Warning for unprincipled colorectal endoscopic submucosal dissection: accurate diagnosis and reasonable treatment strategy

Endoscopic submucosal dissection for colorectal neoplasms: Risk factors for local recurrence and long-term surveillance

Objectives

Endoscopic submucosal dissection (ESD) is an effective procedure for the en bloc resection of colorectal neoplasms. However, risk factors for local recurrence after ESD have not been identified. This study aimed to evaluate such risk factors after ESD for colorectal neoplasms.

Methods

This retrospective study included 1344 patients with 1539 consecutive colorectal lesions who underwent ESD between September 2003 and December 2019. We investigated various factors associated with local recurrence in these patients. The main outcomes were the incidence of local recurrence and its relationship with clinicopathological factors during long-term surveillance.

Results

The en bloc resection rate was 98.6%, the R0 resection rate was 97.2%, and the histologically complete resection rate was 92.7%. Local recurrence was observed in 7/1344 (0.5%) patients and the median follow-up period was 72 months (range 4-195 months). The incidence of local recurrence was significantly higher in lesions ≥40 mm in diameter (hazard ratio [HR] 15.68 [1.88-130.5]; p = 0.011), piecemeal resection (HR 48.42 [10.7-218.7]; p < 0.001), non-R0 resection (HR 41.05 [9.025-186.7]; p < 0.001), histologically incomplete resection (HR 16.23 [3.627-72.63]; p<0.001), and severe fibrosis (F2; HR 9.523 [1.14-79.3]; p = 0.037).

Conclusions

Five risk factors for local recurrence after ESD were identified. Patients with such factors should undergo careful surveillance colonoscopy.

The Management of Direct Oral Anticoagulants for Colorectal Endoscopic Submucosal Dissection: A Multicenter Observational Study

BACKGROUND

There is a lack of reports on the use of direct oral anticoagulants (DOACs) during colorectal endoscopic submucosal dissection (ESD).

AIMS

We aimed to assess whether the use of DOACs is associated with a higher incidence of delayed bleeding (DB) after ESD.

METHODS

A total of 4175 colorectal neoplasms in 3515 patients were dissected at our hospitals during study period. We included 3909 lesions in the final analysis. The lesions were divided into two groups: the no-AT group (3668 neoplasms) and the DOAC group (241 neoplasms). We also compared the DOAC withdrawal group (154 neoplasms) and the DOAC continuation group (87 neoplasms).

RESULTS

Among the 3909 lesions, DB occurred in a total of 90 cases (2.3%). The rate of DB was 2.2% (82/3668), and 3.3% (8/241), respectively. There were no significant differences in the rate of DB between the no-AT group and the DOAC group. In the DOAC group, there were no significant differences in the rate of DB between the withdrawal group (5.2%, 8/154) and the continuation group (0%, 0/87). The multivariable analysis identified the location of the lesion in the rectum (odds ratio [OR], 4.04; 95% confidence interval [CI], 2.614-6.242; p < 0.001) and lesions ≥ 30 mm in diameter (OR, 4.14; 95% CI, 2.349-7.34; p < 0.001) as independent risk factors for DB.

CONCLUSIONS

Our findings suggest that DOAC use has no significant important on the rate of DB. Prospective studies are warranted to determine whether treatment with DOACs should be interrupted prior to colorectal ESD.

Complications after endoscopic submucosal dissection for early colorectal cancer (Review)

Colorectal cancer (CRC) is a gastrointestinal malignancy that seriously threatens human life and health, resulting in a heavy disease burden. Endoscopic submucosal dissection (ESD) is widely used in clinical practice and is an effective treatment for early CRC (ECC). Colorectal ESD is a challenging operation, and the incidence of postoperative complications is relatively high because of the thin intestinal wall and limited space for endoscopic operations. Systematic reports on the postoperative complications of colorectal ESD, such as fever, bleeding and perforation, from both China and elsewhere are lacking. In the present review, progress in research on postoperative complications after ESD for ECC is summarized.

Association of IL-17A promoter region SNP-rs2275913 with urinary bladder cancer

Objective

Urinary bladder cancer (UBC) is the fourth most common cancer among men and tenth most common cancer in women. This study investigated an association of interleukins -17A promoter region single nucleotide polymorphism (SNP)-rs2275913 with UBC in Pakistani population.

Methods

Population-based study was designed with 127 UBC patients and 100 healthy individuals. Only UBC Patients were included and other diseases hepatitis or any other malignancy/cancer were excluded from the study. Polymerase chain reaction Restriction fragment length polymorphism technique was used to genotype the rs2275913 SNP in patients and control. Linear regression analysis was performed on the genotype data and allelic frequency data. Online statistical tool was used to calculate ratio of odds.

Results

Linear regression analysis showed that there was no association between rs2275913 SNP and UBC patients in the dominant model (OR = 0.815, CI = 0.415-1.6), recessive model (OR = 0.389, CI = 0.014-5.565), codominant model (OR = 0.376, CI=0.013-5.420) and (OR = 0.855, CI = 0.427-1.713). Moreover, among the UBC samples, low-grade non-muscle invasive UBC samples dominant model (OR = 0.722, CI = 0.316-1.637), recessive model (OR = 0.000, CI = 0.000-5.864), codominant model (OR = 0.864, CI = 0.030-12.668), and (OR = 0.788, CI = 0.341-1.806) did also not show any association. When same analysis was performed for high-grade muscle invasive UBC, dominant (OR = 0.936, CI = 0.403-2.155), recessive model (OR = 0.875, CI = 0.031-12.696), and codominant model (OR = 0.864, CI = 0.030-12.668,), and (OR = 0.942, CI = 0.394-2.232) did not show any association.

Conclusion

Results revealed that rs2275913 did not show any associated with the high risk of UBC in Pakistani population. Some limitations of the studies are firstly, the samples size and other are detailed information on UBC and role of inflammation.

Risk factors of delayed post-polypectomy bleeding after treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection

Context

Gastrointestinal polyps are common gastrointestinal diseases that involve localised hyperplastic masses derived from gastrointestinal mucosa.

Aims

To investigate the risk factors of delayed post-polypectomy bleeding (DPPB) after the treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection (ESD) and to construct a nomogram model to predict the risk of DPPB.

Settings and Design

A total of 226 patients who underwent snare-assisted ESD for gastrointestinal polyps from May 2018 to November 2020 were divided into DPPB group (n = 10) and non-DPPB group (n = 216).

Subjects and Methods

The correlations of clinical data and endoscopic data with DPPB were compared. Univariate analysis was performed to screen the influencing factors of DPPB. Multivariate logistic regression analysis was used to screen the risk factors of DPPB, which was employed to construct a nomogram prediction model.

Statistical Analysis Used

SPSS 16.0 software was utilised for statistical analysis. Numerical data were expressed as percentage (n [%]), and Chi-square test was performed for univariate analysis. The significant factors (P < 0.05) in univariate analysis were included in multivariate logistic regression analysis, and the variables with statistical significance (P < 0.05) were considered as independent risk factors. The factors were used to construct a nomogram model for predicting the risk of DPPB. Bootstrap method was employed to perform repeated sampling 1000 times for internal verification. The consistency index (C-index) was used to evaluate the discrimination of the model, and C-index ≥0.70 represented a good discrimination. Two-tailed P < 0.05 indicated that a difference was statistically significant.

