaque-Silva
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska Hospital, Stockholm, Sweden
- Advanced Endoscopy Center Carlos Moreira da Silva, Pedro Hispano Hospital, Matosinhos, Portugal
| | - Masami Omae
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska Hospital, Stockholm, Sweden
| | - Krijn J.C. Haasnoot
- Gastroenterology & Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Kate Nobbenhuis
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolein van der Kraan
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jeanin E. van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Wilmar de Graaf
- Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Arjun D. Koch
- Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Paul Didden
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leon M.G. Moons
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - James C.H. Hardwick
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Jurjen J. Boonstra
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
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Mun EJ, Wagh MS. Recent advances and current challenges in endoscopic resection with the full-thickness resection device. World J Gastroenterol 2023; 29:4009-4020. [PMID: 37476589 PMCID: PMC10354579 DOI: 10.3748/wjg.v29.i25.4009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
Endoscopic full-thickness resection (EFTR) has emerged as a viable technique in the management of mucosal and subepithelial lesions of the gastrointestinal tract (GIT) not amenable to conventional therapeutic approaches. While various devices and techniques have been described for EFTR, a single, combined full-thickness resection and closure device (full-thickness resection device, FTRD system, Ovesco Endoscopy AG, Tuebingen, Germany) has become commercially available in recent years. Initially, the FTRD system was limited to use in the colorectum only. Recently, a modified version of the FTRD has been released for EFTR in the upper GIT as well. This review provides a broad summary of the FTRD, highlighting recent advances and current challenges.
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Affiliation(s)
- Elijah J Mun
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Mihir S Wagh
- Interventional Endoscopy, Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO 80045, United States
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Gao P, Zhou K, Su W, Yu J, Zhou P. Endoscopic management of colorectal polyps. Gastroenterol Rep (Oxf) 2023; 11:goad027. [PMID: 37251504 PMCID: PMC10224796 DOI: 10.1093/gastro/goad027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/01/2023] [Accepted: 04/23/2023] [Indexed: 05/31/2023] Open
Abstract
Colorectal polyps are premalignant lesions in the lower gastrointestinal tract. Endoscopic polypectomy is an effective strategy to prevent colorectal cancer morbidity and more invasive procedures. Techniques for the endoscopic resection of polyps keep evolving, and endoscopists are required to perform the most appropriate technique for each polyp. In this review, we outline the evaluation and classification of polyps, update the recommendations for optimal treatment, describe the polypectomy procedures and their strengths/weaknesses, and discuss the promising innovative methods or concepts.
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Affiliation(s)
| | | | - Wei Su
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Jia Yu
- Surgery Department, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
- Shanghai Medical College, Fudan University, Shanghai, P. R. China
| | - Pinghong Zhou
- Corresponding author. Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Xuhui District, Shanghai 200032, P. R. China. Tel: +86-21-64041990;
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Noh SM, Hwang SW, Park SH, Yang DH, Ye BD, Park IJ, Lim SB, Byeon JS. Comparative Cost Analysis Between Endoscopic Resection and Surgery for Submucosal Colorectal Cancer. Dis Colon Rectum 2023; 66:723-732. [PMID: 35714338 DOI: 10.1097/dcr.0000000000002220] [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: 02/08/2023]
Abstract
BACKGROUND There are few studies analyzing the cost of endoscopic resection and surgical resection in the treatment of submucosal colorectal cancer. OBJECTIVE The objective was to perform a detailed cost analysis of endoscopic resection and surgical resection for submucosal colorectal cancer. DESIGN This was a retrospective observational study. SETTING This study was conducted at a tertiary academic center. PATIENTS Medical records of 484 patients with submucosal colorectal cancer who underwent endoscopic resection or surgical resection between July 2003 and July 2015 were reviewed. MAIN OUTCOME MEASUREMENTS The total costs during index admission and follow-up as well as clinical outcomes between the 2 groups were compared in the whole cohort and propensity score-matched cohort. RESULTS In the propensity score-matched analysis ( n = 155 in each group), the endoscopic resection and surgical resection groups did not show significant differences in the rates of procedure-related adverse events (6.5% vs 3.9%; p = 0.304) and recurrence (0.6% vs 1.3%; p > 0.99). Readmission was more common in the endoscopic resection group (40.6% vs 11.0%; p < 0.001) because 64 (41.3%) patients underwent additional surgery for endoscopic noncurative resection. The endoscopic resection group had a lower cost during the index admission (1335.6 vs 6698.4 USD; p < 0.001), whereas the surgical resection group had