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Ahmed N, Bechara R. Endoscopic submucosal dissection and JNET classification for colorectal neoplasia: A North American academic center experience. DEN OPEN 2024; 4:e322. [PMID: 38023663 PMCID: PMC10681000 DOI: 10.1002/deo2.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023]
Abstract
Objectives Endoscopic submucosal dissection (ESD) enables minimally invasive resection of superficial gastrointestinal neoplasms en bloc regardless of size. The Japan narrow band imaging expert team (JNET) classification utilizes optical magnification and narrow band imaging (NBI) to predict pathology. In North America, ESD is far from ubiquitous, and regional outcomes are not widely described. To date there are no North American studies describing the application and yield of the JNET classification as applied in the practice of ESD. Methods A retrospective, single-center, cohort analysis was performed on a prospectively maintained database of ESD procedures. Between July 2016 and February 2023, all consecutive patients treated with ESD for colorectal lesions were identified and stratified by lesion location, JNET, NBI International Colorectal Endoscopic, lateral spreading tumors, and Paris classifications. Univariate analysis was used for clinicopathological data. p < 0.05 was considered statistically significant. Results A total of 112 patients were identified. One lesion, a lipoma, was excluded. Overall, 49.5% (55/111) of lesions were colonic and 50.5% (56/111) rectal. Most lesions were lateral spreading tumors (60.4%, 67/111). Overall, 96.4% (107/111) ESDs were successfully completed, 98.1% (105/107) en bloc, and 87.9% (94/107) R0. Adverse events occurred in 1.8% (2/111) of procedures. The median diameter was 4.0 cm and resected in a median time of 62.0 min. Overall, 70.1% (47/67) lesions were upstaged from pre-ESD biopsy. JNET 2B showed 80.2% (95% CI 71.5-87.1) accuracy for high-grade dysplasia or sm1. All JNET type 3 were ≥sm2 (p < 0.001). Conclusions ESD permits safe and effective resection of superficial colorectal neoplasms. JNET classification was more accurate than pre-resection biopsy at predicting histology in this series.
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Affiliation(s)
- Nabeel Ahmed
- Faculty of Medicine and Health SciencesMcGill UniversityMontrealCanada
| | - Robert Bechara
- Department of GastroenterologyKingston Health Sciences CenterKingstonCanada
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Nie X, Jiang A, Wu X, Bai J, He S. Curative Effect Analysis of Endoscopic Submucosal Dissection in Giant Laterally Spreading Rectal Tumors. J Clin Gastroenterol 2024; 58:169-175. [PMID: 36961342 DOI: 10.1097/mcg.0000000000001844] [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] [Received: 11/22/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023]
Abstract
GOAL The objective of this study was to investigate the clinical efficacy of endoscopic submucosal dissection (ESD) in the treatment of giant lateral developing rectal-type tumors (laterally spreading tumors, LSTs). BACKGROUND There are no specialized studies on the efficacy of ESD in the treatment of LSTs measuring >5 cm in diameter, surgery was often used in the past, but it has the disadvantages of large trauma, many complications, and high cost. METHODS The data of 185 patients with rectal LSTs who had undergone ESD in the digestive endoscopy center of our hospital from January 2012 to June 2020 were retrospectively analyzed. Based on the size of the lesions, the patients were divided into 2 groups: diameter ≤5 cm (110 cases) and diameter >5 cm (75 cases), and we summarized and analyzed the en bloc resection rate, curative resection rate, procedure time, muscle injury, bleeding, perforation, postoperative stricture, and recurrence. RESULTS There was no difference in the en bloc resection rate and R0 resection rate between the 2 groups ( P =0.531). Moreover, there was no difference in the incidence of delayed perforation, postoperative stenosis, and recurrence, but the incidence of delayed bleeding was significantly higher in the giant LST group than the small LST group ( P =0.001). Moreover, for giant rectal LSTs, the growth pattern of the lesion, JNET classification, and the extent of postoperative mucosal defect do not significantly affect the efficacy of ESD. It is worth mentioning that the operation time was longer in the group with a diameter >5 cm, in which perforation was more frequent and the muscle layer was more likely to be injured during ESD ( P <0.001). The muscle injury during ESD was mainly related to the diameter of the lesion, the crossing the rectal pouch, and the operation time. CONCLUSIONS The use of ESD to treat giant rectal LSTs (>5 cm) is relatively difficult and can easily lead to intraoperative muscle injury, perforation, and late postoperative bleeding. However, if active intervention is performed, patients can still achieve good efficacy and prognosis, which can be applied in hospitals with certain conditions.
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Affiliation(s)
- Xubiao Nie
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University
| | - Airui Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xiaoling Wu
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University
| | - Jianying Bai
- Department of Gastroenterology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Song He
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University
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Nader SM, Lahr RE, Rex DK. Impact of margin thermal treatment after EMR of giant (≥40 mm) colorectal lateral spreading lesions. Gastrointest Endosc 2023; 97:544-548. [PMID: 36306831 DOI: 10.1016/j.gie.2022.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/16/2022] [Accepted: 10/16/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS Increasing lesion size is a risk factor for recurrence after piecemeal EMR (pEMR). Snare-tip soft coagulation (STSC) treatment of the normal-appearing margin after pEMR of lesions ≥ 20 mm has been shown to reduce recurrence rates by 75% to 80%. We sought to evaluate the impact of STSC on giant (≥ 40 mm) lateral spreading lesions treated by pEMR. We describe the relative risk and absolute risks of recurrence with and without STSC margin treatment after EMR of ≥ 40-mm lesions. METHODS We performed a retrospective evaluation of a prospectively collected database on large lesions describing lesion size, location, and methods of resection. We excluded lesions < 40 mm in maximum dimension, those that did not undergo follow-up care at our center, and those in which argon plasma coagulation was used for either ablative treatment of residual polyp or margin treatment. Propensity score analysis was used to account for potential differences between patients treated with and without STSC. RESULTS There were 68 lesions ≥ 40 mm removed by pEMR without STSC treatment and 133 removed and treated with STSC. There were no differences between groups in demographics, polyp size, location, histologic features, and mean follow-up time. The recurrence rate in the no-treatment group was 35% versus 9% with STSC (P < .00001 by direct comparison and P = .008 by using the propensity score analysis). CONCLUSION STSC treatment after pEMR of large lateral spreading lesions in the colorectum reduced recurrences by 75%. However, the absolute recurrence rate of 9% remained clinically significant in the STSC-treated group. Short-term follow-up care after STSC of lesions ≥ 40 mm is still warranted, and additional study of technical factors that eliminate recurrence after pEMR of giant lateral spreading lesions is warranted.