Results

Univariate and multivariate logistic regression analyses revealed that hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were the independent risk factors for DPPB (P < 0.05). The C-index of the nomogram model for predicting the risk of DPPB was 0.791, indicating a good discrimination. The calibration curve showed that the mean absolute error between predicted and actual DPPB occurrence risks was 0.014, indicating a high accuracy.

Conclusions

Hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding are the independent risk factors for DPPB, and the nomogram model established based on these factors for prediction has good discrimination and accuracy. Therefore, it is recommended to perform targeted intervention for high-risk groups to reduce the incidence of DPPB.

[Japan narrow-band imaging Expert Team type 2B colorectal cancer: consistency between endoscopic prediction and pathological diagnosis]

OBJECTIVE

To explore the potential factors that affect the accuracy of endoscopic diagnosis for Japan narrow-band imaging (NBI) Expert Team (JNET) type 2B colorectal lesions.

OBJECTIVE

The clinical data were collected from 261 patients with JNET type 2B colorectal lesions diagnosed in Nanfang Hospital between July, 2018 and July, 2021. We analyzed the macroscopic type, size, location or pit pattern classification of the lesions for their potential influence of the diagnostic accuracy of JNET type 2B lesions.

OBJECTIVE

The 261 lesions included 91 low-grade intramucosal neoplasia lesions (34.9%), 132 high-grade intramucosal neoplasia lesions (50.6%), 13 submucosal invasive cancer lesions (5.0%), and 25 deep submucosal invasive cancer lesions (9.6%). The coincidence rate between endoscopic prediction and pathological diagnosis of these lesions was 55.6% (145/ 261). The macroscopic type and size of the lesions were significantly associated with the diagnostic accuracy of JNET type 2B lesions (P < 0.001). There was a significant difference in the diagnostic accuracy among the lesions with different pit pattern types (P < 0.001).

OBJECTIVE

Both the macroscopic type and size affect the accuracy of endoscopic diagnosis of JNET type 2B colorectal lesions. JNET classification combined with pit pattern types can have better accuracy in predicting the pathological diagnosis of these lesions.

Indications and outcomes of colorectal hybrid endoscopic submucosal dissection: a large multicenter 10-year study

BACKGROUND AND AIMS

Hybrid endoscopic submucosal dissection (ESD) is a colorectal lesion resection procedure that includes both planned and salvage procedures. Previous colorectal hybrid ESD studies have involved single institutions or few operators over a short timeframe, and the size for indication has not been established. In this multicentre study, we investigated the clinical outcomes of hybrid ESD for colorectal tumors that met the 30 mm lesion size criterion.

METHODS

From January 2008 to December 2018, colorectal hybrid ESD was performed for 172 lesions (diameter range, ≥ 20- < 30 mm) at Hiroshima GI Endoscopy Research Group. We compared clinicopathological characteristics and outcomes between 56 and 116 lesions in planned and salvage groups, respectively. We also compared data between 2008 and 2013 (the first period) and 2014 and 2018 (the second period) to assess operator experience.

RESULTS

No significant difference was found in the complete en bloc resection rate between the planned and salvage groups (92.9% vs. 83.6%, respectively). Procedure time was shorter in the planned group (44.5 min) than in the salvage group (72.0 min, p < 0.01). The perforation rate was higher in the salvage group (21.6%) than in the planned group (0%, p < 0.01); however, the perforation rate during snaring in the salvage group was 1.8%. During the second period relative to the first period, we recorded a significantly higher complete en bloc resection rate (95.7% vs. 75.6%, respectively, p < 0.01) and experienced operator rate (75.5% vs. 53.9%, respectively, p < 0.01). Furthermore, no significant difference was found in the complete en bloc resection rate between the planned and salvage groups during the second period (100% vs. 94.4%, respectively).

CONCLUSION

Colorectal hybrid ESD, especially salvage hybrid ESD performed by experienced operators, is adoptable and safe for lesions with diameters ranging from ≥ 20 to < 30 mm.

The Coexistence of Colorectal Polyps in the Right Colon Increases the Malignant Risk of Laterally Spreading Tumors

Background

The coexistence of colorectal polyps with laterally spreading tumors (LSTs) is commonly observed during colonoscopy. However, there are rare studies that assess the malignant risks for LSTs with colorectal polyps, which might largely contribute to further strategies of treatment and follow-up plans in LSTs.

Methods

We conducted a retrospective cohort study that enrolled 206 patients with LSTs in the Endoscopy Center and Endoscopy Research Institute, Renji Hospital, Shanghai Jiao Tong University, China. The subjects with LSTs were divided into two groups: the nonpolyp group with 89 patients and the polyp group with 117 patients. Binary logistic regression was used to identify the independent predictors of outcomes of interest.

Results

The risk of the polyps' coexistence phenomenon increased in males compared with females (OR = 2.138, p = 0.047), especially in those between 50 and 75 years old (OR = 7.074, p = 0.036). Tumor size (3–4 cm), LSTs with tubulovillous types, and history of polyps statistically increased the risk of the polyp coexistence phenomenon (OR = 5.768, p = 0.003; OR = 36.345, p = 0.024; OR = 13.245, p < 0.0001, respectively). LST-NG-PD (OR = 20.982, p = 0.017) and LSTs ≥ 5 cm (OR = 37.604, p = 0.038) notably increased the malignant risk of LSTs. When the simultaneous polyps are located in the right colon, the risk of malignant LSTs (OR = 58.540, p = 0.013) positively increased.

Conclusion

The simultaneous colorectal polyps in the right colon were the most important risk factor to predict the malignant risk of LSTs.

Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also several types of precarcinomatous adenomas. It is important to establish practical guidelines wherein preoperative diagnosis of colorectal neoplasia and selection of endoscopic treatment procedures are appropriately outlined and to ensure that actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society compiled colorectal endoscopic submucosal dissection/endoscopic mucosal resection guidelines by using evidence-based methods in 2014. The first edition of these guidelines was published 5 years ago. Accordingly, we have published the second edition of these guidelines based on recent new knowledge and evidence.

The pocket-creation method facilitates colonic endoscopic submucosal dissection (with video)

BACKGROUND AND AIMS

Colonic endoscopic submucosal dissection (ESD) is more difficult than rectal ESD because of poor maneuverability of the endoscope due to physiologic flexion, peristalsis, and respiratory movements. The aim of this study was to assess the usefulness of the pocket-creation method (PCM) for colonic ESD compared with the conventional method (CM) regardless of lesion shape or location.

METHODS

A total of 887 colorectal lesions were treated by ESD. Of 887 lesions, 271 rectal lesions, 72 lesions smaller than 20 mm in diameter, and 1 non-neoplastic lesion were excluded. This is a retrospective chart review of the remaining 543 colon lesions in 512 patients. We divided them into the PCM group (n = 280) and the CM group (n = 263). The primary outcome was the en bloc resection rate. Secondary outcomes were R0 resection (en bloc resection with negative margin), adverse events, dissection time (in minutes), and dissection speed (in mm²/min).

RESULTS

The PCM group achieved a significantly higher en bloc resection rate (PCM, 100% [280/280], vs CM, 96% [253/263]; P < .001) and R0 resection rate (91% [255/280] vs 85% [224/263], respectively; P = .033) than the CM group. Dissection time was similar (69.5 ± 44.4 vs 78.7 ± 62.6 minutes, P = .676). Dissection speed was significantly faster with the PCM than with the CM (23.5 ± 11.6 vs 20.9 ± 13.6 mm²/min, P < .001). The incidence of adverse events was similar (perforation, 2% vs 4% [P = .152], and delayed bleeding, 2% vs 1% [P = .361]).