a lower cost during follow-up (2488.7 vs 5035.7 USD; p < 0.001). The total cumulative cost was lower in the endoscopic resection group (6371.3 vs 9187.1 USD; p < 0.001). The same trend was observed in the whole cohort without propensity score matching. LIMITATIONS A limitation of this study was the retrospective nature of analysis. CONCLUSIONS The total cumulative cost for treatment and follow-up for submucosal colorectal cancer was lower in the endoscopic resection group, which had comparable oncologic outcomes as the surgical resection group. Endoscopic resection can be considered a cost-effective option for initial treatment for submucosal colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B881 . ANLISIS COMPARATIVO DE COSTOS ENTRE LA RESECCIN ENDOSCPICA Y LA CIRUGA PARA EL CNCER COLORRECTAL SUBMUCOSO ANTECEDENTES: Existen pocos estudios que analizan el costo de la resección endoscópica y la resección quirúrgica en el tratamiento del cáncer colorrectal submucoso.OBJETIVO: El objetivo fue realizar un análisis detallado de costos tanto de la resección endoscópica y la resección quirúrgica para el cáncer colorrectal submucoso.DISEÑO: Este fue un estudio observacional retrospectivo.AJUSTE: Este estudio se realizó en un centro académico terciario.PACIENTES: Se revisaron las historias clínicas de 484 pacientes con cáncer colorrectal submucoso que fueron sometidos a resección endoscópica o resección quirúrgica entre julio de 2003 y julio de 2015.PRINCIPALES MEDICIONES DE RESULTADOS: Los costos totales durante la admisión índice y el seguimiento, así como los resultados clínicos entre los dos grupos, fueron comparados en toda la cohorte y la cohorte emparejada por puntuación de propensión.RESULTADOS: En el análisis emparejado por puntuación de propensión ( n = 155 en cada grupo), los grupos de resección endoscópica y resección quirúrgica no mostraron diferencias significativas en las tasas de eventos adversos relacionados con el procedimiento (6,5% vs 3,9%, p = 0,304) y recurrencia (0,6% vs 1,3%, p > 0,99). La readmisión fue más común en el grupo de resección endoscópica (40,6% vs 11,0%, p < 0,001) porque 64 (41,3%) pacientes fueron sometidos a una cirugía adicional para lograr la resección en aquellos casos en que la resección endoscópica no fue curativa. El grupo de resección endoscópica tuvo un costo menor durante el ingreso índice (1335.6 vs 6698.4 USD, p < 0.001), mientras que el grupo de resección quirúrgica tuvo un costo menor durante el seguimiento (2488.7 vs 5035.7 USD, p < 0.001). El costo total acumulado fue menor en el grupo de resección endoscópica (6371,3 vs 9187,1 USD, p < 0,001). La misma tendencia se observó en toda la cohorte sin emparejamiento por puntuación de propensión.LIMITACIONES: La naturaleza retrospectiva del análisis.CONCLUSIONES: El costo total acumulado para el tratamiento y seguimiento del cáncer colorrectal submucoso fue menor en el grupo de resección endoscópica, que tuvo resultados oncológicos comparables a los del grupo de resección quirúrgica. La resección endoscópica puede considerarse una opción rentable para el tratamiento inicial del cáncer colorrectal submucoso. Consulte Video Resumen en http://links.lww.com/DCR/B881 . (Traducción-Dr Osvaldo Gauto ).
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Affiliation(s)
- Soo Min Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Zwager LW, Mueller J, Stritzke B, Montazeri NSM, Caca K, Dekker E, Fockens P, Schmidt A, Bastiaansen BAJ. Adverse events of endoscopic full-thickness resection: results from the German and Dutch nationwide colorectal FTRD registry. Gastrointest Endosc 2023; 97:780-789.e4. [PMID: 36410447 DOI: 10.1016/j.gie.2022.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Endoscopic full-thickness resection (eFTR) is emerging as a minimally invasive alternative to surgery for complex colorectal lesions. Previous studies have demonstrated favorable safety results; however, large studies representing a generalizable estimation of adverse events (AEs) are lacking. Our aim was to provide further insight in AEs after eFTR. METHODS Data from all registered eFTR procedures in the German and Dutch colorectal full-thickness resection device registries between July 2015 and March 2021 were collected. Safety outcomes included immediate and late AEs. RESULTS Of 1892 procedures, the overall AE rate was 11.3% (213/1892). No AE-related mortality occurred. Perforations occurred in 2.5% (47/1892) of all AEs, 57.4% (27/47) of immediate AEs, and 42.6% (20/47) of delayed AEs. Successful endoscopic closure was achieved in 29.8% of cases (13 immediate and 1 delayed), and antibiotic treatment was sufficient in 4.3% (2 delayed). The appendicitis rate for appendiceal lesions was 9.9% (13/131), and 46.2% (6/13) could be treated conservatively. The severe AE rate requiring surgery was 2.2% (42/1892), including delayed perforations in .9% (17/1892) and immediate perforations in .7% (13/1892). Delayed perforations occurred between days 1 and 10 (median, 2) after eFTR, and 58.8% (10/17) were located on the left side. Other severe AEs were appendicitis (.4%, 7/1892), luminal stenosis (.1%, 2/1892), delayed bleeding (.1%, 1/1892), pain after eFTR close to the dentate line (.1%, 1/1892), and grasper entrapment in the clip (.1%, 1/1892). CONCLUSIONS Colorectal eFTR is a safe procedure with a low risk for severe AEs in everyday practice and without AE-related mortality. These results further support the position of eFTR as an established minimally invasive technique for complex colorectal lesions.