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Affiliation(s)
| | - Rachel E Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Ge PS, Aihara H. Advanced Endoscopic Resection Techniques: Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection. Dig Dis Sci 2022; 67:1521-1538. [PMID: 35246802 DOI: 10.1007/s10620-022-07392-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 02/08/2023]
Abstract
Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.
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Affiliation(s)
- Phillip S Ge
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Yan X, Mitra N, Gamage DN, Shah A, Cekic V, Kumara HMCS, Whelan RL. A colonoscopic overtube system that creates a 'therapeutic zone' and permits retraction facilitates endoscopic submucosal dissection, was associated with fewer deep bowel wall injuries and instrument exchanges, and required less lifting solution vs classic endoscopic submucosal dissection in an ex vivo bovine model. Surg Endosc 2022; 36:5897-5906. [PMID: 35411458 DOI: 10.1007/s00464-022-09203-z] [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: 06/07/2021] [Accepted: 03/22/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is the 'gold standard' for large flat polyps; nevertheless, the rate of adoption in the USA is low. In ESD, the polyp is 'surgically' detached with a needle knife after a submucosal lift; gravity and the dissection cap are used for retraction. ESD would be easier if active retraction were possible. In an ex vivo bovine colon model, this study assessed an overtube system (Boston Scientific ORISE Tissue Retraction System, TRS) that permits retraction and creates 'an operative field' for removal of rectal/sigmoid lesions. METHOD Classic ESD (C-ESD) was compared to TRS-facilitated ESD (TRS-ESD). Cleaned/preserved bovine large bowel was used, and two 2-cm 'lesions'/colon were branded onto the mucosal surface 25 and 35 cm from the anus. Submucosal saline lifts were made using a thin catheter and a standard needle knife. We tracked case length, number of instrument exchanges (to refresh lift), the volume of lift solution, the fullness of resection, and deep muscle injuries. RESULTS Fifty ESDs were carried out in 25 colons (25 C-ESD, 25 TRS-ESD). Complete resections were noted in all cases. The TRS method required fewer instrument exchanges (median 5) vs C-ESD (median 9, p < 0.0001) and less lift solution (median 39 ml) than the C-ESD cases (median 55 ml, p = 0.0003). TRS-ESD was associated with fewer deep muscle injuries (median 2) than C-ESD (median 3, p = 0.0191). Finally, the TRS group's median case length (34.5 min) was shorter than that of C-ESD (41 min, p = 0.0543). CONCLUSION The TRS system provides retraction and facilitates ESD regarding the number of lift injections, the volume of lift solution needed, and avoidance of muscle injuries. Of note, there is an apparent TRS learning curve, and the device mandates a distal-to-proximal approach and initial 360 degree mucosal incision. Further study is warranted.
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Affiliation(s)
- Xiaohong Yan
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York City, New York, USA.
| | - Neil Mitra
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | - Dasuni Niyagama Gamage
- Department of Surgery, Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, New York, USA
| | - Abhinit Shah
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | - Vesna Cekic
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | - H M C Shantha Kumara
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | - Richard L Whelan
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
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Hayat M, Azeem N, Bilal M. Colon Polypectomy with Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection. Gastrointest Endosc Clin N Am 2022; 32:277-298. [PMID: 35361336 DOI: 10.1016/j.giec.2021.12.005] [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: 02/07/2023]
Abstract
Endoscopic resection has become the gold standard for the management of most of the large colorectal polyps. Various endoscopic resection techniques include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). ESD is a minimally invasive method for the resection of advanced lesions in the gastrointestinal (GI) tract to achieve en-bloc resection. While, EFTR is more commonly used in lesions with suspected deeper submucosal invasion, lesions originating from muscularis propria, or those with advanced fibrosis. This article reviews the indications, technique, and adverse events for use of ESD and EFTR in the colon.
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Affiliation(s)
- Maham Hayat
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK 73104, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mohammad Bilal
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA; Advanced Endoscopy, Division of Gastroenterology & Hepatology, Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN 55417, USA.
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Gupta N, Rodríguez-Ruiz G, Siddiqui UD, Chapman CG, Donboli K, Hart J, Xiao SY, Waxman I. Endoscopic submucosal dissection for colorectal lesions: outcomes from a United States experience. Surg Endosc 2022; 36:236-243. [PMID: 33523276 DOI: 10.1007/s00464-020-08262-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/22/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is commonly used in Asia for resection of large non-pedunculated colorectal polyps (LNPCPs) and early (T1) colorectal cancers. It allows for en bloc removal and is often curative. We describe outcomes of colorectal ESD from a United States (US) academic medical center and compare this to international experiences. METHODS Retrospective review was performed of colonic lesions referred to the University of Chicago Medical Center for ESD from 2012 to 2020. Clinical and procedural data were collected. RESULTS The study included 78 lesions with mean size of 29.7 mm (range 10-100 mm). The overall en bloc resection rate was 73.1% (n = 57). Between the first and second half of the study, it improved from 61.5 to 84.6% (p = 0.02). Histology showed adenocarcinoma in fifteen lesions (19.2%). Of all neoplastic lesions (n = 68), resection with negative margins (R0) was achieved in 54 cases (79.4%). Adverse events occurred in 9 cases (11.5%), but most (n = 6, 66.7%) were successfully treated endoscopically. Follow-up endoscopy was performed in 46 patients (59.0%) at a mean interval of 6.8 months (SD ± 5.0 months) with two case of recurrent lesion (4.3%). CONCLUSIONS This study shows successful colorectal ESD outcomes at a US tertiary center. The en bloc resection rate was lower than other cohorts, but a learning curve was demonstrated. The R0 resection, lesion recurrence, and adverse event rates were similar to other non-Asian experiences, but not as favorable as in Asia [Fuccio et al. in Gastrointest Endosc 86:74-86.e17, 2017]. Increased ESD training in the US can help optimize utilization and outcomes.