CONCLUSIONS

Colonic ESD using the PCM significantly improves the rates of en bloc resection and R0 resection and facilitates rapid dissection.

Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection: When Is Emergency Colonoscopy Needed?

BACKGROUND

Endoscopic submucosal dissection (ESD) is an effective treatment for early-colorectal cancer. Although delayed bleeding is a serious potential complication, there is no consensus on the optimal protocol to determine which cases require emergency colonoscopy.

AIMS

This study aimed to assess the risk factors for delayed bleeding after ESD and evaluate the "watch and wait" strategy for delayed bleeding. The "watch and wait" strategy was used for delayed bleeding, unless the shock index was ≥ 1 and/or a moderate amount of hematochezia occurred more than five occurrences.

METHODS

This study included 404 patients who had undergone endoscopic resection for 439 lesions between April 2012 and February 2018. Patients were classified into the bleeding group or the no-bleeding group to investigate the risk factors for delayed bleeding, and to assess the necessity of emergency colonoscopy.

RESULTS

Twenty-seven patients into the bleeding group and 412 into the no-bleeding group were classified. However, no case required emergency colonoscopy for hemostasis under "watch and wait strategy." Multivariate analysis revealed the risk factors for bleeding were rectal lesion (OR 5.547, 95% CI 1.456-21.130; P = 0.012) and lesion size ≥ 40 mm (OR 3.967, 95% CI 1.003-15.696; P = 0.05).

CONCLUSIONS

Risk factors for delayed bleeding are rectal lesions and lesion size ≥ 40 mm. This watch and wait strategy resulted in no requirements for emergency colonoscopy or blood transfusion, and no serious conditions caused by delayed bleeding.

Impact of preoperative biopsy sampling on severe submucosal fibrosis on endoscopic submucosal dissection for colorectal laterally spreading tumors: a propensity score analysis

BACKGROUND AND AIMS

It is believed that preoperative biopsy sampling for superficial-type colorectal tumors should be avoided because submucosal fibrosis caused by biopsy sampling makes EMR impossible. However, few studies have reported the influence of biopsy sampling on colorectal endoscopic submucosal dissection (ESD). This study aimed to examine the effect of biopsy sampling on submucosal fibrosis and treatment outcomes of ESD for laterally spreading tumors (LSTs).

METHODS

Between April 2005 and September 2015, 441 consecutive patients underwent colorectal ESD in Osaka City University Hospital. Using propensity score matching and inverse probability of treatment weighting (IPTW), we retrospectively evaluated risk factors for severe submucosal fibrosis and treatment outcomes for patients with LSTs, with or without preoperative biopsy sampling.

RESULTS

A total of 428 LSTs resected using ESD were enrolled. After matching, there were 136 matched pairs of lesions that did or did not undergo biopsy sampling. Preoperative biopsy sampling increased severe fibrosis compared with that in the non-biopsy sampling group (20.6% vs 11.0%; P = .03) and was significantly associated with severe fibrosis after matching (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.07-4.10; P = .03). After adjustment with IPTW, biopsy sampling also increased the risk of severe fibrosis (OR, 2.33; 95% CI, 1.17-4.63; P = .02). However, no significant differences were observed between the 2 groups in treatment outcomes.

CONCLUSIONS

Preoperative biopsy sampling for colorectal LSTs might cause severe submucosal fibrosis but has no adverse influence on clinical outcomes of ESD.

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

Clinical outcomes of endoscopic submucosal dissection for colorectal tumors: a large multicenter retrospective study from the Hiroshima GI Endoscopy Research Group

BACKGROUND AND AIMS

Although advanced high-volume centers have reported good outcomes of colorectal endoscopic submucosal dissection (ESD), a limited number of highly skilled experts in specialized institutions performed these procedures. We undertook a retrospective multicenter survey, which included nonspecialized hospitals, to investigate the clinical outcomes of colorectal ESD.

METHODS

We recruited 1233 consecutive patients with 1259 colorectal tumors resected by ESD at 12 institutions. We evaluated the en bloc resection rate, histologic complete resection rate, curative (R0) resection rate, adverse events, and the long-term prognoses, including local recurrence, metachronous tumor development, and survival rate.

RESULTS

The en bloc, histologic complete, and R0 resection rates were 92.6%, 87.4%, and 83.7%, respectively. The delayed bleeding, intraoperative perforation, and delayed perforation rates were 3.7%, 3.4%, and .4%, respectively. The long-term outcomes analysis included 1091 patients (88.4%). Local recurrences occurred in 1.7%, and metachronous tumors (>5 mm) developed in 11.0% of the patients. The 3- and 5-year overall survival rates were 95.1% and 92.3%, respectively. The number of colonic tumors, severe submucosal fibrosis, and en bloc resection rates were significantly higher in the high-volume centers (Group H) than those in the low-volume centers (Group L). The average tumor size in Group H was significantly larger than that in Group L.

CONCLUSIONS

Colorectal ESDs are feasible, have acceptable adverse event risks, and favorable long-term prognoses. (Clinical trial registration number: UMIN000016197.).

Continued Use of a Single Antiplatelet Agent Does Not Increase the Risk of Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection

BACKGROUND

With the aging of the population and rising incidence of thromboembolic events, the usage of antiplatelet agents is also increasing. There are few reports yet on the management of antiplatelet agents for patients undergoing colorectal endoscopic submucosal dissection (ESD).

AIMS

The aim of this study is to evaluate whether continued administration of antiplatelet agents is associated with an increased rate of delayed bleeding after colorectal ESD.

METHODS

A total of 1022 colorectal neoplasms in 927 patients were dissected at Yokohama City University Hospital and its three affiliate hospitals between July 2012 and June 2017. We included the data of 919 lesions in the final analysis. The lesions were divided into three groups: the no-antiplatelet group (783 neoplasms), the withdrawal group (110 neoplasms), and the continuation group (26 neoplasms).

RESULTS

Among the 919 lesions, bleeding events occurred in a total of 31 (3.37%). The rate of bleeding after ESD was 3.3% (26/783), 4.5% (5/110), and 0% (0/26), respectively. There were no significant differences in the rate of bleeding after ESD among the three groups (the withdrawal group vs. the no-antiplatelet group, the continuation group vs. the no-antiplatelet group, and the withdrawal group vs. the continuation group).

CONCLUSIONS

Continued administration of antiplatelet agents is not associated with any increase in the risk of delayed bleeding after colorectal ESD. Prospective, randomized studies are necessary to determine whether treatment with antiplatelet agents must be interrupted prior to colorectal ESD in patients who are at a high risk of thromboembolic events.

Diagnostic performance of Japan NBI Expert Team classification for differentiation among noninvasive, superficially invasive, and deeply invasive colorectal neoplasia

BACKGROUNDS AND AIMS

The Japan NBI Expert Team (JNET) classification is the first universal narrow-band imaging magnifying endoscopic classification of colorectal tumors. Considering each type in this classification, the diagnostic ability of Type 2B is the weakest. Generally, clinical behavior is believed to be different in each gross type of colorectal tumor. We evaluated the differences in the diagnostic performance of JNET classification for each gross type (polypoid and superficial) and examined whether the diagnostic performance of Type 2B could be improved by subtyping.