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Affiliation(s)
- Liselotte W Zwager
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Julius Mueller
- Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Nahid S M Montazeri
- Biostatistics Unit, Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, the Netherlands
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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36
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Nakajima Y, Nemoto D, Nemoto T, Takahata Y, Aizawa M, Utano K, Isohata N, Endo S, Lefor AK, Togashi K. Short‐term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions. DEN OPEN 2023; 3:e136. [PMID: 35898832 PMCID: PMC9307737 DOI: 10.1002/deo2.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022]
Abstract
Objectives Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients. Methods Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events. Results A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors. Conclusions No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.
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Affiliation(s)
- Yuki Nakajima
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Daiki Nemoto
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Tetsutaro Nemoto
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Yosuke Takahata
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Masato Aizawa
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Kenichi Utano
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Noriyuki Isohata
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Shungo Endo
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | | | - Kazutomo Togashi
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
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37
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Zachou M, Varytimiadis K, Androutsakos T, Katsaras G, Zoumpouli C, Lalla E, Nifora M, Karantanos P, Nikiteas N, Sougioultzis S, Kalaitzakis E, Kykalos S. Protocol design for randomized clinical trial to compare underwater cold snare polypectomy to conventional cold snare polypectomy for non-pedunculated colon polyps of size 5-10 mm (COLDWATER study). Tech Coloproctol 2023; 27:325-333. [PMID: 36399201 DOI: 10.1007/s10151-022-02731-9] [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: 05/14/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Colorectal cancer is internationally the third leading cause of death from a malignant disease. The aim of screening colonoscopy in adults > 45 years of age is early diagnosis and treatment of precancerous polyps. Endoscopic polyp removal (polypectomy) can be achieved with various techniques depending on the size, morphology, and location of the polyp. According to current guidelines, small non-pedunculated polyps should be removed with a cold snare after the colorectal lumen has been insufflated with air (conventional cold snare polypectomy).In recent years, several studies have described the benefits of water aided colonoscopy, as well as the safety and efficacy of underwater cold snare polypectomy for large colon polyps. However, there are insufficient data on conventional and underwater techniques for small polyps, the most commonly diagnosed colorectal polyps. METHODS We have designed a prospective randomized double-blind clinical trial to compare the safety and efficacy of conventional and underwater cold snare polypectomy for non-pedunculated polyps 5-10 mm in size. A total of 398 polyps will be randomized. Randomization will be carried out using the random numbers method of Microsoft Excel 2016. The primary endpoint is the muscularis mucosa resection rate. Secondary endpoints are the depth and percentage of R0 excisions, complications, and the recurrence rate at follow-up endoscopy 6-12 months after polypectomy. DISCUSSION We hypothesize underwater polypectomy will result in a higher muscularis mucosa resection rate. The results of our study will provide useful data for the development of guidelines in polypectomy techniques for non-pedunculated polyps 5-10 mm in size. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov, NCT05273697.
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Affiliation(s)
- M Zachou
- Second Department of Propaedeutic Surgery, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece. .,Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece.
