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Keane MG, Mony S, Wood LD, Kumbhari V, Khashab MA. Prophylactic appendiceal retrograde intraluminal stent placement (PARIS). VideoGIE 2021; 6:552-554. [PMID: 34917867 PMCID: PMC8646081 DOI: 10.1016/j.vgie.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Margaret G Keane
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Shruti Mony
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Laura D Wood
- Sol Goldamn Pancreatic Cancer Research Center, Johns Hopkins University, Baltimore, Maryland
| | - Vivek Kumbhari
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Mouen A Khashab
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
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2
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Indo N, Anami T, Kitamura Y, Watanabe A. Effectiveness of counter traction using a clip with a looped thread for colorectal endoscopic submucosal dissection. Endosc Int Open 2021; 9:E306-E312. [PMID: 33655026 PMCID: PMC7892277 DOI: 10.1055/a-1336-2460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022] Open
Affiliation(s)
- Naohiko Indo
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan,Kohshinkai Gastroenterological Endoscopic Clinic, Osaka, Japan
| | - Takahiro Anami
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yasuaki Kitamura
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan
| | - Akihiko Watanabe
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan
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3
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Chen W, Zhang YL, Zhao Y, Yang AM, Qian JM, Wu D. Endoscopic resection for non-polypoid dysplasia in inflammatory bowel disease: a systematic review and meta-analysis. Surg Endosc 2021; 35:1534-1543. [PMID: 33523273 DOI: 10.1007/s00464-020-08225-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/03/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND This systematic review and meta-analysis aims to evaluate efficacy and safety of endoscopic treatment for the non-polypoid dysplasia in patients with long-standing IBD. METHODS Medline, Embase, Cochrane, and clinicaltrials.gov registry were comprehensively searched. Pooled estimates of curative, R0, en-bloc resection rates, CRC, metachronous dysplasia, and local recurrence rates were calculated. Subgroup analysis according to areas, lesion size, endoscopic resection techniques, and grades of dysplasia were conducted. Data synthesis was completed in R using the package "meta". RESULTS Of the 973 studies initially identified, 7 met the inclusion/exclusion criteria. These were all single-arm cohorts and included a total of 202 patients with IBD and non-polypoid dysplasia. The combined R0 and en-bloc resection rate were 0.70 (95% CI 0.55-0.81) and 0.86 (95% CI 0.65-0.95), respectively, with a recurrence rate of 0.08 (95% CI 0.05-0.13). CRC and metachronous dysplasia incidences were pooled as 32.53 (95% CI 12.21-86.67) and 90.24 (95% CI 44.91-181.33) per 1000 patient years. CONCLUSIONS Non-polypoid dysplasia associated with IBD can be resected endoscopically, especially by ESD. However, these patients have higher CRC and metachronous dysplasia incidence rates than patients with polypoid dysplasia, indicating a closer endoscopic surveillance.
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Affiliation(s)
- Wei Chen
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yue-Lun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Zhao
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ai-Ming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jia-Ming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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4
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Villa E, Stier M, Donboli K, Chapman CG, Siddiqui UD, Waxman I. Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting gastrointestinal neoplasia of the colon, expanded experience and follow-up. Endosc Int Open 2020; 8:E724-E732. [PMID: 32490156 PMCID: PMC7247895 DOI: 10.1055/a-1132-5323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/20/2020] [Indexed: 11/02/2022] Open
Abstract
Background and study aims Colonic lesions may not be amenable to conventional endoscopic mucosal resection (EMR) due to previous manipulation, submucosal invasion, or lesion flatness. In 2018, we described Dissection-enabled Scaffold Assisted Resection (DeSCAR) to be safe for the endoscopic resection of non-lifting or residual colonic lesions 1 In this study, we expand our original cohort to describe our expanded experience with patients undergoing DeSCAR and assess the efficacy, safety, and feasibility of DeSCAR for endoscopic resection of non-lifting or residual colonic lesions. Patients and methods We retrospectively reviewed 57 patients from 2015-2019 who underwent DeSCAR for colonic lesions with incomplete lifting and/or previous manipulation. Cases were reviewed for location, prior manipulation, rates of successful resection, adverse events, and endoscopic follow up to assess for residual lesions. Results Fifty-seven lesions underwent DeSCAR. Of the patients, 51 % were female, and average patient age was 69 years. Lesions were located in the cecum (n = 16), right colon (n = 27), left colon (n = 10), and rectum (n = 4). Average lesion size was 27.7 mm. Previous manipulation occurred in 54 cases (72 % biopsy, 44 % resection attempt, 18 % intralesional tattoo). The technical success rate for resection of non-lifting lesions was 98 %. There were two delayed bleeding episodes (one required endoscopic intervention) and one small perforation (managed by endoscopic hemoclip closure). Endoscopic follow up was available in 31 patients (54 %) with no residual adenoma in 28 patients (90 % of those surveilled). Conclusions Our expanded experience with DeSCAR demonstrates high safety, feasibility, and effectiveness for the endoscopic management of non-lifting or residual colonic lesions.
