Endoscopic resection outcomes and predictors of failed en bloc endoscopic mucosal resection of colorectal polyps ≤ 20 mm among advanced endoscopy trainees

Predictors of En Bloc, R0 Resection, and Postprocedural Complications After Advanced Endoscopic Resections for Colorectal Neoplasms: Results of 1213 Procedures

BACKGROUND

Advanced endoscopic resection techniques are used to treat colorectal neoplasms that are not amenable to conventional colonoscopic resection. Literature regarding the predictors of the outcomes of advanced endoscopic resections, especially from a colorectal surgical unit, is limited.

OBJECTIVE

To determine the predictors of short-term and long-term outcomes after advanced endoscopic resections.

DESIGN

Retrospective case series.

SETTINGS

Tertiary care center.

PATIENTS

Patients who underwent advanced endoscopic resections for colorectal neoplasms from November 2011 to August 2022.

INTERVENTIONS

Endoscopic mucosal resection, endoscopic submucosal dissection, hybrid endoscopic submucosal dissection, and combined endoscopic laparoscopic surgery.

MAIN OUTCOME MEASURES

Predictors of en bloc and R0 resection, bleeding, and perforation were determined using univariable and multivariable logistic regression models. Cox regression models were used to determine the predictors of tumor recurrence.

RESULTS

A total of 1213 colorectal lesions from 1047 patients were resected (median age 66 [interquartile range, 58-72] years, 484 women [46.2%], median BMI 28.6 [interquartile range, 24.8-32.6]). Most neoplasms were in the proximal colon (898; 74%). The median lesion size was 30 (interquartile range, 20-40; range, 0-120) mm. Nine hundred eleven lesions (75.1%) underwent previous interventions. The most common Paris and Kudo classifications were 0 to IIa flat elevation (444; 36.6%) and IIIs (301; 24.8%), respectively. En bloc and R0 resection rates were 56.6% and 54.3%, respectively. Smaller lesions, rectal location, and procedure type (endoscopic submucosal dissection) were associated with significantly higher en bloc and R0 resection rates. Bleeding and perforation rates were 5% and 6.6%, respectively. Increased age was a predictor for bleeding (OR 1.06; 95% CI, 1.03-1.09; p < 0.0001). Lesion size was a predictor for perforation (OR 1.02; 95% CI, 1.00-1.03; p = 0.03). The tumor recurrence rate was 6.6%. En bloc (HR 1.41; 95% CI, 1.05-1.93; p = 0.02) and R0 resection (HR 1.49; 95% CI, 1.11-2.06; p = 0.008) were associated with decreased recurrence risk.

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

Outcomes of advanced endoscopic resections can be predicted by patient-related and lesion-related characteristics. See Video Abstract .

PREDICTORES DE LA RESECCION R, EN BLOQUE Y LAS COMPLICACIONES POR RESECCIONES ENDOSCPICAS AVANZADAS EN CASOS DE NEOPLASIA COLORRECTAL RESULTADOS DE PROCEDIMIENTOS

ANTECEDENTES:Las técnicas avanzadas de resección endoscópica se utilizan para el tratamiento de neoplasias colorrectales que no son susceptibles de resección colonoscópica convencional. La literatura sobre los predictores de los resultados de las resecciones endoscópicas avanzadas, especialmente en una unidad de cirugía colorrectal, es limitada.OBJETIVO:Determinar los predictores de resultados a corto y largo plazo después de resecciones endoscópicas avanzadas.DISEÑO:Serie de casos retrospectivos.LUGAR:Centro de tercer nivel de atención.PACIENTES:Pacientes sometidos a resecciones endoscópicas avanzadas por neoplasias colorrectales desde noviembre de 2011 hasta agosto de 2022.INTERVENCIÓNES:Resección endoscópica de la mucosa, disección endoscópica submucosa (ESD), ESD híbrida, cirugía laparoscópica endoscópica combinada.PRINCIPALES MEDIDAS DE RESULTADO:Los predictores de resección en bloque y R0, sangrado y perforación se determinaron mediante modelos de regresión logística univariables y multivariables. Se utilizaron modelos de regresión de Cox para determinar los predictores de recurrencia del tumor.RESULTADOS:Se resecaron 1.213 lesiones colorrectales en 1.047 pacientes [edad media 66 (58-72) años, 484 (46,2%) mujeres, índice de masa corporal medio 28,6 (24,8-32,6) kg/m 2 ]. La mayoría de las neoplasias se encontraban en el colon proximal (898, 74%). El tamaño medio de la lesión fue de 30mm (RIC: 20-40, rango: 0-120). 911 (75,1%) lesiones tenían intervenciones previas. Las clasificaciones de París y Kudo más comunes fueron 0-IIa elevación plana (444, 36,6%) y III (301, 24,8%), respectivamente. Las tasas de resección en bloque y R0 fueron del 56,6% y 54,3%, respectivamente. Las lesiones más pequeñas, la ubicación rectal y el tipo de procedimiento (ESD) se asociaron con tasas de resección en bloque y R0 significativamente más altas. Las tasas de sangrado y perforación fueron del 5% y 6,6%, respectivamente. La edad avanzada [1,06 (1,03-1,09), p < 0,0001] fue un predictor de sangrado. El tamaño de la lesión [1,02 (1,00-1,03), p = 0,03] fue un predictor de perforación. La tasa de recurrencia del tumor fue del 6,6%. En bloque [HR 1,41 (IC 95% 1,05-1,93), p = 0,02] y la resección R0 [HR 1,49 (IC 95% 1,11-2,06), p = 0,008] se asociaron con un menor riesgo de recurrencia.LIMITACIONES:Estudio unicéntrico, retrospectivo.CONCLUSIONES:Los resultados de las resecciones endoscópicas avanzadas pueden predecirse según las características del paciente y de la lesión. (Traducción-Dr. Xavier Delgadillo ).