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Affiliation(s)
- Nina Gupta
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL, USA.
| | | | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL, USA
| | - Christopher G Chapman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL, USA
| | - Kianoush Donboli
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL, USA
| | - John Hart
- Department of Pathology, The University of Chicago Medicine, Chicago, IL, USA
| | - Shu-Yuan Xiao
- Department of Pathology, The University of Chicago Medicine, Chicago, IL, USA
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL, USA
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Risk factors for adverse events of colorectal endoscopic submucosal dissection: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2021; 33:e33-e41. [PMID: 33208681 DOI: 10.1097/meg.0000000000001994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colorectal endoscopic submucosal dissection (ESD) is already an established treatment for superficial colorectal tumors. However, its technical difficulty and high adverse events rates, compared to endoscopic piecemeal mucosal resection, are a concern to some specialists and have probably contributed to discouragement in its widespread adoption. The debate mentioned above stimulated us to perform a systematic review aiming to identify risk factors for colorectal ESD-related adverse events. We conducted this study following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement and registered in the PROSPERO (University of York) international database (CRD42016042625). We searched MEDLINE, EMBASE, Cochrane Library and LILACS for the publications focused on risk factors for colorectal ESD-related adverse events from inception until April 2020. We included a total of 22 qualified studies in this analysis. We found that fibrosis had an odds ratio (OR) for perforation of 2.90 [95% confidence interval, (1.83-4.59)], right colon location of 2.35 (1.58-3.50), colonic location of 2.20 (1.44-3.35) and larger size of 2.17 (1.47-3.21), as well as one protective factor, the endoscopist experience OR = 0.62 (0.45-0.86). For bleeding, we considered rectal location a risk factor [OR = 3.55 (2.06-6.12)]. Through the several meta-analyses that we performed in this article, we could summarize the main risk factors for perforation and bleeding on colorectal ESD. Therefore, we provide insightful information for clinical judgment on regions where colorectal ESD is already widespread and help in the learning process of this challenging technique.
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McCarty TR, Bazarbashi AN, Thompson CC, Aihara H. Hybrid endoscopic submucosal dissection (ESD) compared with conventional ESD for colorectal lesions: a systematic review and meta-analysis. Endoscopy 2021; 53:1048-1058. [PMID: 32947624 DOI: 10.1055/a-1266-1855] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hybrid endoscopic submucosal dissection (ESD) is increasingly utilized to overcome the complexity of conventional ESD. This systematic review and meta-analysis evaluated the efficacy and safety of hybrid ESD for treatment of colorectal lesions. METHODS Search strategies were developed in accordance with PRISMA guidelines. Pooled proportions were calculated with rates estimated using random effects models. Measured outcomes included en bloc resection, procedure-associated complications, recurrence, and need for surgery. Subgroup analyses were performed to compare effectiveness of conventional versus hybrid ESD. RESULTS 16 studies (751 patients) were included with a mean (standard deviation [SD]) lesion size of 27.96 (10.55) mm. En bloc resection rate was 81.63 % (95 % confidence interval [CI] 72.07 - 88.44; I2 = 80.89). Complications, recurrences, and need for surgery occurred in 7.74 % (95 %CI 4.78 - 12.31; I2 = 65.84), 4.52 % (95 %CI 1.40 - 13.65; I2 = 76.81), and 3.64 % (95 %CI 1.76 - 7.37; I2 = 15.52), respectively. Mean procedure duration was 48.83 (22.37) minutes. On subgroup analyses comparing outcomes for conventional (n = 1703) versus hybrid ESD (n = 497), procedure duration was significantly shorter for hybrid ESD (mean difference 18.45 minutes; P = 0.003), with lower complication rates (P = 0.04); however, hybrid ESD had lower en bloc resection rates (P < 0.001). There was no difference in rates of recurrence or surgery (P > 0.05). CONCLUSION While hybrid ESD was safe and effective for removal of colorectal lesions, with shorter procedure duration, fewer complications, and no difference in recurrence versus conventional ESD, hybrid ESD was associated with a lower en bloc resection rate.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Envisioning the future of colorectal surgery: preclinical assessment and detailed description of an endoluminal robotic system (ColubrisMX ELS). Tech Coloproctol 2021; 25:1199-1207. [PMID: 34224035 DOI: 10.1007/s10151-021-02481-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND The EndoLuminal Surgical System (ELS) is an emerging non-linear robotic system specifically designed for transanal surgery that allows for excision of colorectal neoplasia and luminal defect closure. METHODS An evaluation of ELS was conducted by a single surgeon in a preclinical setting at the EndoSurgical Center of Florida in Orlando, between October 1st, 2020 and December 31st, 2020, using porcine colon as a model. Mock lesions measured 2.5 to 3.5 cm were excised partial-thickness. Specimen quality and excision time was assessed and evaluated. RESULTS Twenty consecutive robotic transanal minimally invasive surgery (TAMIS) operations utilizing the ELS system were successfully performed without fragmentation. The mean and standard deviation procedure time for all 20 cases was 18.41 ± 14.15 min. The latter 10 cases were completed in substantially less time, suggesting that ELS requires at least 10 preclinical cases for a surgeon to become familiar with the technology. A second task, namely suture closure of the partial-thickness defect, was performed in 9 of the 20 cases. Mean time and standard deviation for this task measured 27.89 ± 10.07 min. There were no adverse events. CONCLUSIONS ELS was successful in performing the tasks of partial-thickness disc excision and closure in a preclinical evaluation. Further study is necessary to determine its clinical applicability.