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Affiliation(s)
- Edward Villa
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Matthew Stier
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Kianoush Donboli
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Christopher Grant Chapman
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Uzma D. Siddiqui
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Irving Waxman
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
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5
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Guillaumot MA, Barret M, Jacques J, Legros R, Pioche M, Rivory J, Rahmi G, Lepilliez V, Chabrun E, Leblanc S, Chaussade S. Endoscopic full-thickness resection of early colorectal neoplasms using an endoscopic submucosal dissection knife: a retrospective multicenter study. Endosc Int Open 2020; 8:E611-E616. [PMID: 32355878 PMCID: PMC7164998 DOI: 10.1055/a-1127-3092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic full-thickness resection allows resection of early gastrointestinal neoplasms not amenable to conventional endoscopic resection techniques, due to their location, presence of submucosal fibrosis, or suspected deep mural invasion. It is typically achieved using a dedicated over-the-scope device (full-thickness resection device or FTRD). The aim of our study was to evaluate the feasibility, safety, and clinical outcomes of endoscopic full-thickness resection using an endoscopic submucosal dissection (ESD) knife. Patients and methods Consecutive patients who underwent full-thickness endoscopic resection at six tertiary care centers from August 2010 to June 2017 were retrospectively included. We conducted a comparative analysis of patient characteristics, technical success, adverse events, and time to discharge between patients treated by a full-thickness resection using an ESD knife. Results Twenty-one procedures were performed using an ESD knife. En-bloc resection and R0 resection rates were 95.2 % and 65 %, respectively. Clinical symptoms of perforation occurred in 66.7 %. There was no need for surgery or additional endoscopic procedures. Conclusion Endoscopic full-thickness resection of early colorectal neoplasms using an ESD knife might be feasible and safe. It allows complete resection of lesions with no limitation in size. The technique may be preferable to an other-the-scope resection device in lesions larger than 20 mm, and to surgery in selected cases of low-risk T1 colorectal carcinomas, non-lifting adenomas, submucosal tumors, or technically challenging lesion locations.
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Affiliation(s)
- Marie-Anne Guillaumot
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Jérémie Jacques
- Department of Gastroenterology, Limoges University Hospital, Limoges, France
| | - Romain Legros
- Department of Gastroenterology, Limoges University Hospital, Limoges, France
| | - Mathieu Pioche
- Department of Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Jérome Rivory
- Department of Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Digestive Endoscopy, Georges Pompidou European Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Vincent Lepilliez
- Department of Gastroenterology, Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Edouard Chabrun
- Department of Endoscopy and Gastroenterology, Bordeaux University Hospital, Bordeaux, France
| | - Sarah Leblanc
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
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6
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A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions. Surg Endosc 2020; 35:1296-1306. [PMID: 32180001 DOI: 10.1007/s00464-020-07504-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/03/2020] [Indexed: 02/07/2023]
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7
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Costa D, Brandão M, Costa R, Gonçalves R, Braga A, Rolanda C. Long-term follow-up after EMR of large colorectal lesions: metachronous lesions, predictors and surveillance timing. Scand J Gastroenterol 2019; 54:1487-1493. [PMID: 31821050 DOI: 10.1080/00365521.2019.1694066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Endoscopic mucosal resection (EMR) is the first-line approach to large colorectal sessile lesions. These patients have been associated with high rates of metachronous lesions (ML), but long-term follow-up (LtFU) data are lacking. We aimed at evaluating the efficacy of an LtFU protocol and analyse the development and risk factors for ML.Methods: A prospectively collected database was analysed. Seventy-six patients submitted to EMR of large colorectal sessile lesions between 2007 and 2013 complied with a specific endoscopic surveillance, consisting of two protocols - initial follow-up (iFU) and LtFU. iFU intended to inspect the mucosectomy scars twice (at 3-6 and 12 months) and remove synchronous lesions (SL). Protocol examinations of LtFU were carried out at the first- and fourth-year post-iFU, aiming to remove ML. Statistical analysis included variables related to patient, index lesion, SL and ML characteristics.Results: Rates of ML were 39.5% and 20.4% at the first- and fourth-year of LtFU, and respectively 11.8% and 3.7% of them were advanced ML. All ML were endoscopically resectable. At univariate analysis, male gender (OR: 2.91; p=.029), the presence of SL (OR 3.86, p=.010) and advanced SL (OR 4.25, p=.006) were risk factors for ML. At multivariate analysis, male gender (p=.031) and advanced SL (p=.006) were significant predictors of ML development.Conclusions: We confirmed the increased risk of ML in patients with large colorectal lesions. A significant number of advanced ML was removed at the first LtFU colonoscopy, probably it should be carried out earlier than currently recommended.
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Affiliation(s)
- Dalila Costa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal.,Department of Gastroenterology, Braga Hospital, Braga, Portugal
| | - Mariana Brandão
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - Rita Costa
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
| | | | - Ana Braga
- ALGORITMI Centre, University of Minho, Braga, Portugal
| | - Carla Rolanda
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal.,Department of Gastroenterology, Braga Hospital, Braga, Portugal
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8
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Emmanuel A, Lapa C, Ghosh A, Gulati S, Burt M, Hayee B, Haji A. Response. Gastrointest Endosc 2019; 90:542. [PMID: 31439145 DOI: 10.1016/j.gie.2019.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/12/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King's College Hospital, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Christo Lapa
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - Anil Ghosh
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - Shraddha Gulati
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Margaret Burt
- Department of Colorectal Surgery, King's College Hospital, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Bu'Hussain Hayee
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
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9
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Emmanuel A, Lapa C, Ghosh A, Gulati S, Burt M, Hayee B, Haji A. Risk factors for early and late adenoma recurrence after advanced colorectal endoscopic resection at an expert Western center. Gastrointest Endosc 2019; 90:127-136. [PMID: 30825536 DOI: 10.1016/j.gie.2019.01.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Few large Western series examine risk factors for recurrence after endoscopic resection (ER) of large (≥20 mm) colorectal laterally spreading tumors. Recurrence beyond initial surveillance is seldom reported, and differences between residual/recurrent adenoma and late recurrence are not scrutinized. We report the incidence of recurrence at successive surveillance intervals, identify risk factors for recurrent/residual adenoma and late recurrence, and describe the outcomes of ER of recurrent adenomas. METHODS Recurrence was calculated for successive surveillance periods after colorectal ER. Multiple logistic regression was used to identify independent risk factors for recurrent/residual adenoma and late recurrence (≥12 months). RESULTS Six hundred twenty colorectal ERs were performed, and 456 eligible patients (98%) had completed 3- to 6-month surveillance. Residual/recurrent adenoma (3-6 months) was detected in 8.3%, at 12 months in 6.1%, between 24 and 36 months in 6.4%, and after 36 months in 13.5%. Independent risk factors for residual/recurrent adenoma were piecemeal resection (odds ratio [OR], 13.0; P = .01), adjunctive argon plasma coagulation (OR, 2.4; P = .01), and lesion occupying ≥75% of the luminal circumference (OR, 5.6; P < .001) and for late recurrence were lesion size >60 mm (OR, 6.3; P < .001) and piecemeal resection (OR, 4.4; P = .04). Of 66 patients with recurrence, 5 required surgery, 8 left the treatment pathway, 20 are still receiving ER or surveillance, and 33 had ER with normal subsequent surveillance. CONCLUSIONS Recurrence occurs at successive periods of surveillance after ER even beyond 3 years. Aside from piecemeal resection, risk factors for residual/recurrent adenoma and late recurrence are different. Recurrence can be challenging to treat, but surgery is rarely required.