Clinical outcomes and learning curve of Tip-in endoscopic mucosal resection for 15-25 mm colorectal neoplasms among non-experts

BACKGROUND AND AIM

Tip-in endoscopic mucosal resection (EMR) has a high en bloc resection rate for large colorectal neoplasms. However, non-experts' performance in Tip-in EMR has not been investigated. We investigated whether Tip-in EMR can be achieved effectively and safely even by non-experts.

METHODS

This retrospective study included consecutive patients who underwent Tip-in EMR for 15-25 mm colorectal nonpedunculated neoplasms at a Japanese tertiary cancer center between January 2014 and December 2020. Baseline characteristics, treatment outcomes, learning curve of non-experts, and risk factors of failing self-achieved en bloc resection were analyzed.

RESULTS

A total of 597 lesions were analyzed (438 by experts and 159 by non-experts). The self-achieved en bloc resection (69.8% vs 88.6%, P < 0.001) and self-achieved R0 resection (58.3% vs 76.5%, P < 0.001) rates were significantly lower in non-experts with <10 cases of experience than in experts, but not in non-experts with >10 cases. Adverse event (P = 0.165) and local recurrence (P = 0.892) rates were not significantly different between experts and non-experts. Risk factors of failing self-achieved en bloc resection were non-polypoid morphology (OR 3.4, 95% CI 1.6-7.3, P = 0.001), lesions with an underlying semilunar fold (OR 3.6, 95% CI 1.6-7.3, P < 0.001), positive non-lifting sign (OR 3.1, 95% CI 1.2-8.0, P = 0.023), and non-experts with an experience of ≤10 cases (OR 3.6, 95% CI 2.1-6.3, P < 0.001).

CONCLUSION

The clinical outcomes of Tip-in EMR for 15-25 mm lesions performed by non-experts were favorable.

Development of American Society for Gastrointestinal Endoscopy standards for training in advanced endoscopy within dedicated advanced endoscopy fellowship programs

BACKGROUND AND AIMS

Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically with a concurrent increase in the breadth and complexity of interventional endoscopy procedures. Accreditation is governed by competency-based education, yet what constitutes a "high-quality" nonaccredited AEFP has not been defined. Using an evidence-based consensus process, we aimed to establish standards for AEFPs.

METHODS

The RAND UCLA appropriateness method, a well-described modified Delphi process to develop quality indicators, was used. A task force established by the American Society for Gastrointestinal Endoscopy drafted potential quality indicators (structure, process, and outcome) in 6 categories: activity preceding training; structure of AEFPs; training in ERCP, EUS, and EMR; and luminal stent placement. Three rounds of iterative feedback from 20 experts were conducted. Round 0 involved discussion of project details. In round 1, experts independently ranked proposed quality indicators on a 9-point interval scale ranging from highly inappropriate (1) to highly appropriate (9). Next, proposed quality indicators were discussed and reworded in a group meeting followed by round 2, in which experts independently reranked proposed quality indicators and provided benchmarks (when applicable). The median score for each quality indicator was calculated. Mean absolute deviation from the median was calculated, and appropriateness of potential quality indicators was assessed using the BIOMED concerted action on appropriateness definition, P value method, and interpercentile range adjusted for symmetry definition. A quality indicator was deemed appropriate if the median score was ≥7 and met criteria for appropriateness using all 3 defined statistical methods.

RESULTS

Of 89 proposed quality indicators, 37 statements met criteria as appropriate for a quality indicator (activity preceding training, 2; structure of AEFPs, 10; training in ERCP, 7; training in EUS, 8; training in EMR, 7; luminal stent placement, 3). Minimum thresholds were defined for 19 relevant quality indicators for number of trainers, procedures during fellowship, and procedures before assessment of competence. Among the final appropriate quality indicators were that all trainees should undergo qualitative and quantitative competence assessments using validated tools at least quarterly with documented feedback throughout the training period and that trainees should track outcomes and relevant quality metrics for specific procedures.

CONCLUSIONS

This consensus process using validated methodology established standards for an AEFP in an effort to ensure adequate training in the most commonly taught interventional endoscopic procedures (ERCP, EUS, EMR, and luminal stent placement) during fellowship. An important component of an AEFP is the use of competency-based assessments that are compliant with the Accreditation Council for Graduate Medical Education's Next Accreditation System, with the goal of ensuring that trainees achieve specific milestones in their progression to achieving cognitive and technical competency.

Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicentre cluster randomised trial

OBJECTIVE

Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. We evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals.

DESIGN

In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months.

RESULTS

A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs 30 mm, 45% vs 52% size, morphology, site and access (SMSA) score IV, 64% vs 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs 25%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 1.36; p=0.720). Recurrences were more often unifocal in the intervention group (92% vs 76%; p=0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20-40 mm LNPCPs (5% vs 20% in 20-29 mm, p=0.001; 10% vs 21% in 30-39 mm, p=0.013) but less evident in ≥40 mm LNPCPs (24% vs 31%; p=0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high.

CONCLUSION

A compact standardised EMR training for LNPCPs significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥40 mm.

TRIAL REGISTRATION NUMBER

NTR7477.