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Rex DK, Risio M, Hassan C. Prioritizing an oncologic approach to endoscopic resection of pedunculated colorectal polyps. Gastrointest Endosc 2021; 94:155-159. [PMID: 33931206 DOI: 10.1016/j.gie.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/05/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mauro Risio
- Institute for Cancer Research and Treatment, Candiolo (Torino), Italy
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Visrodia K, Sethi A. A knife plus a snare, but how will it fare? Gastrointest Endosc 2021; 93:679-681. [PMID: 33583523 DOI: 10.1016/j.gie.2020.11.019] [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: 11/09/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Kavel Visrodia
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Medical Center-NYPH, New York, New York, USA
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Barbour JA, O'Toole P, Suzuki N, Dolwani S. Learning endoscopic submucosal dissection in the UK: Barriers, solutions and pathways for training. Frontline Gastroenterol 2020; 12:671-676. [PMID: 34917325 PMCID: PMC8640414 DOI: 10.1136/flgastro-2020-101526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jamie A Barbour
- Department of Gastroenterology, QE Gateshead, Gateshead, Tyne and Wear, UK
| | - Paul O'Toole
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK
| | - Sunil Dolwani
- Department of Gastroenterology, Cardiff and Vale NHS Trust, Cardiff, UK
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McCarty TR, Aihara H. Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA. Dig Endosc 2020; 32:851-860. [PMID: 31797470 DOI: 10.1111/den.13591] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
Abstract
Endoscopic submucosal dissection (ESD) is a rigorous and technically sophisticated method for removal of lesions within the gastrointestinal tract. Despite having advantages of en-bloc resection of lesions, regardless of size, and widespread use in Japan and Asia, ESD has not become widely adopted in the USA for a variety of reasons. Based upon Japanese education and the master-apprentice model, modification to the education system and additional techniques designed to facilitate broader adoption are required for trainees in the USA. This article will review the current state of education and training for ESD in the USA.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Hosotani K, Imai K, Hotta K, Ito S, Kishida Y, Yoshida M, Kawata N, Kakushima N, Takizawa K, Ishiwatari H, Matsubayashi H, Ono H. Can Advanced Endoscopic Imaging Help Us Avoid Surgery for Endoscopically Resectable Colorectal Neoplasms? A Proof-of-Concept Study. Dig Dis Sci 2020; 65:1829-1837. [PMID: 31630341 DOI: 10.1007/s10620-019-05894-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/03/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND European guidelines recommend advanced endoscopic imaging (AEI) to guide therapeutic decisions; however, data are limited concerning its clinical effects on the management of colorectal polyps. The aim of this study was to investigate the effect of standard chromoendoscopic imaging (SCI) and AEI on decision-making regarding therapeutic techniques. METHODS We retrospectively analyzed prospectively collected endoscopic and pathological data on colorectal neoplasms ≥ 10 mm removed at a Japanese tertiary cancer center between January 2010 and December 2016. We assumed a virtual approach to manage the decisions for endoscopic resection or surgery for each lesion using the following test modalities: (1) endoscopic size measurement (ESM), (2) SCI, and (3) AEI. Virtual surgical management was indicated using the following criteria: (1) ESM: lesion ≥ 40 mm, (2) SCI: depression, excavation, or ulceration, (3) AEI: Japan NBI Expert Team type 3 (magnifying NBI), VI high-grade, or VN (magnifying chromoendoscopy). We compared the incidence of hypothetical redundant surgery, defined as virtual surgical management for cases of dysplasia or superficial submucosal invasive cancers (SM-S). RESULTS A total of 3509 lesions from 2693 patients were analyzed, including 142 SM-S and 457 deep submucosal invasive cancer (SM-D). The incidence of hypothetical redundant surgery was 9.2% with ESM, 5.1% with SCI, and 2.9% with AEI. When compared with ESM, hypothetical redundant surgery was significantly reduced with SCI (relative risk 0.55; 95% confidence interval 0.44-0.69) and AEI (0.31; 0.23-0.41). CONCLUSIONS Therapeutic decision-making according to SCI or AEI can reduce surgery for endoscopically resectable colorectal neoplasms.
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Affiliation(s)
- Kazuya Hosotani
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan.
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Suntogun, Shizuoka, 411-8777, Japan
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Dickinson KJ, Dunkin BJ, Nguyen-Lee JJ, Ali AB, Zajac S. Task Deconstruction of Colonic Endoscopic Submucosal Dissection (cESD): An Expert Consensus. World J Surg 2020; 44:2401-2408. [PMID: 32133568 DOI: 10.1007/s00268-020-05454-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Slow adoption of colonic ESD (cESD) in the US is multifactorial due to: lack of clinical training construct (e.g., gastric ESD in Japan), complication risks, and technical difficulty. More than 28,000 patients/year undergo colonic resection for benign lesions that could be managed effectively with cESD. Selected patients could avoid surgery if procedural adoption of cESD increased due to more accessible training. Current US cESD training is scarce, and existing programs are piecemeal. There is a need to develop an effective national training program for practicing endoscopists. A prerequisite to training development is a comprehensive task list delineating procedural steps. The aim of this work was to describe an evidence-based method of deconstructing cESD into the essential steps to provide a task list to guide teaching and assessment. METHODS Subject-matter experts (SMEs) performed a literature review to create an initial procedural step list. Eleven clinical cESD SMEs and four educational SMEs formed a 'cESD Working Group' to develop consensus regarding steps. Through a two-stage modified Delphi process, a consensus on a comprehensive standard cESD deconstructed task list was reached. The aim was to standardize cESD teaching to efficiently bring a novice to safe performance. RESULTS A literature review identified eight initial cESD steps. First-round Delphi consensus was gained on seven steps. Semi-structured focus group discussions resulted in consensus on a modified version of 7 of the initial steps, with addition of two steps. Consensus on procedural actions needed to perform each step was achieved after the hands-on laboratory. The final result was a ten-step deconstructed task list for standard cESD. CONCLUSION The development of a standardized cESD procedural task list provides a foundation to safely and efficiently teach cESD to practicing endoscopists. This list can be used to develop a training pathway to increase procedural adoption. Selected patients currently undergoing colonic resections could benefit from increased adoption of cESD.
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Affiliation(s)
- Karen J Dickinson
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA. .,Department of Surgery, Houston Methodist Hospital, Houston, USA.
| | - Brian J Dunkin
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
| | - John J Nguyen-Lee
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
| | - Aman B Ali
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
| | - Stephanie Zajac
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
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17
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Jang SR, Truong H, Oh A, Choi J, Tramontano AC, Laszkowska M, Hur C. Cost-effectiveness Evaluation of Targeted Surgical and Endoscopic Therapies for Early Colorectal Adenocarcinoma Based on Biomarker Profiles. JAMA Netw Open 2020; 3:e1919963. [PMID: 32150269 PMCID: PMC7063501 DOI: 10.1001/jamanetworkopen.2019.19963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States. The prognosis for patients with CRC varies widely, but new prognostic biomarkers provide the opportunity to implement a more individualized approach to treatment selection. OBJECTIVE To assess the cost-effectiveness of 3 therapeutic strategies, namely, endoscopic therapy (ET), laparoscopic colectomy (LC), and open colectomy (OC), for patients with T1 CRC with biomarker profiles that prognosticate varying levels of tumor progression in the US payer perspective. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation study, a Markov model was developed for the cost-effectiveness analysis. Risks of all-cause mortality and recurrent cancer after ET, LC, or OC were estimated with a 35-year time horizon. Quality of life was based on EuroQoL 5 Dimensions scores reported in the published literature. Hospital and treatment costs reflected Medicare reimbursement rates. Deterministic and probabilistic sensitivity analyses were performed. Data from patients with T1 CRC and 6 biomarker profiles that included adenomatous polyposis coli (APC), TP53 and/or KRAS, or BRAFV600E were used as inputs for the model. Data analyses were conducted from February 27, 2019, to May 13, 2019. EXPOSURES Endoscopic therapy, LC, and OC. MAIN OUTCOMES AND MEASURES The primary outcomes were unadjusted life-years, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) between competing treatment strategies. RESULTS Endoscopic therapy had the highest QALYs and the lowest cost and was the dominant treatment strategy for T1 CRC with the following biomarker profiles: BRAFV600E, APC(1)/KRAS/TP53, APC(2) or APC(2)/KRAS or APC(2)/TP53, or APC(1) or APC(1)/KRAS or APC(1)/TP53. The QALYs gained ranged from 16.97 to 17.22, with costs between $68 902.75 and $77 784.53 in these subgroups. For the 2 more aggressive biomarker profiles with worse prognoses (APC(2)/KRAS/TP53 and APCwt [wild type]), LC was the most effective strategy (with 16.45 and 16.61 QALYs gained, respectively) but was not cost-effective. Laparoscopic colectomy cost $65 234.87 for APC(2)/KRAS/TP53 and $71 250.56 for APCwt, resulting in ICERs of $113 290 per QALY and $178 765 per QALY, respectively. CONCLUSIONS AND RELEVANCE This modeling analysis found that ET was the most effective strategy for patients with T1 CRC with less aggressive biomarker profiles. For patients with more aggressive profiles, LC was more effective but was costly, rendering ET the cost-effective option. This study highlights the potential utility of prognostic biomarkers in T1 CRC treatment selection.