METHODS

We analyzed 2933 consecutive cases of colorectal lesions, including 136 hyperplastic polyps/sessile serrated polyps, 1926 low-grade dysplasias (LGDs), 571 high-grade dysplasias (HGDs), and 300 submucosal (SM) carcinomas. We classified lesions as polypoid and superficial type and compared the diagnostic performance of the classification system in each type. Additionally, we subtyped Type 2B into 2B-low and 2B-high based on the level of irregularity in surface and vessel patterns, and we evaluated the relationship between the subtypes and histology, as analyzed separately for polypoid and superficial types. We also estimated interobserver and intraobserver variability.

RESULTS

The diagnostic performance of JNET classification did not differ significantly between polypoid and superficial lesions. Ninety-nine percent of Type 2B-low lesions were LGDs, HGDs, or superficial submucosal invasive (SM-s) carcinomas. In contrast, 60% of Type 2B-high lesions were deep submucosal invasive (SM-d) carcinomas. The results were not different between each gross type. Interobserver and intraobserver agreements for Type 2B subtyping were good, with kappa values of .743 and .786, respectively.

CONCLUSIONS

Type 2B subtyping may be useful for identifying lesions that are appropriate for endoscopic resection. JNET classification and Type 2B sub classification are useful criteria, regardless of gross type.

Colorectal endoscopic submucosal dissection: patient selection and special considerations

Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered.

Case of pediatric traditional serrated adenoma resected via endoscopic submucosal dissection

Traditional serrated adenoma (TSA) is a type of serrated polyp of the colorectum and is thought to be a precancerous lesion. There are three types of serrated polyps, namely, hyperplastic polyps, sessile serrated adenomas/polyps, and TSAs. TSA is the least common of the three types and accounts for about 5% of serrated polyps. Here we report a pediatric case of TSA that was successfully resected by endoscopic submucosal dissection (ESD). This rare case report describes a pediatric patient with no family history of colonic polyp who was admitted to our hospital with hematochezia. On colonoscopy, we found a polypoid lesion measuring 10 mm in diameter in the lower rectum. We selected ESD as a surgical option for en bloc resection, and histopathological examination revealed TSA. The findings in this case suggest that TSA with precancerous potential can occur in children, and that ESD is useful for treating this lesion.

Colonic Laterally Spreading Tumor Diagnosed as an Early Cancer and Treated with Endoscopic Mucosal Resection: A Case Report and Review of Literature

Laterally spreading tumors (LSTs) are generally defined as superficial lesions ≥10 mm in diameter that typically extend laterally rather than vertically along the colonic wall. Such lesions are now increasingly reported because of increased awareness and the introduction of chromo and magnifying colonoscopy. Although the clinicopathological characteristics and the efficacy of endoscopic management of LSTs have been defined in Japanese cohorts, reports from the Middle East are lacking where surgical resection is the mainstay of treatment. We report a case with an LST about 20 cm from anal verge removed by endoscopic mucosal resection. After histopathological evaluation of the removed specimen, we categorized the patient as having high risk early colon cancer. The intensive follow-up as an additional treatment strategy was chosen for the patient. This review addresses the management of early carcinoma in colorectal polyp with reference to proper preoperative assessment, treatment selection with special attention to role of biomarkers, the need for additional treatment on the basis of the presence of risk factors and endoscopic follow-up after treatment.

Long-term outcomes after endoscopic submucosal dissection for superficial colorectal tumors

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective procedure for en bloc resection of superficial colorectal tumors regardless of tumor size or location. However, there are few reports on long-term outcomes for patients with superficial colorectal tumors after ESD. We therefore aimed to evaluate the long-term outcomes after ESD for superficial colorectal tumors.

METHODS

ESD was performed on 257 colorectal tumors in 255 consecutive patients at Hiroshima University Hospital between June 2003 and July 2010. We investigated the following variables: patient characteristics, the American Society of Anesthesiologists score, tumor location, tumor size, growth type, histology, en bloc resection rate, achievement of curative resection, procedure time, and adverse events. The 5-year overall survival (OS), 5-year disease-specific survival (DSS), local recurrence, and metachronous tumor occurrence were also analyzed.

RESULTS

We identified 224 tumors in 222 patients who were confirmed dead or had follow-up data for more than 5 years. After a median follow-up of 79 months, 5-year OS and DSS rates were 94.6% and 100%, respectively. The local recurrence rate (1.5%) was significantly higher in patients undergoing piecemeal resection (9.1%) compared with en bloc resection (0.6%), in cases of histologic incomplete resection compared with complete resection, and in cases of non-R0 resection compared with R0 resection. The rates of total number of tumors (≥6 mm) and carcinoma metachronous tumors after ESD without additional surgical resection were 18.9% (38/201) and 4.0% (8/201), respectively.

CONCLUSIONS

Long-term outcomes after ESD for superficial colorectal tumors are favorable. Patients should be surveyed for both local recurrence and metachronous tumors after ESD.

Evaluation for the Clinical Efficacy of Colon Capsule Endoscopy in the Detection of Laterally Spreading Tumors

BACKGROUND AND AIM

The manner in which colorectal lesions are being detected with PillCam COLON2 capsule endoscopy (CCE2) has markedly improved in recent days. However, limited data are available on CCE2 for detecting laterally spreading tumors (LSTs). The aim of this study was to compare CCE2 with optical colonoscopy (OC), which is currently the gold standard used in the detection of LSTs.

METHODS

We performed a prospective, single-academic center study comparing CCE2 with OC in patients with LSTs diagnosed using OC, which was performed during the 3-month period prior to CCE2. We focused on the sensitivity and specificity of CCE2 for detecting LSTs. LSTs were classified into the LST-granular type (LST-G) or the LST-non-granular type (LST-NG).

RESULTS

Thirty patients (mean age 59.5 years) were enrolled. Of them, 21 LSTs (7 LST-Gs and 14 LST-NGs) were evaluated in this study. The mean diameter of the LSTs was 27 ± 15 mm (range 10-60 mm). Histopathological diagnoses of the LSTs were as follows: tubular adenoma, 12 cases (57%); sessile serrated adenoma/polyp (SSA/P), 4 cases (19%); Tis carcinoma, 1 case (5%); and T1 carcinoma, 4 cases (19 LSTs were found in the following locations: cecum, 1 case (5%); ascending colon, 6 cases (29%); transverse colon, 6 cases, (29%); descending colon, 1 case (5%); sigmoid colon, 3 cases (13%); and rectum, 4 cases (19%). The colon cleansing level was adequate in all cases. The sensitivity and specificity of CCE2 for detecting LSTs were 81 and 100% respectively. For detecting LST-Gs and LST-NGs, the sensitivity and specificity were 71 and 100%, and 86 and 100%, respectively. There were 4 false-negative cases (LST-G (18 mm), cecum; LST-G (20 mm), sigmoid colon; LST-NG (25 mm), transverse colon; LST-NG (20 mm), transverse colon).

CONCLUSIONS

The sensitivity for detecting LSTs is lower with CCE2 than it is with OC, especially for LSTs located on the right colon or for SSA/P.

Surgical margin-negative endoscopic mucosal resection with simple three-clipping technique: a randomized prospective study (with video)

BACKGROUND

Although endoscopic mucosal resection is an established colorectal polyp treatment, local recurrence occurs in 13 % of cases due to inadequate snaring. We evaluated whether pre-clipping to the muscularis propria resulted in resected specimens with negative surgical margins without thermal denaturation.