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Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Christo Lapa
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Anil Ghosh
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Shraddha Gulati
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Margaret Burt
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Bu'Hussain Hayee
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
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10
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Velegraki M, Trikola A, Vasiliadis K, Fragaki M, Mpitouli A, Dimas I, Voudoukis E, Giannikaki E, Kapranou A, Kordelas A, Stefanidis G, Paspatis GA. Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: clinical experience from two referral centers in Greece. Ann Gastroenterol 2019; 32:482-488. [PMID: 31474795 PMCID: PMC6686092 DOI: 10.20524/aog.2019.0392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD®) is an invasive treatment for colorectal lesions not resectable by conventional endoscopic techniques. This study presents the first Greek experience of the FTRD® procedure, assessing the efficacy and safety of EFTR. Methods: We conducted a retrospective analysis of 17 consecutive patients treated with the FTRD® at 2 referral centers from October 2015 through December 2018. The indications included difficult adenomas (non-lifting and/or at difficult locations), early adenocarcinomas and subepithelial tumors. Primary endpoints were technical success and R0 resection. Results: Technical success and R0 resection were achieved in 82.3% procedures (14/17) and in 87.5% of those with difficult adenomas (8 patients). In the subgroup with carcinomas (n=3), the rate of technical success and R0 resection was 66.6%, while in the subgroup with subepithelial tumors (n=6) the rate was 83.3%. Technical success and R0 resection were significantly lower for lesions >20 mm vs. ≤20 mm (P=0.0429). In the 17 patients a total of 3 adverse events occurred (17.6%) and one of the patients underwent laparoscopic appendectomy because of EFTR around the appendix. Conclusions: Our study showed favorable results concerning EFTR feasibility, efficacy and safety, especially for lesions ≤20 mm, non-lifting adenomas, and subepithelial tumors. Technical success, R0 resection, and adverse events rates were comparable with previously published data. Larger randomized studies are needed to better define the clinical benefit and long-term outcomes of EFTR in selected patients.
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Affiliation(s)
- Magdalini Velegraki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Artemis Trikola
- Department of Gastroenterology, Athens Naval Hospital, Athens (Artemis Trikola, Konstantinos Vasiliadis, Gerasimos Stefanidis)
| | - Konstantinos Vasiliadis
- Department of Gastroenterology, Athens Naval Hospital, Athens (Artemis Trikola, Konstantinos Vasiliadis, Gerasimos Stefanidis)
| | - Maria Fragaki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Afroditi Mpitouli
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Ioannis Dimas
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Evangelos Voudoukis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Elpida Giannikaki
- Department of Histopathology, Venizeleion General Hospital, Heraklion, Crete (Elpida Giannikaki)
| | - Amalia Kapranou
- Department of Histopathology, Athens Naval Hospital, Athens (Amalia Kapranou, Athanasios Kordelas), Greece
| | - Athanasios Kordelas
- Department of Histopathology, Athens Naval Hospital, Athens (Amalia Kapranou, Athanasios Kordelas), Greece
| | - Gerasimos Stefanidis
- Department of Gastroenterology, Athens Naval Hospital, Athens (Artemis Trikola, Konstantinos Vasiliadis, Gerasimos Stefanidis)
| | - Gregorios A Paspatis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
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11
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Andrisani G, Soriani P, Manno M, Pizzicannella M, Pugliese F, Mutignani M, Naspetti R, Petruzziello L, Iacopini F, Grossi C, Lagoussis P, Vavassori S, Coppola F, La Terra A, Ghersi S, Cecinato P, De Nucci G, Salerno R, Pandolfi M, Costamagna G, Di Matteo FM. Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD ®): A multicenter Italian experience. Dig Liver Dis 2019; 51:375-381. [PMID: 30377063 DOI: 10.1016/j.dld.2018.09.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/15/2018] [Accepted: 09/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Endoscopic full-thickness resection(EFTR) with FTRD® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety. MATERIAL AND METHODS In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ± 11 years, range 20-90) underwent EFTR using FTRD®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated. RESULTS TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients. CONCLUSIONS EFTR using FTRD® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.