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Affiliation(s)
- Se Ryeong Jang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- now with College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Han Truong
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Aaron Oh
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jin Choi
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Monika Laszkowska
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
| | - Chin Hur
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
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Lee JK, Kidambi TD, Kaltenbach T, Bhat YM, Shergill A, McQuaid KR, Terdiman JP, Soetikno RM. Impact of observational training on endoscopic mucosal resection outcomes and competency for large colorectal polyps: single endoscopist experience. Endosc Int Open 2020; 8:E346-E353. [PMID: 32140557 PMCID: PMC7055616 DOI: 10.1055/a-1107-2711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is standard treatment for large colorectal polyps. However, it is a specialized technique with limited data on the effectiveness of training methods to acquire this skill. The aim of this study was to evaluate the impact of observational training on EMR outcomes and competency in an early-stage endoscopist. Patients and methods A single endoscopist completed comprehensive EMR training, which included knowledge acquisition and direct observation of EMR cases, and proctored supervision, during the third year of gastroenterology fellowship. After training, EMR was independently attempted on 142 consecutive, large (i. e., ≥ 20 mm), non-pedunculated colorectal polyps between July 2014 and December 2017 (mean age 61.7 years; mean polyp size 30.4 mm; en-bloc resection 55 %). Surveillance colonoscopy for evaluation of residual neoplasia was available for 86 % of the cases. Three primary outcomes were evaluated: endoscopic assessment of complete resection, rate of adverse events (AEs), and rate of residual neoplasia on surveillance colonoscopy. Results Complete endoscopic resection was achieved in 93 % of cases, the rates of AEs and residual neoplasia were 7.8 % and 7.3 %, respectively. The rate of complete resection remained stable (at 85 % or greater) with increasing experience while rates of AEs and residual neoplasia peaked and decreased after 60 cases. Conclusions An early-stage endoscopist can acquire the skills to perform effective EMR after completing observational training. At least 60 independent EMRs for large colorectal polyps were required to achieve a plateau for clinically meaningful outcomes.
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Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, United States,Kaiser Permanente Division of Research, Oakland, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Trilokesh D. Kidambi
- Division of Gastroenterology, City of Hope National Medical Center, Duarte, California, United States
| | - Tonya Kaltenbach
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Yasser M. Bhat
- Division of Gastroenterology, Palo Alto Medical Foundation, Palo Alto, California, United States
| | - Amandeep Shergill
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Kenneth R. McQuaid
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Jonathan P. Terdiman
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Roy M. Soetikno
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Advanced Gastrointestinal Endoscopy, Mountain View, California, United States
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Abstract
BACKGROUND There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment. OBJECTIVE We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions. DESIGN This was a retrospective study. SETTING The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer. PATIENTS A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported. RESULTS After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up. LIMITATIONS This was a retrospective study from a tertiary referral unit. CONCLUSIONS Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.
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Stasinos I, Toyonaga T, Suzuki N. Double-tunneling butterfly method for endoscopic submucosal dissection of extensive rectal neoplasms. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2020; 5:80-85. [PMID: 32051917 PMCID: PMC7004922 DOI: 10.1016/j.vgie.2019.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is the preferred technique for en bloc resection of superficial colorectal neoplasms. Resection of extensive lesions with ESD can be challenging, owing to loss of orientation in the submucosal space. In this case series, we describe the double-tunneling (DoT) butterfly method for ESD of extensive rectal neoplasms. METHODS The key feature of the DoT butterfly method is the creation of 2 tunnels that are transformed into bilateral flaps, leaving a submucosal septum between them. RESULTS Four rectal neoplasms measuring (maximum diameter) 7 cm, 8 cm, 9 cm, and 18 cm, respectively, were resected in 4 patients by use of the DoT butterfly method. The lesions included recurrent adenoma (n = 1) and dysplasia (n = 1) in longstanding ulcerative colitis. Curative R0 resection was confirmed in all 4 cases. Histologic examination showed tubular adenomas with low-grade dysplasia in 1 of 4 patients and focal high-grade dysplasia in 3 of 4 patients. One patient experienced postprocedural bleeding that required endoscopic reintervention. CONCLUSION The DoT butterfly method appears to be useful for the resection of extensive rectal neoplasms. A prospective study is required to assess whether these results can be reproduced in a large cohort of patients.
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Affiliation(s)
- Ioannis Stasinos
- The Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | | | - Noriko Suzuki
- The Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
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21
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Iqbal S, Ali A, Razzaq A, Shahzad E. Lack of proper reimbursement is hampering adoption of minimally invasive gastrointestinal endoscopy in North America. World J Gastrointest Endosc 2020; 12:49-52. [PMID: 31942234 PMCID: PMC6939120 DOI: 10.4253/wjge.v12.i1.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/18/2019] [Accepted: 11/05/2019] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) and related procedures are minimally invasive and cost-effective alternates to surgery. However, there is no approved or listed current procedural terminology (CPT) for ESD. We aimed to review the current reimbursement process hurdles for ESD procedures in private practice model in United States. We reviewed the data of two advanced endoscopists (one in New York and other in Pennsylvania State) performing ESD in their private practice set-ups. We found the reimbursement process was complex, with number of refusals varied from 0-9 for ESD procedures. It was not paid at all in 8.3% of cases by the medical insurance. Endoscopic mucosal resection, which is considered inferior as compared to ESD, but has a listed CPT, was denied in only 0.83% cases. Our data highlights the billing hurdles by the endoscopists to adopt ESD-related procedures in private practice model.