| | - K Varytimiadis
- Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece
| | - T Androutsakos
- Department of Pathophysiology, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Katsaras
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Medical School, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Paediatric Department, General Hospital of Pella-Hospital Unit of Edessa, Edessa, Greece
| | - C Zoumpouli
- Department of Pathology, Sismanogleio General Hospital, Athens, Greece
| | - E Lalla
- Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece
| | - M Nifora
- Department of Pathology, Sismanogleio General Hospital, Athens, Greece
| | - P Karantanos
- Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece
| | - N Nikiteas
- Second Department of Propaedeutic Surgery, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - S Sougioultzis
- Department of Pathophysiology, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - E Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - S Kykalos
- Second Department of Propaedeutic Surgery, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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38
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Endoscopic submucosal tunnel dissection vs conventional endoscopic submucosal dissection for large colorectal neoplasms: a single-centre retrospective study. Tech Coloproctol 2023; 27:317-323. [PMID: 36394695 DOI: 10.1007/s10151-022-02732-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Colorectal endoscopic submucosal dissection (ESD) is still not widely used due to its technical difficulty and the risk of complications. Several techniques, such as traction techniques, pocket techniques and others, have been proposed to facilitate it. One modified pocket technique especially suitable for large lesions is endoscopic submucosal tunnel dissection (ESTD). The aim of this study was to evaluate the safety and efficacy of ESTD and compare ESTD to the conventional ESD (CESD) for treating large colorectal lesions. METHODS The charts of consecutive patients referred to the Arcispedale Santa Maria Nuova (Reggio Emilia, Italy) for colorectal ESD between January 2014 and February 2021 for colorectal neoplasms > 40 mm were retrospectively analysed. The primary outcome of the study was the en bloc resection rate. Secondary outcomes were complete and curative resection rates, procedure speed, the adverse events rate and the recurrence rate. RESULTS There were 59 patients (M:F ratio 29:30, median age 70 years [range 50-93 years]). Of 59 colorectal lesions > 40 mm, 25 were removed by ESTD and 34 by CESD. The en bloc resection rate was 100% in both groups and the complete resection rate was similar (ESTD 92% vs CESD 97.1%, p = 0.569), while the curative resection rate was higher in the CESD group, but not significantly (94.1% vs 76%, p = 0.061). Procedure speed was significantly faster with ESTD (22 vs 17 mm2/min, p = 0.045), and the overall incidence of adverse events was low (6.8%). Eight patients were referred to surgery due to non-curative resection. During follow-up, no recurrence was observed in either treatment group. CONCLUSION ESTD achieves a very high en bloc resection rate and is faster than CESD.
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Abu Arisha M, Scapa E, Wishahi E, Korytny A, Gorelik Y, Mazzawi F, Khader M, Muaalem R, Bana S, Awadie H, Bourke MJ, Klein A. Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice. Gastrointest Endosc 2023; 97:559-567. [PMID: 36328207 DOI: 10.1016/j.gie.2022.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/14/2022] [Accepted: 10/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice. METHODS We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy. RESULTS Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P < .001; RR = .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups. CONCLUSION TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.
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Affiliation(s)
- Muhammad Abu Arisha
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Erez Scapa
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Efad Wishahi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Alexander Korytny
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yuri Gorelik
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Fares Mazzawi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Majd Khader
- Department of Gastroenterology, Barzilai Medical Center, Ashkelon, Israel
| | - Rawia Muaalem
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Suzan Bana
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Halim Awadie
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia, and Westmead Clinical School, University of Sydney, New South Wales, Australia
| | - Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.
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Santos-Antunes J, Pioche M, Ramos-Zabala F, Cecinato P, Gallego Rojo FJ, Barreiro P, Félix C, Sferrazza S, Berr F, Wagner A, Lemmers A, Figueiredo Ferreira M, Albéniz E, Uchima H, Küttner-Magalhães R, Fernandes C, Morais R, Gupta S, Martinho-Dias D, Rios E, Faria-Ramos I, Marques M, Bourke MJ, Macedo G. Risk of residual neoplasia after a noncurative colorectal endoscopic submucosal dissection for malignant lesions: a multinational study. Endoscopy 2023; 55:235-244. [PMID: 35863354 DOI: 10.1055/a-1906-8000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND : Endoscopic submucosal dissection (ESD) in colorectal lesions is technically demanding and a significant rate of noncurative procedures is expected. We aimed to assess the rate of residual lesions after a noncurative ESD for colorectal cancer (CRC) and to establish predictive scores to be applied in the clinical setting. METHODS : Retrospective multicenter analysis of consecutive colorectal ESDs. Patients with noncurative ESDs performed for the treatment of CRC lesions submitted to complementary surgery or with at least one follow-up endoscopy were included. RESULTS : From 2255 colorectal ESDs, 381 (17 %) were noncurative, and 135 of these were performed in CRC lesions. A residual lesion was observed in 24 patients (18 %). Surgery was performed in 96 patients and 76 (79 %) had no residual lesion in the colorectal wall or in the lymph nodes. The residual lesion rate for sm1 cancers was 0 %, and for > sm1 cancers was also 0 % if no other risk factors were present. Independent risk factors for lymph node metastasis were poor differentiation and lymphatic permeation (NC-Lymph score). Risk factors for the presence of a residual lesion in the wall were piecemeal resection, poor differentiation, and positive/indeterminate vertical margin (NC-Wall score). CONCLUSIONS : Lymphatic permeation or poor differentiation warrant surgery owing to their high risk of lymph node metastasis, mainly in > sm1 cancers. In the remaining cases, en bloc and R0 resections resulted in a low risk of residual lesions in the wall. Our scores can be a useful tool for the management of patients who undergo noncurative colorectal ESDs.