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Affiliation(s)
- G Andrisani
- Digestive Endoscopy Unit, Campus Bio-Medico, Rome, Italy.
| | - P Soriani
- Digestive Endoscopy Unit, Ramazzini Hospital, Carpi, Modena, Italy
| | - M Manno
- Digestive Endoscopy Unit, Ramazzini Hospital, Carpi, Modena, Italy
| | | | - F Pugliese
- Diagnostic and Interventional Digestive Endoscopy, Niguarda Ca-Granda Hospital, Milan, Italy
| | - M Mutignani
- Diagnostic and Interventional Digestive Endoscopy, Niguarda Ca-Granda Hospital, Milan, Italy
| | - R Naspetti
- Surgical Endoscopy Unit, Careggi Hospital, Florence, Italy
| | - L Petruzziello
- Digestive Endoscopy Unit, Gemelli University Hospital, Rome, Italy
| | - F Iacopini
- Gastroenterology Endoscopy Unit, S.Giuseppe Hospital, Albano Laziale, Rome,Italy
| | - C Grossi
- Gastroenterology Endoscopy Unit, S.Giuseppe Hospital, Albano Laziale, Rome,Italy
| | - P Lagoussis
- Division Of General Surgery I, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - S Vavassori
- Division Of General Surgery I, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - F Coppola
- Department Gastroenterology, San Giovanni Bosco Hospital, Torino, Italy
| | - A La Terra
- Department Gastroenterology, San Giovanni Bosco Hospital, Torino, Italy
| | - S Ghersi
- Gastroenterology and Digestive Endoscopy Unit, AUSL Bologna, Bologna, Italy
| | - P Cecinato
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - G De Nucci
- Gastroenterology and Digestive Endoscopy Unit, A.O. Salvini, Garbagnate Milanese, Italy
| | - R Salerno
- Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - M Pandolfi
- Digestive Endoscopy Unit, Campus Bio-Medico, Rome, Italy
| | - G Costamagna
- Digestive Endoscopy Unit, Gemelli University Hospital, Rome, Italy
| | - F M Di Matteo
- Digestive Endoscopy Unit, Campus Bio-Medico, Rome, Italy
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12
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Thorlacius H, Rönnow CF, Toth E. European experience of colorectal endoscopic submucosal dissection: a systematic review of clinical efficacy and safety. Acta Oncol 2019; 58:S10-S14. [PMID: 30724676 DOI: 10.1080/0284186x.2019.1568547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is an advanced method allowing en bloc resection of large and complex lesions in colon and rectum. Herein, the European experience of colorectal ESD was systematically reviewed in the medical literature to determine the clinical efficacy and safety of colorectal ESD in Europe. MATERIAL AND METHODS A systematic search of PubMed for full-text studies including more than 20 cases of colorectal ESD emanating from European centres was performed. Data were independently extracted by two authors using predefined data fields, including efficacy and safety. RESULTS We included 15 studies containing a total of 1404 colorectal ESD cases (41% in the colon) performed between 2007 and 2018. Lesion size was 40 mm (range 24-59 mm) and procedure time was 102 min (range 48-176 min). En bloc resection rate was 83% (range 67-93%) and R0 resection rate was 70% (range 35-91%). Perforation rate was 7% (range 0-19%) and bleeding rate was 5% (range 0-12%). The percentage of ESD cases undergoing emergency surgery was 2% (range 0-6%). Additional elective surgery was performed in 3% of all cases due to histopathological findings showing deep submucosal invasion or more advanced cancer. The recurrence rate was 4% (range 0-12%) after a median follow-up time of 12 months (range 3-24 months). CONCLUSIONS This review shows that ESD is effective and safe for treating large and complex colorectal lesions in Europe although there is room for improvement. Thus, it is important to develop standardized and high-quality educational programs in colorectal ESD in Europe.
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Affiliation(s)
- Henrik Thorlacius
- Department of Clinical Sciences, Section of Surgery Skåne University Hospital Lund University, Malmö, Sweden
| | - Carl-Fredrik Rönnow
- Department of Clinical Sciences, Section of Surgery Skåne University Hospital Lund University, Malmö, Sweden
| | - Ervin Toth
- Department of Clinical Sciences, Section of Gastroenterology, Skåne University Hospital Lund University, Malmö, Sweden
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13
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Wu HH, East JE. Will endoscopic submucosal dissection (ESD) become the gold standard for laterally spreading tumors (LST)? Endosc Int Open 2019; 7:E260-E263. [PMID: 30707212 PMCID: PMC6353647 DOI: 10.1055/a-0808-4580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Henry H.L. Wu
- Academic Foundation Programme, Lancaster University and Royal Lancaster Infirmary, University Hospitals of Morecambe Bay, United Kingdom
| | - James E. East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, and Oxford NIHR Biomedical Research Centre, Oxford University Hospitals, United Kingdom
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14
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Rönnow CF, Elebro J, Toth E, Thorlacius H. Endoscopic submucosal dissection of malignant non-pedunculated colorectal lesions. Endosc Int Open 2018; 6:E961-E968. [PMID: 30083585 PMCID: PMC6070376 DOI: 10.1055/a-0602-4065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/12/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is an established method for en bloc resection of large non-pedunculated colorectal lesions in Asia but dissemination of ESD in Western countries is limited. The aim of this study was to evaluate the role of ESD in the management of malignant non-pedunculated colorectal lesions in a European center. PATIENTS AND METHODS Among 255 patients undergoing colorectal ESD between 2014 and 2016, 29 cases were identified as submucosal invasive cancers and included in this study. The main outcomes were en bloc, R0 and curative resection as well as procedural time, complications and recurrence. RESULTS Median tumor size was 40 mm (range 20 - 70 mm). Thirteen cancers were located in the colon and 16 were located in the rectum. Procedural time was 89 minutes (range 18 - 594 minutes). Complete resection was achieved in 28 cases, en bloc and R0 resection rates were 83 % and 69 %, respectively. Curative resection rate was 38 %. One case had a perforation in the sigmoid colon requiring emergency surgery. No significant bleeding occurred. Six patients underwent additional surgery after ESD, one of whom had residual tumor. One recurrence was detected in 20 patients that were followed-up endoscopically, median follow-up time was 13 months (range 2 - 30 months). CONCLUSION ESD seems to be a safe and effective method for treating non-pedunculated malignant colorectal lesions after careful patient selection and proper endoscopic training.
