ESD versus EMR in non-ampullary superficial duodenal tumors: a systematic review and meta-analysis

Outcomes of endoscopic submucosal dissection in cirrhotic patients: First American cohort

BACKGROUND

Among patients with cirrhosis and pre-malignant or early malignant mucosal lesions, surgical intervention carries a much higher bleeding risk. When such lesions are discovered, endoscopic submucosal dissection (ESD) may offer curative therapy with lower risks than surgery and improved outcomes compared to traditional endoscopic resection.

AIM

To evaluate the outcomes of ESD in patients with cirrhosis.

METHODS

Patients with cirrhosis undergoing ESD between July 2015 and August 2022 were retrospectively matched in 1:2 fashion to controls based on lesion location, size, and anticoagulation use. Procedural outcomes were compared between groups.

RESULTS

A total of 64 Lesions from 59 patients were included (16 cirrhosis, 43 control). There were no differences in patient or lesion characteristics between groups. En bloc and curative resection was achieved in 84.21%, 78.94% of the cirrhosis group and 88.89%, 68.89% of controls, respectively, with no significant differences. Cirrhotic patients had significantly higher rates of intra-procedural coagulation grasper use for control of bleeding (47.37% vs 20%; P = 0.02). There were otherwise no significant differences in adverse event rates. In the 29 patients with follow up, we found higher rates of recurrence in the cirrhosis group compared to controls (40% vs 5.26%; P = 0.019), however this effect did not persist on multivariable analysis controlling for known confounders.

CONCLUSION

ESD may be safe and effective in patients with cirrhosis. Most procedure related outcomes were not significantly different between groups. Intra-procedural bleeding requiring use of the coagulation grasper use was expectedly higher in the cirrhosis group given the known effects of liver disease on hemostasis.

Comparison of scissor-type knife to non-scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis

BACKGROUND/AIMS

Scissor-type endoscopic submucosal dissection (ST-ESD) knives can reduce the adverse events associated with ESDs. This study aimed to compare ST-ESD and non-scissor-type (NST)-ESD knives.

METHODS

We identified ten studies that compared the performance characteristics and safety profiles of ST-ESD and NST-ESD knives. Fixed- and random-effects models were used to calculate the pooled proportions. Heterogeneity was assessed using the I2 test.

RESULTS

On comparing ST-ESD knives to NST-ESD knives, the weighted odds of en bloc resection was 1.61 (95% confidence interval [CI], 0.90-2.90; p=0.14), R0 resection was 1.10 (95% CI, 0.71-1.71; p=0.73), delayed bleeding was 0.40 (95% CI, 0.17-0.90; p=0.03), perforation was 0.35 (95% CI, 0.18-0.70; p<0.01) and ESD self-completion by non-experts was 1.89 (95% CI, 1.20-2.95; p<0.01). There was no heterogeneity, with an I2 score of 0% (95% CI, 0%-54.40%).

CONCLUSION

The findings of reduced odds of perforation, a trend toward reduced delayed bleeding, and an improvement in the rates of en bloc and R0 resection with ST-ESD knives compared to NST-ESD knives support the use of ST-ESD knives when non-experts perform ESDs or as an adjunct tool for challenging ESD procedures.

Safety of Duodenal Endoscopic Submucosal Dissection for Superficial Non-Ampullary Duodenal Epithelial Tumor: A Single-Center Study in the United States

Endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is associated with a high rate of en bloc resection and low rate of recurrence. However, in the United States, SNADETs are predominantly managed using endoscopic mucosal resection (EMR) or surgery because the feasibility and safety of duodenal ESD have not yet been established. In this study, we analyzed the outcomes of duodenal ESD for SNADETs. This single-center retrospective study reviewed the data of patients who underwent ESD for SNADETs between June 2018 and August 2023. Baseline patient characteristics, histopathology of the resected lesions, adverse events, and recurrence rates were evaluated. The primary outcome measures were en bloc resection, complications, and recurrence rate. Thirty ESD procedures were performed on 24 patients. All 30 lesions were adenomas, with no cancerous lesions. The en bloc resection rate and R0 resection rates were both 53%. There were no cases of procedure-associated perforation. Post-ESD bleeding was observed in six cases. No ESD-related mortality was observed. The recurrence rate was 14% in 1 year follow up, and 28% the during all follow-up period. ESD is a safe option for SNADET in the United States; however further comparative studies are necessary to determine the optimal procedure for North American populations.

