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Gordon SR, Eichenwald LS, Systrom HK. Endoscopic techniques for management of large colorectal polyps, strictures and leaks. Surg Open Sci 2024; 20:156-168. [PMID: 39100384 PMCID: PMC11296069 DOI: 10.1016/j.sopen.2024.06.012] [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: 03/17/2024] [Revised: 06/17/2024] [Accepted: 06/29/2024] [Indexed: 08/06/2024] Open
Abstract
The implementation of screening colonoscopy with polyp removal has significantly decreased mortality rates associated with colorectal cancer (CRC), although it remains a major cause of cancer-related deaths globally. CRC typically originates from adenomatous polyps, and increased removal of these growths has led to reduced CRC incidence and mortality. Endoscopic polypectomy techniques, including hot and cold snare polypectomy, play a pivotal role in this process. While both methods are effective for small polyps (<10 mm), recent evidence favors cold snare polypectomy due to its superior safety profile and comparable complete resection rates. Large polyps (>10 mm), particularly those with advanced features, pose increased cancer risks and often require meticulous assessment and advanced endoscopic techniques, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for resection. This chapter also provides a practical overview of endoscopic techniques for managing colonic obstructions and pericolonic fluid collections, detailing their indications, advantages, disadvantages, and complications. The goal is to improve understanding and application in clinical practice. Additionally, we provide a summary of endoscopic closure techniques that have revolutionized the management of perforations and fistulas, offering safe and effective alternatives to surgery.
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Affiliation(s)
- Stuart R. Gordon
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, NH, Lebanon
| | - Lauren S. Eichenwald
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, NH, Lebanon
| | - Hannah K. Systrom
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, NH, Lebanon
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2
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Walia A, Trasolini RP, Shahidi N. Double-nylon purse-string suture technique: Another addition to the endoscopist's toolbox for full-thickness defect closure. World J Gastroenterol 2024; 30:3152-3154. [PMID: 39006385 PMCID: PMC11238673 DOI: 10.3748/wjg.v30.i25.3152] [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: 03/30/2024] [Revised: 05/23/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024] Open
Abstract
Iatrogenic perforation is the most feared adverse event in endoscopy. With the expansion of interventional endoscopy in favor of traditional surgery, it is now more crucial than ever to develop effective defect closure techniques. This has culminated in the dissemination of multiple novel closure technologies, including through-the-scope clips, over-the-scope clips, through-the-scope suturing and over-the-scope suturing devices. In this editorial, we comment on the recent publication by Wang and colleagues discussing the performance of the double-nylon purse-string suture technique in the closure of large (> 3 cm) gastric full-thickness defects. This technique offers a promising, practical and cost-effective approach to closure of large full-thickness defects that can be readily implemented across diverse healthcare settings.
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Affiliation(s)
- Angad Walia
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, BC, Canada
| | | | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, BC, Canada
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Mandarino FV, Danese S, Uraoka T, Parra-Blanco A, Maeda Y, Saito Y, Kudo SE, Bourke MJ, Iacucci M. Precision endoscopy in colorectal polyps' characterization and planning of endoscopic therapy. Dig Endosc 2024; 36:761-777. [PMID: 37988279 DOI: 10.1111/den.14727] [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: 08/25/2023] [Accepted: 11/19/2023] [Indexed: 11/23/2023]
Abstract
Precision endoscopy in the management of colorectal polyps and early colorectal cancer has emerged as the standard of care. It includes optical characterization of polyps and estimation of submucosal invasion depth of large nonpedunculated colorectal polyps to select the appropriate endoscopic resection modality. Over time, several imaging modalities have been implemented in endoscopic practice to improve optical performance. Among these, image-enhanced endoscopy systems and magnification endoscopy represent now well-established tools. New advanced technologies, such as endocytoscopy and confocal laser endomicroscopy, have recently shown promising results in predicting the histology of colorectal polyps. In recent years, artificial intelligence has continued to enhance endoscopic performance in the characterization of colorectal polyps, overcoming the limitations of other imaging modes. In this review we retrace the path of precision endoscopy, analyzing the yield of various endoscopic imaging techniques in personalizing management of colorectal polyps and early colorectal cancer.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Hospital IRCSS, Milan, Italy
- Department of Gastrointestinal Endoscopy, Westmead Hospital, Sydney, NSW, Australia
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Hospital IRCSS, Milan, Italy
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gumma, Japan
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Yasuharu Maeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Michael J Bourke
- Department of Gastrointestinal Endoscopy, Westmead Hospital, Sydney, NSW, Australia
| | - Marietta Iacucci
- Department of Gastroenterology, University College Cork, Cork, Ireland
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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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Cronin O, Bourke MJ. Endoscopic Management of Large Non-Pedunculated Colorectal Polyps. Cancers (Basel) 2023; 15:3805. [PMID: 37568621 PMCID: PMC10417738 DOI: 10.3390/cancers15153805] [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: 06/13/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Large non-pedunculated colorectal polyps ≥20 mm (LNPCPs) comprise approximately 1% of all colorectal polyps. LNPCPs more commonly contain high-grade dysplasia, covert and overt cancer. These lesions can be resected using several means, including conventional endoscopic mucosal resection (EMR), cold-snare EMR (C-EMR) and endoscopic submucosal dissection (ESD). This review aimed to provide a comprehensive, critical and objective analysis of ER techniques. Evidence-based, selective resection algorithms should be used when choosing the most appropriate technique to ensure the safe and effective removal of LNPCPs. Due to its enhanced safety and comparable efficacy, there has been a paradigm shift towards cold-snare polypectomy (CSP) for the removal of small polyps (<10 mm). This technique is now being applied to the management of LNPCPs; however, further research is required to define the optimal LNPCP subtypes to target and the viable upper size limit. Adjuvant techniques, such as thermal ablation of the resection margin, significantly reduce recurrence risk. Bleeding risk can be mitigated using through-the-scope clips to close defects in the right colon. Endoscopic surveillance is important to detect recurrence and synchronous lesions. Recurrence can be readily managed using an endoscopic approach.