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Affiliation(s)
- Carl-Fredrik Rönnow
- Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Jacob Elebro
- Department of Clinical Sciences, Malmö, Section of Pathology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Ervin Toth
- Department of Clinical Sciences, Malmö, Section of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Henrik Thorlacius
- Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden,Corresponding author Henrik Thorlacius, MD, PhD Department of Clinical Sciences, MalmöSection of SurgerySkåne University HospitalLund UniversityS-205 02 MalmöSweden+46-40-336207
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Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center. Dis Colon Rectum 2018; 61:955-963. [PMID: 29944575 DOI: 10.1097/dcr.0000000000001144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm. OBJECTIVE We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions. DESIGN This was a retrospective study. SETTINGS The study was conducted in a tertiary referral unit for interventional endoscopy. PATIENTS A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm. MAIN OUTCOME MEASURES Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission. RESULTS Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%). LIMITATIONS This was a retrospective study. CONCLUSIONS Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.
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16
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Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, Neuhaus H, Albers D, Birk M, Thimme R, Probst A, Faehndrich M, Frieling T, Goetz M, Riecken B, Caca K. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67:1280-1289. [PMID: 28798042 DOI: 10.1136/gutjnl-2016-313677] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 06/14/2017] [Accepted: 07/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device. DESIGN 181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection. RESULTS EFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%. CONCLUSION EFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions. TRIAL REGISTRATION NUMBER NCT02362126; Results.
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Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany.,Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torsten Beyna
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | | | - Hans-Juergen Richter-Schrag
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Horst Neuhaus
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | - Michael Birk
- Department of Gastroenterology, University Hospital, Ulm, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Faehndrich
- Department of Gastroenterology, Klinikum Dortmund, Dortmund, Germany
| | - Thomas Frieling
- Department of Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany
| | - Martin Goetz
- Department of Gastroenterology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Bettina Riecken
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
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17
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Using Endoscopic Submucosal Dissection as a Routine Component of the Standard Treatment Strategy for Large and Complex Colorectal Lesions in a Western Tertiary Referral Unit. Dis Colon Rectum 2018; 61:743-750. [PMID: 29722731 DOI: 10.1097/dcr.0000000000001081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal endoscopic submucosal dissection results in high rates of en bloc resection, few recurrences, and accurate diagnosis, and it is useful in lesions with significant fibrosis. However, endoscopic submucosal dissection has not been widely adopted by Western endoscopists and the published experience from Western centers is very limited. OBJECTIVES This study aims to report the outcomes from a UK tertiary center using colorectal endoscopic submucosal dissection as part of a standard lesion specific treatment approach. DESIGN This was a retrospective study. SETTING The study was conducted in a tertiary referral unit for interventional endoscopy in the United Kingdom. PATIENTS A total of 116 colorectal lesions were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection in 107 patients. MAIN OUTCOME MEASURES Outcomes included complications, recurrence, requirement for surgery, en bloc and R0 resection. RESULTS One hundred sixteen lesions (mean size 58.8mm) were resected using endoscopic submucosal dissection (n = 58) and hybrid endoscopic submucosal dissection (n = 58). Eighty-two (70.7%) had failed attempts at resection (n = 58) or extensive sampling before referral. Twelve contained invasive adenocarcinoma; endoscopic resection was curative in 6. Only 2 of 6 patients with noncurative endoscopic resection agreed to surgery, and none had lymph node metastases. Six of 7 perforations were successfully treated with endoscopic clips. Where endoscopic submucosal dissection was used alone, en bloc resection was achieved in 93% and R0 resection was achieved in 91%. Two patients experienced recurrence; both were managed with endoscopic resection. LIMITATIONS This was a retrospective study. Procedures were planned as endoscopic submucosal dissection, but some may have been converted to hybrid endoscopic submucosal dissection and not recorded. CONCLUSION Colorectal endoscopic submucosal dissection can be used in a Western center as part of a standard lesion-specific approach to deliver effective organ-conserving treatment to patients with large challenging lesions. Lesion assessment in Western practice should be improved to reduce the incidence of prior heavy manipulation and to guide appropriate referral. See Video Abstract at http://links.lww.com/DCR/A601.
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18
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Gulati S, Emmanuel A, Burt M, Dubois P, Hayee B, Haji A. Outcomes of Endoscopic Resections of Large Laterally Spreading Colorectal Lesions in Inflammatory Bowel Disease: a Single United Kingdom Center Experience. Inflamm Bowel Dis 2018; 24:1196-1203. [PMID: 29668968 DOI: 10.1093/ibd/izx113] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The SCENIC consensus statement recommends endoscopic resection of all visible dysplasia in inflammatory bowel disease, but patients with large or complex lesions may still be advised to have colectomy. This article presents outcomes for large nonpolypoid resections associated with colitis at our institution. METHODS Data including demographics, clinical history, lesion characteristics, method of resection, and postresection surveillance were collected prospectively in patients with visible lesions within colitic mucosa from January 2011 to November 2016. Resection techniques included endoscopic mucosal resection , endoscopic submucosal dissection (ESD), and hybrid ESD. Surveillance with magnification chromoendoscopy was performed at 3 months, 1-year postresection, and annually thereafter. RESULTS Fifteen lesions satisfied the inclusion criteria in 15 patients. Mean lesion size was 48.3+/-21.7 (20-90) mm. All lesions were non-polypoid with distinct margins and no ulceration. 73% lesions were scarred of which 64% had undergone prior instrumentation. En bloc resection was achieved in n=6. Presumed endoscopic diagnosis was confirmed histopathologically in all resected lesions. One case of perforation and another with bleeding were both managed endoscopically. Median follow-up was 28 months (12-35) with no recurrence. CONCLUSION This cohort series demonstrates that endoscopic resection of large non-polypoid lesions associated with colitis is feasible and safe using an array of resection methods supporting the role of advanced endoscopic therapeutics for the management of colitis associated dysplasia in a western tertiary endoscopic center.