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Affiliation(s)
- João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, Porto, Portugal
- Ipatimup/i3S (Instituto de Investigação e Inovação em Saúde da Universidade do Porto), Porto, Portugal
| | - Mathieu Pioche
- Department of Hepatology and Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Felipe Ramos-Zabala
- Department of Gastroenterology, Department of Clinical Medical Sciences, Hospital Universitario HM Montepríncipe, HM Hospitales, Universidad San Pablo-CEU, CEU Universities Madrid, Madrid, Spain
| | - Paolo Cecinato
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Pedro Barreiro
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental EPE, Lisbon, Portugal
- Lisbon Advanced Endoscopic Center, Hospital Lusíadas, Lisbon, Portugal
| | - Catarina Félix
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental EPE, Lisbon, Portugal
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento, Italy
| | - Frieder Berr
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Andrej Wagner
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mariana Figueiredo Ferreira
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Eduardo Albéniz
- Navarrabiomed Research Institute, Complejo Hospitalario de Navarra, Public University of Navarra, IdiSNA, Pamplona, Spain
| | - Hugo Uchima
- Digestive Endoscopy Service, Centro Médico Teknon, Barcelona, Spain
- Gastroenterology Service, Hospital Universitario Germans Trias i Pujol, Barcelona, Spain
| | - Ricardo Küttner-Magalhães
- Gastroenterology Department, Hospital Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Carlos Fernandes
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Rui Morais
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Daniel Martinho-Dias
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Elisabete Rios
- Pathology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Isabel Faria-Ramos
- Ipatimup/i3S (Instituto de Investigação e Inovação em Saúde da Universidade do Porto), Porto, Portugal
| | - Margarida Marques
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar Universitário S. João, Porto, Portugal
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Steinbrück I, Pohl J, Grothaus J, von Hahn T, Rempel V, Faiss S, Dumoulin FL, Schmidt A, Hagenmüller F, Allgaier HP. Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study. Surg Endosc 2023:10.1007/s00464-023-09920-z. [PMID: 36759355 DOI: 10.1007/s00464-023-09920-z] [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: 11/17/2022] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Iatrogenic colorectal perforation is a rare event with a relevant mortality and the need for surgical therapy in around ¾ of cases. METHODS In this retrospective multicentric cohort study iatrogenic colorectal perforations from 2004 to 2021 were analyzed. Primary outcome parameters were incidence and clinical success of 1st line endoscopic treatment. Comparative analysis of interventional and non-interventional perforations was performed and predictors for clinical success of endoscopic therapy were identified. RESULTS From 103,570 colonoscopies 213 (0.2%) iatrogenic perforations were identified. 68.4% were interventional (80 during polypectomy/EMR, 54 during ESD and 11 for other reasons) and 31.6% non-interventional perforations (39 by the tip, 19 by the shaft, 7 by inversion, two by biopsy and one by distension). Incidence of 1st line endoscopic therapy was 61.0% and clinical success 81.5%. Other non-surgical therapies were conducted in 8.9% with clinical success in 94.7% of cases. In interventional perforations both incidence and clinical success of 1st line endoscopic therapy were significantly higher compared to non-interventional perforations [71.7% vs. 38.2% (p < 0.01) resp. 86.5% vs. 61.5% (p < 0.01)]. Mortality was 2.3% and significantly lower in the group of interventional perforations (0.7% vs. 5.9%, p = 0.037). Multivariable analysis revealed perforation size < 5 mm as only independent predictor for clinical success of 1st line endoscopic treatment [OR 14.85 (1.57-140.69), p = 0.019]. CONCLUSIONS Endoscopic therapy is treatment of choice in the majority of iatrogenic colorectal perforations. In case of interventional perforations it is highly effective but only a minority of non-interventional perforations are good candidates for endoscopic treatment.
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Affiliation(s)
- Ingo Steinbrück
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital, University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany.