METHODS

Of 245 polyps from 114 patients with colorectal polyps under 20 mm, we included 188 polyps from 81 patients. We randomly allocated polyps to the conventional injection group (CG) (97 polyps) or the pre-clipping injection group (PG) (91 polyps). The PG received three-point pre-clipping to ensure ample gripping to the muscle layer on the oral and both sides of the tumor with 4 mL local injection. Endoscopic ultrasonography was performed to measure the resulting bulge. Outcomes included the number of instances of thermal denaturation of the horizontal/vertical margin (HMX/VMX) or positive horizontal/vertical margins (HM+/VM+), the shortest distance from tumor margins to resected edges, and the maximum bulge distances from tumor surface to the muscularis propria.

RESULTS

The numbers of HMX and HM+ in the CG and PG were 27 and 6, and 9 and 2 (P = 0.001), and VMX and VM+ were 8 and 5, and 0 and 0 (P = 0.057). The shortest distance from tumor margin to resected edge [median (range), mm] in polyps in the CG and PG was 0.6 (0-2.7) and 4.7 (2.1-8.9) (P = 0.018). The maximum bulge distances were 4.6 (3.0-8.0) and 11.0 (6.8-17.0) (P = 0.005).

CONCLUSIONS

Pre-clipping enabled surgical margin-negative resection without thermal denaturation.

Clinical impact of dual red imaging in colorectal endoscopic submucosal dissection: a pilot study

BACKGROUND

Dual red imaging (DRI), a novel image-enhanced endoscopic technique, is expected to improve visibility of thin vessels, but no reports of the clinical use of DRI in colorectal endoscopic submucosal dissection (ESD) have been published. We aimed to compare the visibility of vessels, demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine, and fibrosis on DRI with that on white light imaging (WLI). We applied the principle of DRI to the image of the submucosal layer during colorectal ESD as a pilot study.

METHODS

A total of seven physicians compared 17 DRI images to the corresponding WLI images in colorectal ESD. The physicians compared the number of arteries identified on DRI with the actual number of arteries. The physicians rated the visibility of vessels, the demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine, and fibrosis. Inter-observer agreement was also examined using the kappa statistic.

RESULTS

Visibility of vessels and the demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine improved with the use of DRI compared with that using WLI. DRI can discriminate between arteries and veins clearly through the color of the vessels.

CONCLUSIONS

DRI improves the visibility of vessels, especially that of arteries, as they appear orange, and the demarcation line of the muscle layer. DRI may help to make colorectal ESD safer and faster.

Management of a large mucosal defect after duodenal endoscopic resection

Duodenal endoscopic resection is the most difficult type of endoscopic treatment in the gastrointestinal tract (GI) and is technically challenging because of anatomical specificities. In addition to these technical difficulties, this procedure is associated with a significantly higher rate of complication than endoscopic treatment in other parts of the GI tract. Postoperative delayed perforation and bleeding are hazardous complications, and emergency surgical intervention is sometimes required. Therefore, it is urgently necessary to establish a management protocol for preventing serious complications. For instance, the prophylactic closure of large mucosal defects after endoscopic resection may reduce the risk of hazardous complications. However, the size of mucosal defects after endoscopic submucosal dissection (ESD) is relatively large compared with the size after endoscopic mucosal resection, making it impossible to achieve complete closure using only conventional clips. The over-the-scope clip and polyglycolic acid sheets with fibrin gel make it possible to close large mucosal defects after duodenal ESD. In addition to the combination of laparoscopic surgery and endoscopic resection, endoscopic full-thickness resection holds therapeutic potential for difficult duodenal lesions and may overcome the disadvantages of endoscopic resection in the near future. This review aims to summarize the complications and closure techniques of large mucosal defects and to highlight some directions for management after duodenal endoscopic treatment.

Clinical usefulness of a single-use splinting tube for poor endoscope operability in deep colonic endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Poor endoscope operability remains a significant challenge during colorectal endoscopic submucosal dissection (ESD). We retrospectively evaluated the experience and clinical usefulness of a new single-use splinting tube in deep colonic ESD in the setting of poor scope operability.

PATIENTS AND METHODS

Among 691 patients with colorectal tumors treated with ESD at Hiroshima University Hospital between November 2009 and July 2015, we analyzed 20 consecutive patients who underwent deep colonic ESD using a single-use splinting tube because of poor scope operability. Poor operability was defined as paradoxical movement of the endoscope, poor control with adhesions, and lesion motion with heartbeat or breathing. Technical and clinical success rates and adverse events were assessed.

RESULTS

Paradoxical movement and poor control with adhesions were improved in all cases using the single-use splinting tube. The en bloc resection rate was 95 % (19/20) and histological en bloc resection rate was 100 % (20/20). There were no complications related to use of the splinting tube.

CONCLUSIONS

Use of a single-use splinting tube helped to overcome poor scope operability in deep colonic ESD.

Clinical significance and validity of the subclassification for colorectal laterally spreading tumor granular type

BACKGROUND AND AIM

Colorectal laterally spreading tumor granular type (LST-G) is generally divided into two subtypes based on morphology. Here, we retrospectively investigated the clinical significance of a concrete, objective LST-G subclassification.

METHODS

This study examined 636 consecutive cases that were resected endoscopically or surgically. LST-G was subclassified as follows: Type 1, a lesion with homogenous uniform granules with uniform (<5 mm) nodules; Type 2, a lesion with granules and small nodules (≥5 mm, <10 mm); or Type 3, a lesion accompanied by large nodules (≥10 mm). For the validation study, 194 images were compiled from 97 cases investigated using conventional colonoscopy and chromoendoscopy with indigo carmine dye spraying. Images were distributed in a randomized order to students without prior endoscopy experience, less-experienced endoscopists (LEE group), and highly experienced endoscopists (HEE group). Diagnostic accuracy and interobserver agreement were then evaluated.

RESULTS

There was no submucosal invasion in Type 1 lesions. The incidence of deep submucosal invasive carcinoma was higher for Type 3 lesions than for Type 2 lesions. Interobserver agreement was good in each group. Diagnostic accuracy was higher in the HEE group than in the student and LEE groups. Chromoendoscopy had a higher accuracy rate than conventional colonoscopy in the LEE and HEE groups (LEE, 0.74 vs 0.69, P < 0.05; HEE, 0.84 vs 0.78, P < 0.05).

CONCLUSIONS

This subclassification of LST-G according to the diameters of granules and nodules was both useful for choosing therapeutic strategies in the clinical setting and universally applicable.

Optimizing post-polypectomy surveillance: A practical guide for the endoscopist

Several gastrointestinal societies strongly recommend colonoscopy surveillance after endoscopic and surgical resection of colorectal neoplasms. Common denominators to these recommendations include: high-quality baseline colonoscopy before inclusion in a surveillance program; risk stratification based on clinicopathological profiles to guide surveillance intervals; and endoscopist responsibility for providing surveillance advice. Considerable variability also exists between guidelines (i.e. regarding risk classification and surveillance intervals). In this review, we examine key factors for quality of post-polypectomy surveillance practice, in particular bowel preparation, endoscopic findings at baseline examination and adherence to surveillance recommendations. Frequently asked questions by the practising endoscopist are addressed.