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Affiliation(s)
| | | | | | | | | | - Amyn Haji
- King's Institute of Therapeutic Endoscopy
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19
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Combining eastern and western practices for safe and effective endoscopic resection of large complex colorectal lesions. Eur J Gastroenterol Hepatol 2018; 30:506-513. [PMID: 29406437 DOI: 10.1097/meg.0000000000001086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic resection of large colorectal polyps is well established. However, significant differences in technique exist between eastern and western interventional endoscopists. We report the results of endoscopic resection of large complex colorectal lesions from a specialist unit that combines eastern and western techniques for assessment and resection. PATIENTS AND METHODS Endoscopic resections of colorectal lesions of at least 2 cm were included. Lesions were assessed using magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion-specific approach to resection with endoscopic mucosal resection or endoscopic submucosal dissection (ESD) was used. Surveillance endoscopy was performed at 3 (SC1) and 12 (SC2) months. RESULTS Four hundred and sixty-six large (≥20 mm) colorectal lesions (mean size 54.8 mm) were resected. Three hundread and fifty-six were resected using endoscopic mucosal resection and 110 by ESD or hybrid ESD. Fifty-one percent of lesions had been subjected to previous failed attempts at resection or heavy manipulation (≥6 biopsies). Nevertheless, endoscopic resection was deemed successful after an initial attempt in 98%. Recurrence occurred in 15% and could be treated with endoscopic resection in most. Only two patients required surgery for perforation. Nine patients had postprocedure bleeding; only two required endoscopic clips. Ninety-six percent of patients without invasive cancer were free from recurrence and had avoided surgery at last follow-up. CONCLUSION Combining eastern and western practices for assessment and resection results in safe and effective organ-conserving treatment of complex colorectal lesions. Accurate assessment before and after resection using magnification chromoendoscopy and a lesion-specific approach to resection, incorporating ESD where appropriate, are important factors in achieving these results.
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20
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Stier MW, Chapman CG, Kreitman A, Hart JA, Xiao SY, Siddiqui UD, Waxman I. Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting GI neoplasia of the colon (with video). Gastrointest Endosc 2018; 87:843-851. [PMID: 29158178 DOI: 10.1016/j.gie.2017.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/09/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS As a result of previous manipulation or submucosal invasion, GI lesions referred for EMR frequently have flat areas of visible tissue that cannot be snared. Current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. Our aim is to describe dissection-enabled scaffold-assisted resection (DeSCAR), a new technique combining circumferential ESD with EMR for removal of superficial non-lifting or residual "islands" with suspected submucosal involvement/fibrosis. METHODS From 2015 to 2017, lesions referred for EMR were retrospectively reviewed. Cases were identified where lifting and/or snaring of the lesion was incomplete and the DeSCAR technique was undertaken. Cases were reviewed for location, previous manipulation, rates of successful hybrid resection, and adverse events. RESULTS Twenty-nine lesions underwent DeSCAR because of non-lifting or residual "islands" of tissue. Fifty-two percent of the patients were male and 48% were female; average age was 66 years (standard deviation ±9.9 years). Lesions were located in the cecum (n = 10), right side of the colon (n = 12), left side of the colon (n = 4), and rectum (n = 3). Average size was 31 mm (standard deviation ±20.6 mm). Previous manipulation had occurred in 28 of 29 cases (83% biopsy, 34% resection attempt, 52% tattoo). The technical success rate for resection of non-lifting lesions was 100%. There was one episode of delayed bleeding but no other adverse events. CONCLUSIONS DeSCAR is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual GI lesions, providing en bloc resection of tissue for histologic review. Further studies are needed to demonstrate long-term eradication and for comparison with other methods.
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Affiliation(s)
- Matthew W Stier
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Christopher G Chapman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Allie Kreitman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - John A Hart
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Shu-Yuan Xiao
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
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21
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Iwatate M, Kitagawa T, Katayama Y, Tokutomi N, Ban S, Hattori S, Hasuike N, Sano W, Sano Y, Tamano M. Post-colonoscopy colorectal cancer rate in the era of high-definition colonoscopy. World J Gastroenterol 2017; 23:7609-7617. [PMID: 29204060 PMCID: PMC5698253 DOI: 10.3748/wjg.v23.i42.7609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/02/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the post-colonoscopy colorectal cancer (PCCRC) rate for high-definition (HD) colonoscopy compared with that for standard-definition colonoscopy reported previously.
METHODS Using medical records at Sano Hospital (SH) and Dokkyo Medical University Koshigaya Hospital (DMUKH), we retrospectively obtained data on consecutive patients diagnosed as having CRC between January 2010 and December 2015. The definition of PCCRC was diagnosis of CRC between 7 and 36 mo after initial high-definition colonoscopy that had detected no cancer, and patients were divided into a PCCRC group and a non-PCCRC group. The primary outcome was the rate of PCCRC for HD colonoscopy. The secondary outcomes were factors associated with PCCRC and possible reason for occurrence of early and advanced PCCRC.