| | - Jürgen Pohl
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Johannes Grothaus
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Thomas von Hahn
- Department of Gastroenterology, Hepatology and Endoscopy, Asklepios Klinik Barmbek, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Viktor Rempel
- Department of Gastroenterology, St. Anna Hospital Herne, Academic Teaching Hospital Ruhr University Bochum, Herne, Germany
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Academic Teaching Hospital, Universtiy of Berlin, Berlin, Germany
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | - Arthur Schmidt
- Department of Gastroenterology and Hepatology, University of Freiburg, Freiburg, Germany
| | - Friedrich Hagenmüller
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Hans-Peter Allgaier
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital, University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany
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Ichijima R, Ikehara H, Sumida Y, Inada T, Nemoto D, Nakajima Y, Minagawa T, Sumiyoshi T, Inoki K, Yoshida N, Inoue K, Fukuzawa M, Minoda Y, Tsutsumi K, Esaki M, Gotoda T. Randomized controlled trial comparing conventional and traction endoscopic submucosal dissection for early colon tumor (CONNECT-C trial). Dig Endosc 2023; 35:86-93. [PMID: 35997037 DOI: 10.1111/den.14426] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/22/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Endoscopic submucosal dissection (ESD) is a widely used treatment for early gastrointestinal cancer. However, colon ESD remains challenging. Previous studies on colon ESD using the traction method used a small sample, single-center design, providing insufficient evidence of this procedure's efficacy. We thus aimed to investigate the efficacy and safety of the traction method in colon ESD in this multicenter randomized trial. METHODS We conducted a prospective, multicenter, randomized, two-arm controlled trial at 10 facilities in Japan. A 1:1 allocation was conducted for the conventional ESD (C-ESD) and traction ESD (T-ESD) groups. The primary end-point was ESD procedure time. RESULTS We included 128 C-ESD and 123 T-ESD cases from April 2020 to August 2021. The median procedure times for C-ESD and T-ESD were 61 (40-100) and 53 (40-76) min (P = 0.18), respectively, and no significant differences were observed between the groups. Subgroup analysis showed that the median procedure times for patients with a lesion diameter of ≥30 mm in the C-ESD and T-ESD groups were 89 (57-80) and 69 (50-104) min (P = 0.05), respectively, and for nonexpert operators were 81 (62-120) and 64 (52-109) min (P = 0.07), respectively. CONCLUSIONS The traction method did not contribute to a significantly shortened ESD procedure time. However, this method may be useful when the tumor diameter is large or if the procedure is conducted by nonexpert endoscopists.
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Affiliation(s)
- Ryoji Ichijima
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hisatomo Ikehara
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Taisuke Inada
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Daiki Nemoto
- Department of Coloproctology, Fukushima Medical University Aizu Medical Center, Fukushima, Japan
| | - Yuki Nakajima
- Department of Coloproctology, Fukushima Medical University Aizu Medical Center, Fukushima, Japan
| | | | | | - Kazuya Inoki
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ken Inoue
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yosuke Minoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koshiro Tsutsumi
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Fukuoka, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Mueller J, Kuellmer A, Schiemer M, Thimme R, Schmidt A. Current status of endoscopic full-thickness resection with the full-thickness resection device. Dig Endosc 2023; 35:232-242. [PMID: 35997598 DOI: 10.1111/den.14425] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/21/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD) is an integral part of diagnostic and therapeutic endoscopy. Since its market launch in Europe in 2014, its safety and effectiveness have been proven in numerous studies. Adaptations in design as well as new techniques, such as hybrid EFTR, expand the spectrum of the FTRD system. The following review is intended to provide an overview of the clinical application and current evidence of EFTR with the FTRD system.
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Affiliation(s)
- Julius Mueller
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Schiemer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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A Look into the Future of Endoscopic Submucosal Dissection and Third Space Endoscopy: The Role for Robotics and Other Innovation. Gastrointest Endosc Clin N Am 2023; 33:197-212. [PMID: 36375883 DOI: 10.1016/j.giec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endoscopic resection has been widely applied especially in endoscopic submucosal dissection and third space endoscopy (TSE). Flexible endoluminal robotics allow performance of endoscopic submucosal dissection with exposure of the submucosal plane for precise dissection using two robotic arms. The introduction of TSE revolutionized the horizon of therapeutic endoscopy to the submucosal space beneath and beyond the mucosa. Advantages of TSE include avoidance of full thickness incision in gastrointestinal tract through the submucosal tunneling for performance of peroral endoscopic myotomy and submucosal tunneling endoscopic resection. In future, robotic-driven devices should be developed to enhance performance of complex endoluminal procedures and TSE.
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Abdallah M, Suryawanshi G, McDonald N, Chandan S, Umar S, Azeem N, Bilal M. Endoscopic full-thickness resection for upper gastrointestinal tract lesions: a systematic review and meta-analysis. Surg Endosc 2022; 37:3293-3305. [PMID: 36517704 DOI: 10.1007/s00464-022-09801-x] [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: 04/27/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Endoscopic full-thickness resection (EFTR) is used to resect difficult superficial mucosal lesions and sub-epithelial lesions (SELs). We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of EFTR for upper gastrointestinal tract (GIT) lesions. METHODS We conducted a comprehensive literature search of MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov, and Scopus databases for studies published in the English language that addressed outcomes of EFTR for upper GIT lesions through November 2021. The weighted pooled rates with the 95% confidence interval (CI) were calculated. Cochran Q test and I statistics were used to calculate heterogeneity. RESULTS We identify 740 articles on the initial search and six studies met the inclusion criteria. 140 patients (45.7% females) with 142 lesions were analyzed. Four studies used the full-thickness resection device (FTRD®). EFTR was performed for 26 adenomas, 97 SELs, six adenocarcinomas, and ten full-thickness biopsies. The overall technical success rate was 86.9% (CI 79.8-94%, I 2 = 38.9%), R0 resection was 80% (CI 67.6-92.3%, I 2 = 75.6%), and the overall adverse events rate was 18.6% (9.8-27.2%, I 2 = 49.4%). Major adverse events included six episodes of major bleeding, three micro-perforations, one large duodenal perforation, and one case of mucosal damage from FTRD®. At 3-6 months follow-up, there were only two cases of recurrence (R0 was not achieved in both). CONCLUSION EFTR has a high technical and clinical success rate in managing upper GIT lesions with an acceptable safety profile. Large prospective studies comparing EFTR with conventional endoscopic resection techniques are needed.