What is the best therapeutic strategy for colonoscopy of colorectal neoplasia? Future perspectives from the East

Development and improvement of endoscopic techniques and devices have changed the treatment of colorectal tumors over the last decade. For the treatment of diminutive polyps, the cold snare technique of the West is becoming a promising treatment in the East because of its short procedure time and low rate of delayed bleeding by eliminating the delayed effect of electrocautery. Rather than using piecemeal endoscopic mucosal resection or surgical resection for the treatment of large superficial tumors, the technique of the East of endoscopic submucosal dissection (ESD) achieves a high success rate of en bloc R0 resection, enabling detailed pathological evaluation with less invasive treatment. This procedure should also be useful in the West where large colorectal tumors are more frequent than in the East. Regarding outcomes, however, in the literature, the definition of 'curative resection' remains somewhat inconsistent and long-term outcomes of patients with deep submucosal and/or lymphovascular invasion in the en bloc specimen have not yet been determined. Large prospective, as well as retrospective, studies of these patients are warranted. When colorectal ESD is difficult because of size or location, the pocket-creation method and/or double-balloon-assisted technique may be useful. In the East, high-quality magnified chromoendoscopy is widely available, and endoscopists try to identify focal submucosal invasion. In the West, a systematic evaluation of surveillance for the prevention of colorectal cancer has been done and is highly refined. The East and West have much to learn from each other.

Endoscopic resection of colorectal lesions: The narrowing divide between East and West

Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques now exist for the resection of polyps, and the endoscopist must decide on the appropriate resection approach for individual patients and lesions. This decision should maximize efficacy, safety and cost-effectiveness and provide optimal oncological outcomes while minimizing unnecessary surgical treatment. Advances in endoscopic imaging technology are improving the accuracy of endoscopic diagnosis and allowing more precise risk assessment of colonic lesions. Resection technique can be tailored to the endoscopic findings. Diminutive (≤5 mm) and small polyps (≤9 mm) are best resected primarily by snare techniques. Cold snare polypectomy has proven safety, but efficacy and technique require further study. There is variation in techniques used for polyps 6-20 mm in size and incomplete resection rates for conventional polypectomy may be considerable. Endoscopic mucosal resection (EMR) is well established, safe and effective for lesions without submucosal invasion (SMI); however, recurrence is a key limitation. Endoscopic submucosal dissection (ESD) is well established in the East; however, it is resource intensive and its role in lesions with a low risk of SMI is questionable. ESD in the West remains incompletely defined and is associated with high adverse event rates, but it is becoming increasingly available and successful as experience grows. Emerging full-thickness resection technologies are still in their infancy and remain experimental as a result of the absence of reliable closure devices and techniques. Patient-focused outcomes should guide technique selection.

Efficacy and safety of endoscopic submucosal dissection for superficial colorectal tumors more than 50 mm in diameter

BACKGROUND AND AIMS

The feasibility of endoscopic submucosal dissection (ESD) for large superficial colorectal tumors is undefined. The aim of this study was to assess the outcomes for patients undergoing ESD of superficial colorectal tumors larger than 50 mm.

METHODS

A total of 472 patients who underwent ESD for superficial colorectal tumors from 2010 to 2014 were enrolled. We retrospectively reviewed their records.

RESULTS

We compared patients with 20-mm to 50-mm lesions and those with lesions >50 mm regarding demographics, the ESD procedure, and histopathology. Among patients with lesions >50 mm, laterally spreading tumors nongranular and protruded types were uncommon. Histopathologically, deeply invasive (≥1000 μm) submucosal carcinomas were more frequent in lesions >50 mm (14% [10/70] vs 5% [20/402], P < .01). Technically, en bloc resection was successfully accomplished in 99% of patients (69/70). Although the total dissection time for lesions >50 mm was significantly longer than for lesions 20 mm to 50 mm (mean ± SD, 157 ± 114 minutes vs 68 ± 50 min; P < .01), dissection speed for lesions >50 mm was significantly faster than for lesions 20 mm to 50 mm (P < .01). There were no significant differences in en bloc R0 resection rate comparing both groups (>50 mm, 83% vs 20 mm to 50 mm, 87%; P = .31). No perforations or postoperative bleeding occurred in patients with lesions >50 mm. Post-ESD colorectal strictures requiring intervention did not develop in any patient.

CONCLUSIONS

ESD for superficial colorectal tumors >50 mm is feasible. ESD of these lesions had a high R0 resection rate and a low adverse event rate. En bloc resection by ESD provides adequate pathological specimens and may limit the need for surgical intervention.

Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection

BACKGROUND

Most mucosal defects that occur with endoscopic submucosal dissection (ESD) can be closed completely using endoscopic clips. However, benefits of such closure in wound healing are unknown. A randomized controlled study evaluated the efficacy of closure with clips compared with no closure.

METHOD

Twenty-eight patients who had undergone ESD were randomly divided into two groups: closure (n = 14) and non-closure groups (n = 14). In the closure group, the mucosal defect resulting from ESD was closed using endoscopic clips. Four weeks after ESD, defects in both groups were observed by colonoscopy. Efficacy was based on change in the area of the defect, percentage of complete healing in each group, and complications.

RESULT

Data were analyzed for 26 of the 28 patients (13, closure group; 13, non-closure group). All tumors were resected en bloc by ESD without bleeding or perforation. In the closure group, the area of the defect just after ESD was 677 ± 306 mm(2) (mean ± SD) as determined by the size of the removed lesion and had decreased to 2.17 ± 4.51 mm(2) at 4 weeks after ESD (reduction, 99.7 %), but in the non-closure group that area was 790 ± 221 mm(2) and had decreased to 27.42 ± 25.72 mm(2) at 4 weeks post-ESD (reduction, 96.2 %). The reduction rate was significantly higher in the closure than in the non-closure group (99.7 vs. 96.2 %, p = 0.010). Complete healing was 69.2 % in the closure group vs. 7.7 % in the non-closure group (p = 0.005). Multivariate analysis showed that closure of the mucosal defect (OR 24.029, 95 % CI 2.09-276.15, p = 0.011) was an independent factor associated with complete healing at 4 weeks after ESD. Delayed perforation or post-ESD bleeding was not observed in any participant.

CONCLUSION

Use of endoscopic clips for closure of defects after ESD is safe and efficacious in accelerating wound healing.

TRIAL REGISTRATION

UMIN-CTR UMIN000009112.

Risk of infection after iatrogenic perforation of the gut wall? Evaluation of preventive strategies in a randomized controlled animal trial

BACKGROUND

Interventional endoscopies entail a risk of infection secondary to perforation of the luminal wall. Thereby, bacteria may be introduced into the sterile environment of the peritoneal cavity (PC). Limited data are available regarding the efficacy of prophylactic anti-infective treatments. The aim of the study was to examine the efficacy/safety of anti-infective means in the prevention of infection by interventional endoscopies in a randomized controlled animal trial.

METHODS

Forty pigs were randomized to: 1: control; 2: oral lavage; 3: gastric lavage; 4: oral/gastric lavage; 5: i.m. antibiotics. Lavage was performed with Octenisept prior to the operation. After gastric wall perforation, peritoneoscopy was performed. Before the procedure, after closure and prior to autopsy, intraabdominal lavage for bacterial culture was taken using mini-laparoscopy. At autopsy, macroscopic appearance of the PC was scored. Lavage fluids were grown to identify/quantify bacterial load. Concentration of intraperitoneal bacteria at autopsy was defined as main outcome parameter.