RESULTS Among 892 CRC patients, 11 were diagnosed as having PCCRC and 881 had non-PCCRC. The PCCRC rate was 1.7% (8/471) at SH and 0.7% (3/421) at DMUKH. In comparison with the non-PCCRC group, the PCCRC group had a significantly higher preponderance of smaller tumors (39 mm vs 19 mm, P = 0.002), a shallower invasion depth (T1 rate, 25.4% vs 63.6%, P = 0.01), a non-polypoid macroscopic appearance (39.0% vs 85.7%, P = 0.02) and an earlier stage (59.7% vs 90.9%, P = 0.03). Possible reasons for PCCRC were “missed or new” in 9 patients (82%), “incomplete resection” in 1 (9%), and “inadequate examination’” in 1 (9%). Among 9 “missed or new” PCCRC, the leading cause was non-polypoid shape for early PCCRC and blinded location for advanced PCCRC.
CONCLUSION The PCCRC rate for HD colonoscopy was 0.7%-1.7%, being lower than that for standard-definition colonoscopy (1.8%-9.0%) reported previously employing the same methodology.
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Affiliation(s)
- Mineo Iwatate
- Gastrointestinal Center and Institute of Minimally-Invasive Endoscopic Care, Sano Hospital, Kobe, Hyogo 655-0031, Japan
- Department of Gastroenterology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan
| | - Tomoyuki Kitagawa
- Department of Gastroenterology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan
| | - Yasumi Katayama
- Department of Gastroenterology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan
| | - Naohiko Tokutomi
- Department of Gastroenterology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan
| | - Shinichi Ban
- Department of Pathology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan
| | - Santa Hattori
- Gastrointestinal Center and Institute of Minimally-Invasive Endoscopic Care, Sano Hospital, Kobe, Hyogo 655-0031, Japan
| | - Noriaki Hasuike
- Gastrointestinal Center and Institute of Minimally-Invasive Endoscopic Care, Sano Hospital, Kobe, Hyogo 655-0031, Japan
| | - Wataru Sano
- Gastrointestinal Center and Institute of Minimally-Invasive Endoscopic Care, Sano Hospital, Kobe, Hyogo 655-0031, Japan
| | - Yasushi Sano
- Gastrointestinal Center and Institute of Minimally-Invasive Endoscopic Care, Sano Hospital, Kobe, Hyogo 655-0031, Japan
| | - Masaya Tamano
- Department of Gastroenterology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan
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Mori H, Kobara H, Kobayashi N, Nishiyama N, Kobayashi S, Yagi T, Masaki T. One-to-One Correspondence Locations of Resected Polyps after Endoscopic Resection Using Catcher Tagged Method: A Randomized Prospective Study. Digestion 2017; 96:239-247. [PMID: 29136630 DOI: 10.1159/000484043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Multiple colorectal polyps with a diameter in the range of 10-19 mm are unable to be retrieved through a 3-mm endoscopic channel by the aspiration method. This study aims to assess the usefulness of Catcher Tag retrieval, which not only allows the accurate identification of the resected location but also enables the easiest retrieval in a short time without any special device. METHODS One hundred thirty five patients (483 polyps) were diagnosed with colorectal neoplasm, and 64 patients (225 polyps) were enrolled and randomly allocated into the Net forceps group (NET) and the Catcher Tagged group (TAG). In TAG, 3 types of colored ring-threads were used to retrieve resected polyps. After local injection of natural saline, ring-threads were placed close to polyps. The primary outcome was the number of one-to-one correspondence locations (UMIN000020826). RESULTS There was significant difference in one-to-one correspondence (p = 0.004). The average retrieval procedure time was 13.56 ± 3.47 (min) in NET and 3.55 ± 1.68 in TAG (p = 0.006). In NET, 1 polyp in each of 4 cases was lost during endoscopic mucosal resection and 2 polyps were lost in 1 case. In TAG, no polyp was lost (p = 0.016). CONCLUSION The Catcher Tagged method is very useful for accurate one-to-one correspondence locations and pathological evaluation, and easy-to-retrieve multiple resected specimens.
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Affiliation(s)
- Hirohito Mori
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki, Japan.,Department of Gastroenterological Surgery, Ehime Rosai Hospital, Niihama, Japan
| | - Hideki Kobara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Nobuya Kobayashi
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Seiki Kobayashi
- Department of Gastroenterological Surgery, Ehime Rosai Hospital, Niihama, Japan
| | - Takaharu Yagi
- Department of Gastroenterological Surgery, Ehime Rosai Hospital, Niihama, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki, Japan
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Von Renteln D, Bouin M, Barkun AN. Current standards and new developments of colorectal polyp management and resection techniques. Expert Rev Gastroenterol Hepatol 2017; 11:835-842. [PMID: 28319429 DOI: 10.1080/17474124.2017.1309279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colonoscopy and endoscopic removal of precancerous polyps play an important role in colorectal cancer (CRC) prevention. Improved endoscopes and quality standards have led to an increasing polyp and adenoma detection rate. Optimal polyp resection techniques and management strategies are key for an effective colonoscopy practice. Areas covered: Strategies for how to improve diminutive polyp (polyps up to 5 mm in size) management are discussed because of their high prevalence. Systematic removal of diminutive polyps leads to increasing costs of colonoscopy practice, while the effect on colorectal cancer prevention might be negligible. Furthermore, polypectomy recommendations for mid-size and large polyps are provided. For all larger polyps larger, complete and safe resection is mandatory to avoid post colonoscopy cancers. The focus for managing such larger polyps is to use new techniques (i.e. cold snares) and to attempt complete removal and to reduce post-polypectomy complications. Expert commentary: The resect-and-discard strategy is a promising management strategy for diminutive polyps. However, modification of this approach might be required in order to make widespread adoption feasible. Cold snare polypectomy is a promising new approach for small polyp resection. For resection of large polyps adequate treatment recommendations with regard to endoscopic mucosal resection and complication prevention are provided.