Duodenal neuroendocrine tumors: Short-term outcomes of endoscopic submucosal dissection performed in the Western setting

Background and study aims Endoscopic resection (ER) is recommended for the management of duodenal neuroendocrine tumors (D-NETs) confined to the submucosal layer, without lymph node or distant metastasis. While this is accepted practice for lesions < 10 mm, consensus for larger lesions remains unclear. Although endoscopic submucosal dissection (ESD) has been proposed as the preferred ER technique for DNETs ≥10 mm, there are limited data on efficacy and safety, particularly in the Western setting. Patients and methods We performed a retrospective analysis of patients with D-NETs who underwent ESD between 2012 and 2022 in three tertiary referral centers in Australia, France, and Belgium. Results Fourteen patients with 15 D-NETs were evaluated. Median patient age was 64 years (interquartile range [IQR] 58-70 years). All D-NETs were confined to the duodenal bulb. Median D-NET size was 10 mm (IQR 7-12 mm) and specimen size was 15 mm (IQR 15-20 mm). Median procedure time was 60 minutes (IQR 25-90 minutes). The rate of en bloc resection was 100%. Intra-procedural perforation occurred in four patients (26.7%), with all closed endoscopically without long-term sequelae. There were no episodes of clinically significant bleeding. No local recurrence, lymph node or distant metastasis was observed at a median follow-up of 19.9 months (IQR 10.3-49.3 months). Conclusions In experienced hands, ESD for D-NETs can achieve a 100% en bloc resection rate. There were no cases of local recurrence or distant metastatic spread, indicating that ESD may be a viable option for patients with D-NETs 10 to 15 mm that are not surgical candidates.

Efficacy of scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis

Background

Endoscopic submucosal dissection (ESD) is an effective resection technique for early cancers and large gastrointestinal luminal lesions. However, ESD is technically challenging, with the potential for severe adverse events. Scissor-type ESD (ST-ESD) knives with an inner cutting edge and an electrically insulated external coating could mitigate some of these risks. This study aimed to evaluate the performance of ST electrosurgical knives when used for ESDs.

Methods

Electronic databases were queried for studies from January 2005 through December 2022 evaluating the performance of ST-ESD knives. Fixed- and random-effects models were used to calculate pooled proportions. Heterogeneity was assessed using the I2 test and by constructing funnel plots, while bias was calculated using Egger and Harbord bias indicators.

Results

Final analysis included data from 17 studies comprising 1652 ESD procedures. The pooled en bloc resection rate and R0 resection rate were 97.94% (95% confidence interval [CI] 97.20-98.57) and 94.32% (95%CI 93.11-95.43), respectively. The main adverse events were perforation and delayed post-procedural bleeding, with pooled rates of 1.07% (95%CI 0.63-1.62) and 1.86% (95%CI 1.26-2.56), respectively. There was no heterogeneity, as indicated by an I2 score of 0% (95%CI 0-44.50%). The mean procedure time was 67.45 min (95%CI 58.01-76.89).

Conclusions

Our analysis shows that ST-ESD knives deliver consistently good performance across various locations in the gastrointestinal lumen and lesion sizes, with a good safety profile. This could be particularly appealing to newer adopters of ESD.

The Characteristics and Treatment Outcomes of 71 Duodenal Brunner's Gland Adenomas with Endoscopic Submucosal Dissection

INTRODUCTION

The aim of this study was to investigate outcomes of patients with duodenal Brunner's gland adenomas (BGAs) that were treated endoscopically.

METHODS

We identified 71 consecutive patients treated at our center with endoscopic submucosal dissection (ESD) for their duodenal tumors diagnosed pathologically as BGAs over the period between January 1, 2011 and December 31, 2021. We retrospectively analyzed our experience and short- and long-term outcomes of ESD therapy on patients with BGAs.

RESULTS

Among 71 BGA patients with an average age of 57 ± 11.7 years (range: 30-82), 48 (67.6%) were male and 23 (32.4%) were female. The accuracy of preoperative diagnosis with endoscopic ultrasonography was 44.0% (22/50). The H. pylori infection was found in 29 patients (29/71, 40.8%). The median size of BGAs was 1.5 cm (interquartile range [IQR] 0.8-2.7 cm). The most common location was the duodenum bulb (50/71, 64.8%). For the ESD procedure, the median operation time was 15.0 min (IQR 9.5-25.5 min). The en bloc and the complete resection rates were 97.2% and 92.3%, respectively. ESD-related mild acute obstructive pancreatitis was present in 2 patients (2/4, 50%) with BGAs located in the ampulla region. During the follow-up period, 1 patient with a positive peripheral margin experienced tumor recurrence 2 years after the initial ESD. There was no disease-related death for the cohort.

CONCLUSION

ESD was an effective and safe therapeutic option for BGA patients with excellent outcomes. Long-term follow-up is needed.