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Affiliation(s)
- Mohamed Abdallah
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA.
| | - Gaurav Suryawanshi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
| | - Nicholas McDonald
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology and Nutrition, Creighton University, Omaha, NE, USA
| | - Shifa Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
| | - Mohammad Bilal
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
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Tatar C, Ozgur I, Justiniano CF, Bhatt A, Liska D, Hull T, Steele SR, Gorgun E. Is Endoscopic Submucosal Dissection for Colorectal Lesions Performed in the Endoscopy Suite Safe and Cost Saving? Surg Laparosc Endosc Percutan Tech 2022; 32:688-691. [PMID: 36468893 DOI: 10.1097/sle.0000000000001118] [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: 07/13/2022] [Accepted: 10/11/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND We aimed to compare the outcomes and the cost differences of endoscopic submucosal dissection (ESD) procedures in the endoscopy suite (ES) versus the operating room (OR). MATERIALS AND METHODS The procedures in the OR were compared with procedures performed in the ES for demographics, lesion characteristics, procedure outcome, and procedure charges. The study included 163 procedures in the ES and 73 in the OR. RESULTS Both were similar in age, sex, body mass index, and intraprocedural and postoperative 30-day (late) complications. ES cases had significantly greater polyp size, were more commonly right-sided polyps, and had shorter hospital stays, with similar en bloc and margin-negative resection rates. The overall cost ratio of ESD procedures in ES to OR was 0.47 ( P <0.001). CONCLUSIONS Colorectal ESD procedures performed in the ES have similar efficacy and safety as those in the OR. Procedures performed in the ES were associated with a shorter length of stay and significant periprocedural cost savings.
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Affiliation(s)
| | | | | | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Takada K, Hotta K, Imai K, Ito S, Kishida Y, Minamide T, Yamamoto Y, Yabuuchi Y, Yoshida M, Maeda Y, Kawata N, Takizawa K, Ishiwatari H, Matsubayashi H, Kawabata T, Ono H. Tip-in EMR as an alternative to endoscopic submucosal dissection for 20- to 30-mm nonpedunculated colorectal neoplasms. Gastrointest Endosc 2022; 96:849-856.e3. [PMID: 35798055 DOI: 10.1016/j.gie.2022.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/01/2022] [Accepted: 06/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Tip-in EMR, which includes anchoring the snare tip, has recently shown a favorable en-bloc and R0 resection rate for colorectal neoplasms. Thus, Tip-in EMR may be an alternative to endoscopic submucosal dissection (ESD). We aimed to compare clinical outcomes between Tip-in EMR and ESD for large colorectal neoplasms. METHODS This retrospective study evaluated consecutive patients who underwent Tip-in EMR or ESD for 20- to 30-mm nonpedunculated colorectal neoplasms at a Japanese tertiary cancer center between January 2014 and December 2019. Baseline characteristics, treatment results, and long-term outcomes were analyzed using 1:1 propensity score matching. RESULTS Seven hundred nine lesions were evaluated. The Tip-in EMR group included 1 lesion with a nonlifting sign but no lesions with fold convergence. After propensity score matching, each group included 140 lesions. The ESD group showed significantly higher en-bloc resection rates (99.3% vs 85.0%) and R0 resection rates (90.7% vs 62.9%). Procedure time was significantly shorter in the Tip-in EMR group (8 minutes vs 60 minutes). The Tip-in EMR and ESD groups did not differ significantly with respect to local recurrence rate (2.1% vs 0%). CONCLUSIONS Tip-in EMR is comparable with ESD with respect to the local recurrence rate but has a shorter procedure time, despite the lower en-bloc and R0 resection rates for 20- to 30-mm nonpedunculated colorectal neoplasms without fold convergence or nonlifting sign. Thus, Tip-in EMR could be a feasible alternative to ESD in these lesions.