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Affiliation(s)
- Daniel Von Renteln
- a Department of Medicine, Division of Gastroenterology , Montreal University Hospital (CHUM) , Montreal , Canada
| | - Mickael Bouin
- a Department of Medicine, Division of Gastroenterology , Montreal University Hospital (CHUM) , Montreal , Canada
| | - Alan N Barkun
- b Division of Gastroenterology , McGill University Health Center, McGill University , Montreal , Quebec , Canada
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Emmanuel A, Gulati S, Burt M, Hayee B, Haji A. Colorectal endoscopic submucosal dissection: patient selection and special considerations. Clin Exp Gastroenterol 2017; 10:121-131. [PMID: 28761366 PMCID: PMC5516776 DOI: 10.2147/ceg.s120395] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Emmanuel
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Shraddha Gulati
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Margaret Burt
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Bu'Hussain Hayee
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Amyn Haji
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
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25
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Training and competency in endoscopic mucosal resection. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hewett DG, Sakata S. Classifications for optical diagnosis of colorectal lesions: not 2B with JNET. Gastrointest Endosc 2017; 85:822-828. [PMID: 28317692 DOI: 10.1016/j.gie.2017.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/07/2017] [Indexed: 02/06/2023]
Affiliation(s)
- David G Hewett
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Mater Health, Brisbane, Queensland, Australia
| | - Shinichiro Sakata
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Sakamoto H, Hayashi Y, Miura Y, Shinozaki S, Takahashi H, Fukuda H, Okada M, Ino Y, Takezawa T, Sunada K, Lefor AK, Yamamoto H. Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type. Endosc Int Open 2017; 5:E123-E129. [PMID: 28337483 PMCID: PMC5361878 DOI: 10.1055/s-0042-122778] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and study aims The pocket-creation method (PCM) is a novel strategy for endoscopic submucosal dissection (ESD). The aim of this study is to determine the efficacy of the PCM for colorectal laterally spreading tumors, non-granular type (LST-NG). Patients and methods The records of 126 consecutive patients with colorectal LST-NG who underwent ESD between April 2012 and July 2015 were retrospectively reviewed. Patients were divided into PCM (n = 73) and conventional method (CM) (n = 53) groups. Results The en bloc resection rate in the PCM group was significantly higher than in the CM group (100 % [73/73] vs. 92 % [49/53], P = 0.03). The en bloc resection rate with severe fibrosis was higher in the PCM group than in the CM group (100 % [3/3] vs. 60 % [3/5]). The R0 resection rate for the two groups was not statistically significantly different (93 % [68/73] vs. 91 % [48/53], P = 0.74). The perforation rate in the PCM group was lower than in the CM group although not statistically significantly less (0 % 0/73 vs. 4 % 2/53, P = 0.18). For lesions resected en bloc, dissection speed for the PCM group was significantly faster than for the CM group (median [IQR], 19 [13 -24] vs. 14 [10 - 22] mm2/min, P = 0.03). Conclusion ESD using PCM achieves a reliable and safe resection of colorectal LST-NG.
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Affiliation(s)
- Hirotsugu Sakamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshikazu Hayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshimasa Miura
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Satoshi Shinozaki
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan,Shinozaki Medical Clinic, Utsunomiya, Japan
| | - Haruo Takahashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Hisashi Fukuda
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Masahiro Okada
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yuji Ino
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Takahito Takezawa
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Keijiro Sunada
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | | | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan,Corresponding author Hironori Yamamoto, MD PhD 3311-1 YakushijiShimotsukeTochigi 329-0498Japan+81-285-406598
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Holmes I, Kim HG, Yang DH, Friedland S. Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos). Gastrointest Endosc 2016; 84:822-829. [PMID: 27080417 DOI: 10.1016/j.gie.2016.03.1512] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/30/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS EMR is used widely for treatment of nonpedunculated colorectal adenomas ≥ 2 cm. Recurrence at the resection site occurs in 10% to 30% of cases. METHODS Records of consecutive patients referred for endoscopic resection over a 4-year period were reviewed retrospectively. In the first part of the study period, our routine practice was to use argon plasma coagulation (APC) to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. In the second part of the study period, we changed our practice to use avulsion to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. We analyzed the effect of this change in practice on recurrence rates after EMR. RESULTS Two hundred twenty-three resected lesions were analyzed. Fifty-nine (26%) were treated with en-bloc EMR, 55 (25%) by piecemeal EMR with complete snare removal of all visible neoplasia, 63 (28%) by piecemeal EMR with APC of visible residual neoplasia, and 46 (21%) by piecemeal EMR with avulsion of visible residual neoplasia. There was no significant difference in adverse event rates among the 4 groups. The recurrence rates on follow-up colonoscopy were 4.2%, 3.0%, 59.3%, and 10.3%, respectively. The recurrence rate for patients treated with avulsion was significantly lower than for those treated with APC (odds ratio, .079; P < .001). Multivariate analysis demonstrated that use of avulsion instead of APC was a significant predictor of no recurrence. CONCLUSIONS After exhaustive attempts at snare resection during EMR, avulsion is superior to APC for treatment of residual visible neoplasia. Compared with APC, avulsion significantly decreases the recurrence rate without significantly increasing the risk of the procedure.
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Affiliation(s)
- Ian Holmes
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Hyun Gun Kim
- Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Shai Friedland
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
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