Clinical practice guidelines for duodenal cancer 2021

Duodenal cancer is considered to be a small intestinal carcinoma in terms of clinicopathology. In Japan, there are no established treatment guidelines based on sufficient scientific evidence; therefore, in daily clinical practice, treatment is based on the experience of individual physicians. However, with advances in diagnostic modalities, it is anticipated that opportunities for its detection will increase in future. We developed guidelines for duodenal cancer because this disease is considered to have a high medical need from both healthcare providers and patients for appropriate management. These guidelines were developed for use in actual clinical practice for patients suspected of having non-ampullary duodenal epithelial malignancy and for patients diagnosed with non-ampullary duodenal epithelial malignancy. In this study, a practice algorithm was developed in accordance with the Minds Practice Guideline Development Manual 2017, and Clinical Questions were set for each area of epidemiology and diagnosis, endoscopic treatment, surgical treatment, and chemotherapy. A draft recommendation was developed through a literature search and systematic review, followed by a vote on the recommendations. We made decisions based on actual clinical practice such that the level of evidence would not be the sole determinant of the recommendation. This guideline is the most standard guideline as of the time of preparation. It is important to decide how to handle each case in consultation with patients and their family, the treating physician, and other medical personnel, considering the actual situation at the facility (and the characteristics of the patient).

Risk factors of post-polypectomy bleeding and recurrence in children with colorectal polyps after endoscopic mucosal resection: a retrospective cohort study

BACKGROUND

The incidence rate of colorectal polyps in children has gradually increased in recent years. It is still unclear whether endoscopic mucosal resection (EMR) can be performed in children with colorectal polyps as well as their incidences of post-polypectomy bleeding and recurrence. This retrospective study was performed to explore the feasible of EMR in children with colorectal polyps and analyze the risk factors of post-polypectomy bleeding and recurrence.

METHODS

Patients aged younger than 18 years diagnosed with colorectal polyps and received EMR for polypectomy between January 2017 and December 2021 were included in this study. The baseline data of included patients were retrospectively collected. All complications related to polypectomy were recorded during follow up via telephone, internet, or outpatient department, including post-polypectomy bleeding, perforation and polyp recurrence. Patients with and without post-polypectomy complications were divided into 2 groups. The risk factors of post-polypectomy bleeding and polyp recurrence were analyzed using multivariable logistic regression models after adjusting potential risk factors using univariable regression models.

RESULTS

A total of 589 patients were included in this retrospective study. There were 333 male patients and 256 female patients, and their average age was 4.4±1.9 years old. The average diameter of their polyps was 8.4±2.8 mm, and 542 (92.0%) polyps presented as pedunculated lesions. A total of 540 (91.7%) polyps were diagnosed as juvenile polyps and 509 (86.4%) patients had only 1 polyp. There were a total of 75 cases of post-polypectomy complications (12.7%). The most common complication was early post-polypectomy bleeding (5.3%), followed by polyp recurrence (3.7%). Post-polypectomy bleeding occurred the most on the third and fourth day after EMR polypectomy. Larger polyps (OR =1.742, P<0.001), sessile lesions (OR =3.150, P=0.019), and multiple polyps (OR =4.372, P=0.003) were identified to be related to the incidence of post-polypectomy bleeding. Besides, sessile lesions (OR =3.887, P=0.026) were identified as the main risk factor and older patients (OR =0.606, P=0.004) had lower potential for post-polypectomy recurrence.

CONCLUSIONS

More attention should be paid to large, sessile, and multiple polyps during the procedure of EMR in children. The small number of patients in this study limits further analysis of results and a large sample study should be performed.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection (EFTR), with or without laparoscopic assistance, is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors (SMTs) arising from the muscularis propria (MP), especially of the gastric wall. To date, evidence concerning duodenal exposed EFTR is lacking, mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure. However, given the non-negligible morbidity and mortality associated with duodenal surgery, the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers. The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.

Analysis of pathological characteristics and nursing intervention of patients with gastric polyps based on image stitching algorithm and endoscopy

Objectives:

The paper uses image stitching algorithm to understand the clinical and pathological characteristics of gastric polyps under gastroscope, and provides objective basis for the clinical diagnosis and treatment of gastric polyps and nursing intervention.

Methods:

The endoscopic, pathological data and surgical conditions of 111 patients with gastric polyps detected in the hospital from January 2017 to August 2019 were retrospectively analyzed.

Results:

The elderly patients (≥60 years old) in this group were those with high incidence of gastric polyps (56.8%); 80 patients with single polyps (72.1%), 31 patients with multiple polyps (27.9%); polyps were mainly located in the stomach (53.2%); polyps diameter ≤0.5cm are more common (69.4%); polyps are mainly hyperplastic polyps (40.5%) and inflammatory polyps in 37 cases (33.3%). Polyps were removed by biopsy forceps in 30 cases, endoscopic submucosal injection of 0.9% NaCl solution combined with high-frequency electrosurgical removal of 54 cases, endoscopic mucosal resection (EMR) in 6 cases, and endoscopic submucosal dissection (ESD) in treatment of the 4 cases, the remaining 17 cases were treated with surgery, and 12 patients were followed up, 2 of whom relapsed.