RESULTS

No major complications occurred in any of the procedures. Bacterial load of the PC at autopsy was significantly reduced with antibiotics compared to all other groups, whereas it did not differ between the lavage groups and control. Macroscopic scoring of the PC showed significant lower rate of intraabdominal abscesses in the antibiotic group compared to the lavage groups and control (p < 0.01).

CONCLUSION

Only antibiotic prophylaxis is effective for the prevention of infection after iatrogenic perforation of the gastrointestinal wall. There was no difference between any form of lavage and the control group. Further studies in humans are required to prove these animal data.

Risk of bleeding after endoscopic submucosal dissection for colorectal tumors in patients with continued use of low-dose aspirin

BACKGROUND

Although Japanese guidelines proposed by the Japan Gastroenterological Endoscopy Society for endoscopic submucosal dissection (ESD) for colorectal tumors recommend continued use of low-dose aspirin (LDA), this strategy is controversial. It was our practice to interrupt LDA therapy 5-7 days before ESD until December 2010, when we instituted the new guidelines and performed ESD without interrupting LDA therapy. The aim of the present study was to confirm the validity of the noninterrupted use of LDA inpatients undergoing ESD for colorectal tumors.

METHODS

We studied 582 consecutive patients with 609 colorectal tumors who underwent ESD at Hiroshima University Hospital between January 2006 and July 2014. The patients comprised three groups: LDA-interrupted group (13 patients with 13 colorectal tumors), LDA-continued group (28 patients with 31 colorectal tumors), and no anticoagulant/antiplatelet group (541 patients with 565 colorectal tumors).

RESULTS

The en bloc resection rate was 100% (13/13) in the LDA-interrupted group and 90.3% (28/31) in the LDA-continued group. Incidences of poor bleeding control during the procedure and bleeding after the procedure were 7.7% (1/13) and 15.4% (2/13) of patients, respectively, in the LDA-interrupted group, and 3.2% (1/31) and 16.1% (5/31) of patients, respectively, in the LDA-continued group. No patients experienced ischemic events in the perioperative period.

CONCLUSIONS

Our data suggest that continued use of LDA increased the risk of bleeding after ESD for colorectal tumors compared with nonuse of anticoagulant/antiplatelets. No significant difference was seen between the LDA-continued group and the LDA-interrupted group.

Endoscopic submucosal dissection as total excisional biopsy for clinical T1 colorectal carcinoma

BACKGROUND/AIMS

Only the depth of submucosal invasion can be estimated prior to determining the indications for endoscopic submucosal dissection (ESD) as a curative treatment for colorectal carcinoma (CRC). Here we evaluated the outcomes of ESD for clinical T1 CRCs.

METHODS

Of 660 patients who underwent ESD for CRC at the Hiroshima University Hospital between June 2003 and December 2013, we examined the outcomes of 37 (6%; 26 men, 11 women; mean age ± SD, 68 ± 12 years) who underwent ESD as total excisional biopsy for various reasons, in spite of an endoscopic diagnosis of T1 CRC.

RESULTS

The mean lesion size was 25 ± 14 mm; 14 lesions were protruding and 23 were superficial. The en bloc resection rate was 100% (37/37). The histological en bloc resection rate was 92% (34/37). ESD resulted in a positive vertical margin in 3 cases. Deep submucosal invasion was seen in 3 cases, 2 of which had severe submucosal fibrosis. Although severe submucosal fibrosis was not found in other cases, pathologic examination of the deepest invasive portion of the tumor revealed poorly differentiated adenocarcinoma. The rates of post-ESD bleeding and perforation were 8% (3/37) and 5% (2/37), respectively. All patients recovered under conservative therapy. No cases of recurrence were noted in patients without additional surgical resection when the lesions satisfied the curative conditions listed in the 2014 Japanese Society for Cancer of the Colon and Rectum guidelines.

CONCLUSION

En bloc resection by ESD as total excisional biopsy for clinical T1 CRC is a highly effective treatment and establishes a precise histological diagnosis.

Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand?

BACKGROUND AND AIM

Iatrogenic perforation of the gut during endoscopy remains an uncommon but critical complication with significant morbidity and probable mortality than usual surgical treatment. Some authors have adopted a non-surgical closure method in chosen cases and, since 1993, endoclips have been used to close perforation in the stomach. The endoscopic practice of endoclips has been commonly used in the gut for hemostasis. Currently, the use of endoscopic techniques is increasing for the closure of endoscopic submucosal dissection or endoscopic mucosal resection. Endoscopic perforations that improved with endoscopic closure in the literature prior to 2008 have been previously described. In the present article, we present a descriptive review of cases with iatrogenic perforation in the gut treated with endoclips between 2008 and 2014.

METHODS

Comprehensive literature screening and a systematic review using PubMed and Medline was done for all reports published between January 2008 and December 2014 using the endoclip technique in the closure of iatrogenic perforations.

RESULTS

A total of 47 studies published between 2008 and 2014 using endoclips for the closure of iatrogenic perforations of the gut (nine esophagus, 11 stomach, 15 duodenum, 12 colon and rectum) were found. All studies were explained briefly and summarized in a table.

CONCLUSIONS

There is strong evidence to show the efficacy of endoclips in the management of iatrogenic perforations, especially when recognized early. Limitations of endoclipping such as inefficiency against large perforations may be overcome by improving novel techniques in the future.

JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence-based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas.

Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan

OBJECTIVES

Conventional endoscopic resection (CER) is a widely accepted treatment for early colorectal neoplasia; however, large colorectal neoplasias remain problematic, as they necessitate piecemeal resection, increasing the risk of local recurrence. Endoscopic submucosal dissection (ESD) can improve the en bloc resection rate. This study aimed to evaluate local recurrence and its associated risk factors after endoscopic resection (ER) for colorectal neoplasias ≥20 mm.

METHODS

A multicenter prospective study at 18 medium- and high-volume specialized institutions was conducted in Japan. Follow-up colonoscopy was performed after 12 months in cases of complete resection and after 3-6 months in cases of incomplete resection. Local recurrence was confirmed by endoscopic findings and/or pathological analysis.

RESULTS

Follow-up colonoscopy was performed in 1,524 of 1,845 enrolled colorectal neoplasias (mean age, 65 years; 885 men; median tumor size, 32.8 mm). The local recurrence rates were 4.3% (65/1,524), 6.8% (55/808), and 1.4% (10/716) for the entire cohort, for CER, and for ESD, respectively. The relative risks of local recurrence were 0.21 (95% confidence interval, 0.11-0.39) with ESD compared with CER, 0.32 (95% confidence interval, 0.11-0.92) with en bloc ESD compared with en bloc CER, and 0.90 (95% confidence interval, 0.39-2.12) with piecemeal ESD compared with piecemeal CER. Significant factors associated with local recurrence were piecemeal resection, laterally spreading tumors of granular type, tumor size ≥40 mm, no pre-treatment magnification, and ≤10 years of experience in CER, and piecemeal resection only in ESD.

CONCLUSIONS

En bloc ESD reduces the local recurrence rate for large colorectal neoplasias. Piecemeal resection is the most important risk factor for local recurrence regardless of the ER method used.