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Affiliation(s)
- Kazunori Takada
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Yoichi Yamamoto
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan; Department of Gastroenterology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan; Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yuki Maeda
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan; Gastroenterology and Endoscopy, Sapporo Kinentou Hospital, Hokkaido, Japan
| | | | | | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Motchum L, Levenick JM, Djinbachian R, Moyer MT, Bouchard S, Taghiakbari M, Repici A, Deslandres É, von Renteln D. EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos). Gastrointest Endosc 2022; 96:840-848.e2. [PMID: 35724695 DOI: 10.1016/j.gie.2022.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR. METHODS Adult patients (aged 18-89 years) undergoing EMR of nonpedunculated colorectal polyps ≥20 mm were enrolled in a prospective multicenter study. h-APC was used to ablate all defect margins and also the resection surface in selected cases. The primary study outcome was recurrence rates found during the first follow-up colonoscopy. Secondary outcomes were technical success and adverse event rates. RESULTS EMR with h-APC ablation was used in 101 polyps (84 patients, 46.4% women). EMR with h-APC ablation was technically successful in all cases (median EMR time, 15 minutes; median h-APC ablation time, 4 minutes). Median polyp size was 30 mm (range, 20-60). Resected polyps were either adenomas (68/101 [67.3%]), sessile serrated lesions (27/101 [27%]), or adenocarcinomas (6/101 [6%]). The post-EMR recurrence rate was 2.2% (2/91) (95% confidence interval, .27-7.71). All 6 patients with cancer (intramucosal cancer, 4; T1sm cancer, 2) were found to have complete eradication of the primary tumor after EMR with h-APC, and none had lymph node metastasis. Four serious adverse events occurred in 3 patients (2 delayed bleeding [2.4%], 1 abdominal pain [1.2%], and 1 microperforation [1.2%]. All serious adverse events resolved with either endoscopic or antibiotic treatment only. CONCLUSIONS EMR with h-APC showed a high technical success rate, low adverse event rate, and very low post-EMR recurrence rates. (Clinical trial registration number: NCT04015765.).
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Affiliation(s)
- Leslie Motchum
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Faculty of Medicine, Montreal University Montreal, Montreal, Quebec, Canada
| | - John M Levenick
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Roupen Djinbachian
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Matthew T Moyer
- Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Simon Bouchard
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Mahsa Taghiakbari
- Montreal University Medical Research Center, Montreal, Quebec, Canada
| | - Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Érik Deslandres
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Daniel von Renteln
- Montreal University Medical Research Center, Montreal, Quebec, Canada; Division of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
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Li DF, Van Overbeke L, Ohata K, Wang LS, Yao J. Efficacy and safety of cold snare polypectomy for sessile serrated polyps ≥ 10 mm: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1486-1493. [PMID: 35168877 DOI: 10.1016/j.dld.2022.01.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cold snare polypectomy (CSP) is a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. However, the efficacy and safety of this technique remain undetermined. AIMS We aimed to comprehensively evaluate the efficacy and safety of CSP for SSPs ≥ 10 mm. METHODS PubMed, EMBASE, Web of Science and Cochrane Library were searched up to January 2021. RESULTS A total of 10 studies consisting of 1727 SSPs (range, 10-40 mm) from 1021 patients were included. The overall rates of technical success, adverse events (AEs) and residual SSPs were 100%, 0.7% and 2.9%, respectively. Subgroup analysis showed that the rates of technical success and AEs were comparable between CSP and cold endoscopic mucosal resection (EMR) (99.9% vs. 100% and 1.3% vs. 0.5%, respectively), between the proximal and distal colon (100% vs. 99.9% and 0.3% vs. 0, respectively), and between polyps of 10-19 mm and ≥20 mm (99.8% vs. 100% and 0.9% vs. 0, respectively). However, subgroup analysis showed that the rate of residual SSPs was slightly lower in CSP compared with cold EMR (1.3% vs. 3.9%), as well as in polyps of 10-19 mm compared with those ≥20 mm (3.1% vs. 4.7%). CONCLUSION CSP was an effective and safe technique for removing SSPs ≥ 10 mm.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China
| | | | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China.
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), No.1017, Dongmen North Road, Luohu District, Shenzhen, Guangdong 518020, China.
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50
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Forbes N, Gupta S, Frehlich L, Meng ZW, Ruan Y, Montori S, Chebaa BR, Dunbar KB, Heitman SJ, Feagins LA, Albéniz E, Pohl H, Bourke MJ. Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials. Gastrointest Endosc 2022; 96:721-731.e2. [PMID: 35667388 DOI: 10.1016/j.gie.2022.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm. METHODS We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses. RESULTS From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of .31 (95% confidence interval [CI], .17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of .78 (95% CI, .17-3.54) and .67 (95% CI, .20-2.22), respectively. CONCLUSIONS Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Benjamin R Chebaa
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Kerry B Dunbar
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven J Heitman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Linda A Feagins
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eduardo Albéniz
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain; Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA; Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA; Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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