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Affiliation(s)
- Shahzad Iqbal
- Department of Gastroenterology, Good Samaritan Hospital, West Islip, NY 11795, United States
| | - Aman Ali
- Department of Gastroenterology, Lancaster General Hospital, Lancaster, PA 17602, United States
| | - Arham Razzaq
- Herricks High School, New Hyde Park, NY 11040, United States
| | - Eman Shahzad
- Herricks High School, New Hyde Park, NY 11040, United States
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22
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What can colonoscopists do now to move management of large benign laterally spreading lesions in the colorectum from surgery to EMR? Gastrointest Endosc 2020; 91:132-134. [PMID: 31865987 DOI: 10.1016/j.gie.2019.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/21/2019] [Indexed: 01/04/2023]
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Rex DK. Response. Gastrointest Endosc 2019; 90:997-998. [PMID: 31759425 DOI: 10.1016/j.gie.2019.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/24/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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24
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Asokkumar R, Malvar C, Nguyen-Vu T, Sanduleanu S, Kaltenbach T, Soetikno R. Endoscopic Assessment of the Malignant Potential of the Nonpolypoid (Flat and Depressed) Colorectal Neoplasms: Thinking Fast, and Slow. Gastrointest Endosc Clin N Am 2019; 29:613-628. [PMID: 31445686 DOI: 10.1016/j.giec.2019.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Current endoscopy training methodology does not meet the learning traits, skills, and needs of the newer generation of gastroenterologists. This article provides information on assessment of the malignant potential of colorectal neoplasms. It takes a modern approach on the topic and integrates relevant information that aligns with the thinking process. The theory of thinking fast (reflex) and slow (rational) is used. By doing so, it is hoped that the learning process can be expedited and practiced immediately. The focus is on preresection assessment of nonpolypoid colorectal neoplasms. Assessment of polypoid, sessile-serrated adenoma/polyp, or inflammatory bowel disease dysplasia is briefly discussed.
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Affiliation(s)
- Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, 1 Hospital Drive, Singapore 169608, Singapore
| | - Carmel Malvar
- Department of Gastroenterology, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Medicine, University of California, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Tiffany Nguyen-Vu
- Department of Gastroenterology, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Medicine, University of California, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Silvia Sanduleanu
- Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, P. Debyelaan 25, Maastricht 6229 HX, The Netherlands
| | - Tonya Kaltenbach
- Department of Gastroenterology, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Medicine, University of California, 500 Parnassus Avenue, San Francisco, CA 94143, USA; Advanced Gastrointestinal Endoscopy, Mountain View, CA, USA
| | - Roy Soetikno
- Advanced Gastrointestinal Endoscopy, Mountain View, CA, USA; University of Indonesia, Kampus Baru UI Depok, Jawa Barat, Jakarta 16424, Indonesia.
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25
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Rex DK, Shaukat A, Wallace MB. Optimal Management of Malignant Polyps, From Endoscopic Assessment and Resection to Decisions About Surgery. Clin Gastroenterol Hepatol 2019; 17:1428-1437. [PMID: 30268567 DOI: 10.1016/j.cgh.2018.09.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/28/2018] [Accepted: 09/16/2018] [Indexed: 02/06/2023]
Abstract
Colorectal cancer is defined clinically as invasion of dysplastic cells into the submucosa. Lesions with submucosal invasion but without invasion into the muscularis propria are generally called malignant polyps. A stepwise approach produces optimal management of malignant polyps (including polypoid and flat/depressed lesions). The first step is to avoid endoscopic resection of non-pedunculated lesions with endoscopic features that predict deep submucosal invasion. Lesions without such features are candidates for endoscopic resection. The second step is to assess candidates for endoscopic resection for features that predict an increased risk of superficial submucosal invasion. Such lesions should be considered for en bloc endoscopic excision if feasible. The third step is giving patients with endoscopically resected malignant polyps good advice regarding whether to undergo adjuvant therapy, usually surgery. We review the endoscopic and histologic criteria that guide clinicians through these steps.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Jacksonville, Florida
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Development and clinical outcomes of an endoscopic submucosal dissection fellowship program: early united states experience. Surg Endosc 2019; 34:829-838. [DOI: 10.1007/s00464-019-06836-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/15/2019] [Indexed: 02/06/2023]
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Emmanuel A, Ghosh A, Lapa C, Gulati S, Burt M, Hayee B, Haji A. Endoscopic resection of colorectal circumferential and near-circumferential laterally spreading lesions: outcomes and risk of stenosis. Int J Colorectal Dis 2019; 34:829-836. [PMID: 30783739 DOI: 10.1007/s00384-019-03254-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Almost any colorectal superficial neoplastic lesion can be treated by endoscopic resection (ER) but very little is known about outcomes of ER leaving circumferential or near-circumferential mucosal defects. We report the outcomes of ER leaving ≥ 75% circumferential mucosal defects performed in a western expert centre. METHODS Five hundred eighty-seven ERs of large colorectal lesions ≥ 20 mm were grouped according to the extent of the mucosal defect and comparisons made between those with < 75% and ≥ 75% defects. Independent predictors of stenosis were identified. RESULTS Forty-seven patients had ER leaving ≥ 75% circumference defect, most located at or distal to the rectosigmoid, with ≥ 90% defects in 5 and 100% in 11. There were no significant colonic muscle injuries in patients with ≥ 75% defect and no differences in post-procedure bleeding (OR 1.6, 95% CI 0.2-13.7, p = 0.64) between patients with ≥ 75% and < 75% defects. Stenosis developed in 9 patients. ≥ 90% circumference defect was the only independent risk factor for stenosis (OR 286, p < 0.001). Three of 4 patients with asymptomatic stenosis had successful expectant management. The remainder were treated with dilatation. Recurrence was more likely in those with ≥ 75% defect (OR 7.9, 95% CI 3.8-16.4, p < 0.001) but was managed with further ER in all but 2 cases. CONCLUSION ER of colorectal lesions resulting in defects ≥ 75% of the luminal circumference is challenging but safe and effective when performed in an expert centre. The only independent predictor of stenosis is ≥ 90% circumference defect but some patients improve with expectant management; therefore, pre-emptive intervention may not be warranted.
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Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK.,King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Anil Ghosh
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Christo Lapa
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Shraddha Gulati
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Margaret Burt
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK.,King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Bu'Hussain Hayee
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK. .,King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK.