Advanced polypectomy and resection techniques

Most colorectal cancer arises from adenomatous polyps. This gradual process may be interrupted by screening and treatment using colonoscopy and polypectomy. Advances in imaging platforms have led to classification systems that facilitate prediction of histologic type and both stratification for and prediction of the risk of invasion. Endoscopic treatment should be the standard of care even for extensive advanced mucosal neoplasm. Technique selection is influenced by lesion features, location, patient factors, and local expertise. Postprocedural complications are more common following advanced resection and endoscopists should be familiar with risk factors, early detection methods, and management.

Safe and efficient colorectal endoscopic submucosal dissection in European settings: is successful implementation of the procedure possible?

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is gaining worldwide recognition as valuable alternative to treat early colorectal neoplasia. Although the method is perceived as technically difficult and carries a higher risk of complications than conventional endoscopy, the oncological results are very promising. Herein we aim to present the treatment outcomes of ESD for lesions in the colon and rectum at the beginning of our learning curve.

METHODS

Seventy consecutive cases of colorectal ESD carried out in our center between June 2013 and May 2014 were analyzed. Effectiveness of dissection, complications and tumor recurrence after 3 months of treatment were investigated.

RESULTS

Of the 70 ESD procedures, 39 were in the rectum, 10 in the sigmoid, eight in the descending colon, six in the ascending colon and seven in the cecum. Average size of removed tumors was 38.1 mm. In 50 cases, en-block resection was achieved. In this group, 97% cases were R0 resection. Perforation occurred in four cases (5.7%) of which three were managed with endoclips. In four cases, significant bleeding occurred. In a follow-up examination, two of 41 patients (4.9%) had recurrent adenoma that was successfully endoscopically removed.

CONCLUSIONS

The results confirm that ESD is an effective and safe modality for treatment of colorectal epithelial neoplasia in the colon and rectum even at the beginning of the learning curve. After proper training, results in Europe and Japan may be comparable.

Evidence-based clinical practice guidelines for management of colorectal polyps

BACKGROUND

Recently in Japan, the morbidity of colorectal polyp has been increasing. As a result, a large number of cases of colorectal polyps that are diagnosed and treated using colonoscopy has now increased, and clinical guidelines are needed for endoscopic management and surveillance after treatment.

METHODS

Three committees [the professional committee for making clinical questions (CQs) and statements by Japanese specialists, the expert panelist committee for rating statements by the modified Delphi method, and the evaluating committee by moderators] were organized. Ten specialists for colorectal polyp management extracted the specific clinical statements from articles published between 1983 and September 2011 obtained from PubMed and a secondary database, and developed the CQs and statements. Basically, statements were made according to the GRADE system. The expert panel individually rated the clinical statements using a modified Delphi approach, in which a clinical statement receiving a median score greater than seven on a nine-point scale from the panel was regarded as valid.

RESULTS

The professional committee created 91CQs and statements for the current concept and diagnosis/treatment of various colorectal polyps including epidemiology, screening, pathophysiology, definition and classification, diagnosis, treatment/management, practical treatment, complications and surveillance after treatment, and other colorectal lesions (submucosal tumors, nonneoplastic polyps, polyposis, hereditary tumors, ulcerative colitis-associated tumor/carcinoma).

CONCLUSIONS

After evaluation by the moderators, evidence-based clinical guidelines for management of colorectal polyps have been proposed for 2014.

Untutored learning curve to establish endoscopic submucosal dissection on competence level

BACKGROUNDS/AIMS

Endoscopic submucosal dissection (ESD) of early cancer allows precise staging and avoids recurrence or surgery. Tutored by experts, ESD has rapidly spread in Japan, but still demands untutored learning in Western countries. A step-up approach starts with easiest gastric neoplasias, but fails on their low prevalence in Western countries. A prevalence-based approach includes challenging colonic neoplasias.

METHODS

We analyzed an untutored series of initial 50 ESD procedures by an experienced endoscopist on consecutive lesions referred according to prevalence.

RESULTS

Overall, 48 lesions (20% upper gastrointestinal, 80% colorectal; 2 hyperplastic (inflammatory) lesions, 46 neoplasms) were completely resected intention-to-treat with ESD, 2 required a second ESD. Neoplasias were resected 76% en-bloc (46% ESD, 30% ESD with snaring), 17% by ESD with snaring in 2-3 pieces, and 6.5% as ESD with snaring in multiple pieces. None of 15 neoplasias with high-grade intraepithelial neoplasia or an early esophageal cancer (R0) had recurred. Complications were 2 bleedings (4%) and 7 perforations (14%), 5 clipped and 2 (4%) operated. All patients were discharged within 9 days without long-term morbidity.

CONCLUSION

Untutored learning of ESD is feasible on colonic lesions. We propose to establish ESD in Europe with structured training and a prevalence-of-lesions-based approach.

Towards safer and appropriate application of endoscopic submucosal dissection for T1 colorectal carcinoma as total excisional biopsy: future perspectives

According to the Japanese Society for Cancer of the Colon and Rectum Guidelines 2014 for the Treatment of Colorectal Cancer, cases with T1 colorectal carcinoma should be considered for additional colectomy with lymph node dissection when histologically complete en bloc resection is endoscopically carried out and when one of the four risk factors listed below is present. These four risk factors are: (i) submucosal (SM) invasion depth ≥1000 μm; (ii) positive vascular invasion; (iii) poorly differentiated adenocarcinoma, signet ring cell carcinoma, or mucinous carcinoma; and (iv) grade 2/3 budding at the deepest part of SM invasion. However, the probability of lymph node metastasis is extremely low if none of these risk factors are present, with the exception of SM invasion depth ≥1000 μm. Consequently, it is assumed that there will be an increasing number of cases where no additional surgery is done, or cases of moderate invasive carcinoma in which endoscopic treatment is carried out to achieve an excisional biopsy, for which complete resection is applicable. In these cases, the preoperative diagnosis, resection techniques such as endoscopic submucosal dissection, features of resected specimens, and the accuracy of pathological diagnosis are all extremely important.

Simple and reliable treatment for post-EMR artificial ulcer floor with snare cauterization for 10- to 20-mm colorectal polyps: a randomized prospective study (with video)

BACKGROUND

Comparative studies on wound surface treatments after endoscopic mucosal resection (EMR) of 10- to 20-mm colorectal polyps have not been reported. We conducted a prospective trial of postoperative hemorrhage prevention measures after EMR of such polyps.

METHODS

Of 138 patients (397 polyps) who had undergone EMR, 62 patients (148 polyps) with 10- to 20-mm colorectal polyps were enrolled. Using the sealed envelope method, the subjects were randomly assigned to either a snare cauterization (75 polyps) or clip closure group (73 polyps). The primary assessment item was the wound surface treatment time (from immediately after polyp resection to wound surface treatment completion). The secondary assessment items were the incidence of delayed bleeding, perforation incidence 1-7 days after EMR, and difference in medical costs between the groups (University Hospital Medical Information Network: No. 000013473).

RESULTS

The time required for wound surface treatment completion was 3.26 ± 1.57 min in the snare cauterization group and 12.7 ± 2.92 min in the clip closure group, thus demonstrating a significant difference (P = 0.0001). Delayed bleeding was observed in two patients in the clip group, but was not observed in the snare cauterization group (P = 0.098). The clip group required the use of 720 clips that cost \523,410, US $5,163.50, or <euro>3,665.5.

CONCLUSIONS

After EMR of with 10- to 20-mm colorectal polyps, snare cauterization was superior to clip closure in terms of procedure time, and medical costs, and not inferior to clip closure in terms of the preventing effect of delayed bleeding.