Conclusion:

Gastric polyps are small in diameter and mostly single; polyps are mainly located in the stomach body, mainly hyperplastic polyps; treatment methods are mostly endoscopic resection, and there is a possibility of recurrence after polypectomy, and follow-up should be strengthened. Full preparation before the operation, close cooperation during the operation, and careful postoperative care are important links to ensure the safety of the operation and reduce complications such as upper gastrointestinal bleeding.

Endoscopic Suturing for the Prevention and Treatment of Complications Associated with Endoscopic Mucosal Resection of Large Duodenal Adenomas

Background/Aims

Endoscopic mucosal resection (EMR) is the primary treatment for duodenal adenomas; however, it is associated with a high risk of perforation and bleeding, especially with larger lesions. The goal of this study was to demonstrate the feasibility and safety of endoscopic suturing (ES) for the closure of mucosal defects after duodenal EMR.

Methods

Consecutive adult patients who underwent ES of large mucosal defects after EMR of large (>2 cm) duodenal adenomas were retrospectively enrolled. The OverStitch ES system was employed for closing mucosal defects after EMR. Clinical outcomes and complications, including delayed bleeding and perforation, were documented.

Results

During the study period, ES of mucosal defects was performed in seven patients in eight sessions (six for prophylaxis and two for the treatment of perforation). All ES sessions were technically successful. No early or delayed post-EMR bleeding was recorded. In addition, no clinically obvious duodenal stricture or recurrence was encountered on endoscopic follow-up evaluation, and no patients required subsequent surgical intervention.

Conclusions

ES for the prevention and treatment of duodenal perforation after EMR is technically feasible, safe, and effective. ES should be considered an option for preventing or treating perforations associated with EMR of large duodenal adenomas.

The Use of Endoscopic Clipping in Preventing Delayed Complications after Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumors

BACKGROUND/AIMS

Endoscopic resection (ER) has recently been accepted as the standard treatment modality for superficial nonampullary duodenal tumors (SNADTs). However, the procedure can cause adverse events such as perforation and bleeding. This study aimed to investigate the efficacy of prophylactic clipping in the prevention of delayed complications.

METHODS

A retrospective review of the medical records of patients who underwent ER for SNADT from 3 centers was performed. Patients were divided into 2 groups: the immediate clipping group (ICG) and the no clipping group (NCG). Various baseline characteristics and factors associated with the appearance of delayed complications, such as size of the lesion, tumor location, histologic type, and co-morbidities, were compared between the two groups.

RESULTS

A total of 99 lesions from 99 patients were included in this study. Fifty-two patients were allocated into ICG and 47 patients were allocated into NCG. Delayed bleeding occurred in 1 patient from ICG and in 8 patients from NCG. Delayed perforation occurred in 1 patient from ICG and in 3 patients from NCG. There were no procedure-related deaths in both groups.

CONCLUSION

Although the use of endoscopic clipping seemed to reduce the risk of developing delayed complications, further studies using a prospective design is required.

Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is being performed more frequently as a local treatment for superficial duodenal epithelial tumors (SDETs). However, ESD for SDETs is technically difficult because of specific anatomic features that increase the risk of perforation and often require surgery. This study was performed to evaluate the management of ESD-related perforation in patients with SDETs.

METHODS

Patients who underwent ESD for SDETs from July 2010 to December 2018 were studied. We collected data on complete closure, insertion of endoscopic nasobiliary and pancreatic duct drainage (ENBPD) tubes, and additional interventions. We also evaluated clinical outcomes, including the fasting period, hospital stay, and maximum serum C-reactive protein level.

RESULTS

ESD was completed in 264 patients with SDETs. Perforation was observed in 36 patients, including 4 patients with delayed perforation. Among 32 patients with intraoperative perforation, complete closure was achieved in 13 patients. Compared with patients without complete closure, the fasting period and hospital stay were significantly shorter and the maximum serum C-reactive protein level was significantly lower in patients with complete closure, which were equivalent to those in patients without perforation. In patients without complete closure for mucosal defect, no additional interventions were required when an ENBPD tube was inserted, whereas 2 patients without ENBPD tube insertion underwent additional interventions such as percutaneous drainage and a surgical operation.

CONCLUSIONS

Perforation associated with ESD for SDETs required complex conservative management with complete closure or insertion of an ENBPD tube.