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Li JW, Ang TL, Wang LM, Kwek ABE, Tan MTK, Fock KM, Teo EK. Endoscopic submucosal dissection of colorectal neoplasms: an audit of its safety and efficacy in a single tertiary centre in Singapore. Singapore Med J 2019; 60:526-531. [PMID: 30773601 DOI: 10.11622/smedj.2019022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) provides a higher en bloc and R0 resection rate than endoscopic mucosal resection. Colorectal ESD is not widely used because of its technical difficulty and risk of complications, especially for right-sided colonic lesions. We audited the clinical outcomes of our initial experience with colorectal ESD. METHODS We reviewed data collected from a prospective registry of patients who underwent colorectal ESD from December 2014 to March 2018. Therapeutic outcomes and procedure-related complications were analysed. RESULTS A total of 41 patients (mean age 67.4 years, 21 male) underwent colorectal ESD. The distribution of the lesions was as follows: rectum (n = 9), sigmoid colon (n = 8), descending colon (n = 6), splenic flexure (n = 1), transverse colon (n = 5), ascending colon (n = 8) and caecum (n = 4). The mean size was 23 (range 12-50) mm. En bloc resection was achieved in 35 (85.4%) out of 41 patients, and R0 resection or clear resection margins was achieved in 33 (94.3%) of the en bloc resection patients. The lesion was upstaged in 14 (34.1%) patients after ESD. Colonic perforation occurred in 3 (7.3%) patients during ESD and was successfully treated with endoscopic clips. There was no procedure-related bleeding. No patient required surgery for management of complications. The median duration of hospitalisation was 1 (range 0-7) day. Four patients with lesions that were upstaged after ESD, from high-grade dysplasia to intramucosal carcinoma with deep submucosal invasion, were referred for colectomy. CONCLUSION Our early outcome data was comparable to that from large published series. ESD is an effective and feasible treatment for colorectal lesions.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Lai Mun Wang
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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29
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Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience. Surg Endosc 2019; 33:4016-4025. [DOI: 10.1007/s00464-019-06691-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 01/30/2019] [Indexed: 12/11/2022]
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30
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Ge PS, Thompson CC, Jirapinyo P, Aihara H. Response. Gastrointest Endosc 2019; 89:445-446. [PMID: 30665540 DOI: 10.1016/j.gie.2018.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Phillip S Ge
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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31
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Backes Y, Schwartz MP, Ter Borg F, Wolfhagen FHJ, Groen JN, de Vos Tot Nederveen Cappel WH, van Bergeijk J, Geesing JMJ, Spanier BWM, Didden P, Vleggaar FP, Lacle MM, Elias SG, Moons LMG. Multicentre prospective evaluation of real-time optical diagnosis of T1 colorectal cancer in large non-pedunculated colorectal polyps using narrow band imaging (the OPTICAL study). Gut 2019; 68:271-279. [PMID: 29298873 DOI: 10.1136/gutjnl-2017-314723] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study evaluated the preresection accuracy of optical diagnosis of T1 colorectal cancer (CRC) in large non-pedunculated colorectal polyps (LNPCPs). DESIGN In this multicentre prospective study, endoscopists predicted the histology during colonoscopy in consecutive patients with LNPCPs using a standardised procedure for optical assessment. The presence of morphological features assessed with white light, and vascular and surface pattern with narrow-band imaging (NBI) were recorded, together with the optical diagnosis, the confidence level of prediction and the recommended treatment. A risk score chart was developed and validated using a multivariable mixed effects binary logistic least absolute shrinkage and selection (LASSO) model. RESULTS Among 343 LNPCPs, 47 cancers were found (36 T1 CRCs and 11 ≥T2 CRCs), of which 11 T1 CRCs were superficial invasive T1 CRCs (23.4% of all malignant polyps). Sensitivity and specificity for optical diagnosis of T1 CRC were 78.7% (95% CI 64.3 to 89.3) and 94.2% (95% CI 90.9 to 96.6), and 63.3% (95% CI 43.9 to 80.1) and 99.0% (95% CI 97.1 to 100.0) for optical diagnosis of endoscopically unresectable lesions (ie, ≥T1 CRC with deep invasion), respectively. A LASSO-derived model using white light and NBI features discriminated T1 CRCs from non-invasive polyps with a cross-validation area under the curve (AUC) of 0.85 (95% CI 0.80 to 0.90). This model was validated in a temporal validation set of 100 LNPCPs (AUC of 0.81; 95% CI 0.66 to 0.96). CONCLUSION Our study provides insights in the preresection accuracy of optical diagnosis of T1 CRC. Sensitivity is still limited, so further studies will show how the risk score chart could be improved and finally used for clinical decision making with regard to the type of endoresection to be used and whether to proceed to surgery instead of endoscopy. TRIAL REGISTRATION NUMBER NTR5561.
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Affiliation(s)
- Yara Backes
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - John N Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | | | - Jeroen van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | - Bernhard W M Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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32
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Ali S, Hawes RH, Kadkhodayan K, Rafiq E, Navaneethan U, Bang JY, Varadarajulu S, Hasan MK. Utility of rapid onsite evaluation of touch imprint cytology from endoscopic and cholangioscopic forceps biopsy sampling (with video). Gastrointest Endosc 2019; 89:340-344. [PMID: 30193904 DOI: 10.1016/j.gie.2018.08.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 08/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Rapid onsite evaluation of touch imprint cytology (ROSE-TIC) is a simple and rapid method used for the diagnosis of benign and malignant lesions. We evaluated the diagnostic accuracy of ROSE-TIC for advanced intestinal luminal and indeterminate pancreatobiliary lesions during endoscopy. METHODS This is a retrospective descriptive study of patients who underwent endoscopy or ERCP between January 1, 2014 and December 31, 2016. It included patients who were referred for the treatment of intestinal luminal lesions or evaluation of indeterminate pancreatobiliary lesions. The slides were prepared by gently touching the specimen onto a glass slide and were examined under the microscope. The main outcome measure was to determine the diagnostic accuracy of ROSE-TIC by comparing the onsite cytology findings with the corresponding off-site histologic diagnosis. RESULTS All 222 patients (106 pancreatobiliary and 116 GI lesions) had a prior benign diagnosis of intestinal luminal lesions or indeterminate diagnosis of pancreatobiliary lesions. The overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ROSE-TIC were 97%, 85%, 83%, 97.2%, and 90%, respectively. The accuracy varied with the site of the biopsy sample. The accuracy was lowest for upper GI tract, where it was 85.2% but was 95% for lower GI tract lesions. CONCLUSIONS By establishing a rapid onsite diagnosis, ROSE-TIC expedites decision-making on patient management. Prospective studies are needed to confirm these preliminary findings.