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Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
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A Rectum-Specific Selective Resection Algorithm Optimizes Oncologic Outcomes for Large Nonpedunculated Rectal Polyps. Clin Gastroenterol Hepatol 2023; 21:72-80.e2. [PMID: 35526795 DOI: 10.1016/j.cgh.2022.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are complementary techniques for large (≥20 mm) nonpedunculated rectal polyps (LNPRPs). A mechanism for appropriate technique selection has not been described. METHODS We evaluated the performance of a selective resection algorithm (SRA) (August 2017 to April 2021) compared with a universal EMR algorithm (UEA) (July 2008 to July 2017) for LNPRPs within a prospective observational study. In the SRA, LNPRPs with features of superficial submucosal invasive cancer (SMIC) (<1000 μm; Kudo pit pattern Vi), or with an increased risk of SMIC (Paris 0-Is or 0-IIa+Is nongranular, 0-IIa+Is granular with a dominant nodule ≥10 mm) underwent ESD. The remaining LNPRPs underwent EMR. Algorithm performance was evaluated by SMIC identified after EMR, curative oncologic resection (R0 resection, superficial SMIC, absence of negative histologic features), technical success, adverse events, and recurrence at first surveillance colonoscopy. RESULTS A total of 480 LNPRPs were evaluated (290 UEA, 190 SRA). Median lesion size was 40 (interquartile range, 30-60) mm. SMIC was identified in 56 (11.7%) LNPRPs. Significant differences in SMIC after EMR (SRA 1 [1.0%] vs UEA 35 [12.1%]; P = .001) and curative oncologic resection (SRA n = 7 [33.3%] vs UEA n = 2 [5.7%]; P = .010) were identified. No significant differences in technical success or adverse events were identified (all P > .137). Among LNPRPs with SMIC amenable to curative oncologic resection and which underwent ESD, 100% (n = 7 of 7) were cured. CONCLUSIONS A rectum-specific SRA optimizes oncologic outcomes for LNPRPs and mitigates the risk of piecemeal resection of cancers.
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Ebigbo A, Mendel R, Scheppach MW, Probst A, Shahidi N, Prinz F, Fleischmann C, Römmele C, Goelder SK, Braun G, Rauber D, Rueckert T, de Souza LA, Papa J, Byrne M, Palm C, Messmann H. Vessel and tissue recognition during third-space endoscopy using a deep learning algorithm. Gut 2022; 71:2388-2390. [PMID: 36109151 PMCID: PMC9664130 DOI: 10.1136/gutjnl-2021-326470] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/29/2022] [Indexed: 01/26/2023]
Abstract
In this study, we aimed to develop an artificial intelligence clinical decision support solution to mitigate operator-dependent limitations during complex endoscopic procedures such as endoscopic submucosal dissection and peroral endoscopic myotomy, for example, bleeding and perforation. A DeepLabv3-based model was trained to delineate vessels, tissue structures and instruments on endoscopic still images from such procedures. The mean cross-validated Intersection over Union and Dice Score were 63% and 76%, respectively. Applied to standardised video clips from third-space endoscopic procedures, the algorithm showed a mean vessel detection rate of 85% with a false-positive rate of 0.75/min. These performance statistics suggest a potential clinical benefit for procedure safety, time and also training.
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Affiliation(s)
- Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Robert Mendel
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Markus W Scheppach
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Friederike Prinz
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Carola Fleischmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Christoph Römmele
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Georg Braun
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - David Rauber
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Tobias Rueckert
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Luis A de Souza
- Department of Computing, Federal University of São Carlos, São Carlos, Brazil
| | - Joao Papa
- Department of Computing, São Paulo State University, Botucatu, Brazil
| | - Michael Byrne
- Vancouver General Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Christoph Palm
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
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Shahidi N, Rex DK. Defining Conventional Endoscopic Mucosal Resection in 2021: A Burning Issue. Gastroenterology 2022; 162:1776-1777. [PMID: 34499914 DOI: 10.1053/j.gastro.2021.09.008] [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: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Neal Shahidi
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana
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