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Affiliation(s)
- Saeed Ali
- Department of Internal Medicine, Florida Hospital, Orlando, Florida, USA
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Kambiz Kadkhodayan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Ehsan Rafiq
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | | | - Ji Y Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Baldaque-Silva F, Marques M, Andrade AP, Sousa N, Lopes J, Carneiro F, Macedo G. Endoscopic submucosal dissection of gastrointestinal lesions on an outpatient basis. United European Gastroenterol J 2019; 7:326-334. [PMID: 31080617 DOI: 10.1177/2050640618823874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Endoscopic submucosal dissection (ESD) is usually associated with hospital admission. Objectives To evaluate, prospectively, the feasibility, safety and efficacy of outpatient gastrointestinal ESD. Methods Patients with suitable lesions were invited to participate. Those that dwelt more than 1 hour from the hospital, lived alone, had severe co-morbidities, were <18 years old, had duodenal lesions, or that had ESD-related complications were admitted. The remaining patients were discharged if no complications were detected. A patients' inquiry was performed. Results Of the 164 ESD patients, 122 were outpatient-based, corresponding to 115 patients, 47% male and mean age 63 ± 12 years-old. Outpatients tended to be younger, female, to have gastric lesions, less advanced lesions, and shorter and less complicated ESDs (all p < 0.05). Outpatients' mean tumour size was 38 mm, en bloc and R0 resection rates were 88 and 78%, respectively. Seven ESD outpatients (5.7%) had complications: delayed bleeding (n = 4), pneumonitis (n = 2) or emphysema (n = 1), all managed conservatively. Colorectal location of the lesions was predictive of hospital admission (p = 0.03). In total, 97% of patients were satisfied with the outpatient strategy. Conclusion Risks of ambulatory ESD are low and complications can be successfully managed. This strategy has high patient satisfaction. More studies are needed to evaluate its implications on costs and patients' management.
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Affiliation(s)
- Francisco Baldaque-Silva
- Department of Digestive Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | - Margarida Marques
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | | | - Nuno Sousa
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Joanne Lopes
- Department of Pathology, São João University Hospital, Porto, Portugal
| | - Fatima Carneiro
- Department of Pathology, São João University Hospital, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
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Suture pulley countertraction method reduces procedure time and technical demand of endoscopic submucosal dissection among novice endoscopists learning endoscopic submucosal dissection: a prospective randomized ex vivo study. Gastrointest Endosc 2019; 89:177-184. [PMID: 30148993 DOI: 10.1016/j.gie.2018.08.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The lack of reliable countertraction in endoscopic submucosal dissection (ESD) contributes to its technical demand and increased procedure time. We aimed to prospectively evaluate the efficacy of the suture pulley countertraction method in endoscopists new to both suturing and ESD. METHODS Two 30-mm circular lesions were created in an ex vivo porcine stomach model. Endoscopists considered novices for both endoscopic suturing and ESD were randomized to either traditional or suture pulley ESD first and performed ESD using each technique. Procedure time was recorded including time of circumferential incision, suture pulley placement, and submucosal dissection. After completion of each ESD, participants graded the difficulty of the procedure using the National Aeronautical and Space Administration (NASA) Task Load Index. RESULTS Thirteen participants (8 fellows, 5 attendings) completed the study using both methods. Mean total procedure time was shorter using suture pulley ESD compared with traditional ESD (26.7 ± 7.3 vs 59.4 ± 20.4 minutes, P < .001). The suture pulley required a mean 6.2 ± 2.1 minutes to place. Submucosal dissection time was shorter using suture pulley ESD compared with traditional ESD (8.4 ± 2.9 vs 47.2 ± 16.3 minutes, P < .001). All 7 individual indices and total score on the NASA Task Load Index were significantly improved using the suture pulley ESD method (P < .001). CONCLUSIONS The suture pulley countertraction method significantly decreases procedure time and technical demand of ESD among endoscopists at all skill levels who are new to ESD. The results of this study have potential implications for ESD training in the United States.
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Friedel D, Stavropoulos SN. Introduction of endoscopic submucosal dissection in the West. World J Gastrointest Endosc 2018; 10:225-238. [PMID: 30364783 PMCID: PMC6198314 DOI: 10.4253/wjge.v10.i10.225] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/21/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is well established in Asia as a modality for selected advanced lesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence (e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.
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Affiliation(s)
- David Friedel
- Gastroenterology, NYU Winthrop Hospital, Mineola, NY 11501, United States
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36
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Fuccio L, Repici A, Hassan C, Ponchon T, Bhandari P, Jover R, Triantafyllou K, Mandolesi D, Frazzoni L, Bellisario C, Bazzoli F, Sharma P, Rösch T, Rex DK. Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. Gut 2018; 67:1464-1474. [PMID: 29208675 DOI: 10.1136/gutjnl-2017-315103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 µm or less than one-third of the submucosa) on colorectal lesions removed by ESD. DESIGN A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions. RESULTS 51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2%; 95% CI 78.8% to 85.3%) were adenomas (low- and high-grade dysplasia, 26.8% and 55.4%, respectively). Overall, 15.7% were submucosal cancers, but only slightly more than half (8.0%; 95% CI 6.1% to 10.3%) had an infiltration depth of ≤1000 µm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3% (95% CI 52.2% to 89.4%) for malignant lesions, the prevalence of curative resection lowered to 6% (95% CI 4.2% to 7.2%) with an NNT of 16.7. CONCLUSION The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.
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Affiliation(s)
- Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research and University Hospital, Rozzano, Italy
| | | | - Thierry Ponchon
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | | | - Rodrigo Jover
- Service of Digestive Medicine, Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain
| | - Konstantinos Triantafyllou
- Ηepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Daniele Mandolesi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology (CPO), University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Prateek Sharma
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas, Missouri, USA.,Department of Gastroenterology, Veteran Affairs Medical Center, Kansas, Missouri, USA
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
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37
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Repici A, Hassan C. Postsurgery risk for nonmalignant colorectal polyps: the ultimate call. Gastrointest Endosc 2018; 87:251-253. [PMID: 29241853 DOI: 10.1016/j.gie.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 02/08/2023]
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38
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Colorectal endoscopic submucosal dissection (ESD). Best Pract Res Clin Gastroenterol 2017; 31:473-480. [PMID: 28842057 DOI: 10.1016/j.bpg.2017.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/29/2017] [Accepted: 07/05/2017] [Indexed: 02/06/2023]
Abstract
Endoscopic submucosal dissection (ESD) is an interventional procedure for en-bloc resection of gastrointestinal lesions. ESD is a challenging and can involve a reasonable degree of risk, therefore case selection is of crucial importance, especially in the colo-rectum. This procedure should be mainly used for dissection of lesions when there is a high suspicion of superficial malignant invasion; several classifications have been proposed in order to better identify lesions suitable for ESD. However, case selection is still an issue, since only about 8-10% of dissected lesions are superficially invading cancer and most of cases involve benign or massively invading cancer. In addition, significant differences have been reported between Asian and Western countries in regard to main outcomes, and therefore measures should be adopted as soon as possible to reduce this discrepancy.
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