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

Evaluation of a new method, "non-injection resection using bipolar soft coagulation mode (NIRBS)", for colonic adenomatous lesions

BACKGROUND/AIMS

Endoscopic resection of all colorectal adenomatous lesions with a low complication rate, simplicity, and negative residuals is challenging. Hence, we developed a new method called "non-injection resection using bipolar soft coagulation mode (NIRBS)" method, adapted for colorectal lesions. In addition, we evaluated the effectiveness of this method.

METHODS

We performed NIRBS throughout a 12-month period for all colorectal lesions which snare resection was acceptable without cancerous lesions infiltrating deeper than the submucosal layer.

RESULTS

A total of 746 resected lesions were included in the study, with a 4.5 mm mean size (range, 1-35 mm). The major pathological breakdowns were as follows: 64.3% (480/746) were adenomas, and 5.0% (37/746) were intraepithelial adenocarcinomas (Tis lesions). No residuals were observed in any of the 37 Tis lesions (mean size, 15.3 mm). Adverse events included bleeding (0.4%) but no perforation.

CONCLUSIONS

NIRBS allowed the resection of multiple lesions with simplicity because of the non-injection and without perforating due to the minimal burn effect of the bipolar snare set in the soft coagulation mode. Therefore, NIRBS can be used to resect adenomatous lesions easily, including Tis lesions, from small to large lesions without leaving residuals.

Cold Versus Hot Snare Polypectomy for Colorectal Polyps: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

Endoscopic polypectomy is an excellent tool for colon cancer prevention. With the innovation of novel resection techniques, the best method is still being investigated. Hence, we aim to evaluate the efficacy and safety of cold snare polypectomy (CSP) versus hot snare polypectomy (HSP) for colorectal polyp resection.

METHODS

A systematic review and meta-analysis synthesizing evidence from randomized controlled trials retrieved from PubMed, EMBASE, WOS, SCOPUS, and CENTRAL until July 16, 2022. We pooled dichotomous outcomes using risk ratio (RR) with the corresponding CI. This review's protocol was prospectively registered in PROSPERO with ID: CRD42022347496.

RESULTS

We included 18 randomized controlled trials with a total of 4317 patients and 7509 polyps. Pooled RR favored HSP regarding the complete resection rate (RR: 0.96 with 95% CI: 0.95, 1, P = 0.03) and local recurrence incidence (RR: 5.74 with 95% CI: 1.27, 25.8, P = 0.02). Pooled RR favored CSP regarding the colonoscopy time (mean difference: -6.50 with 95% CI: -7.55, -5.44, P = 0.00001) and polypectomy time (mean difference: -57.36 with 95% CI: -81.74, -32.98, P = 0.00001). There was no difference regarding the incidence of immediate bleeding ( P = 0.06) and perforation ( P = 0.39); however, HSP was associated with more incidence of delayed bleeding ( P = 0.01), abdominal pain ( P = 0.007), and postresection syndrome ( P = 0.02).

DISCUSSION

HSP is associated with a higher complete resection and lower recurrence rates; however, HSP is also associated with a higher incidence of adverse events. Therefore, improving the complete resection rate with CSP still warrants more innovation, giving the technique safety and shorter procedure duration.

Bleeding After Endoscopic Resection of Colonic Adenomatous Polyps Sized 4-10 mm

Introduction: Colonoscopy with polypectomy is an efficacious procedure in reducing the risk of colorectal cancer development, the precursor are adenomatous polyps. The most common method for resection of polyps measuring 4-10 mm are cold (CSP) and hot snare polypectomy (HSP). CSP has a lower incidence of adverse events, especially delayed post-polypectomy bleeding. Aim: To evaluate the presence of immediate and delayed bleeding in the cold snare polypectomy of sub-centimeter polyps of the colon compared with hot snare polypectomy. Materials and Methods: This prospective clinical study is comprised all patients who were incidentally detected to have adenomatous colonic polyps measuring 4-10 mm during a colonoscopy screening. Polypectomy was done with (hot snare) or without electrocautery (cold snare). After removal of polyps, immediate bleeding, delayed bleeding, and methods for were analyzed. Results: The CSP and HSP groups included 116 patients, 113 (54.4%) polyps in 61 (52.6%) patients with CSP while 95 (45.6%) polyps in 55 (47.4%) patients with HSP. 25 (22.1%) polyps after CSP had immediate bleeding. In 5 patients (20.0%), five hemostatic clips were inserted after CSP for bleeding longer than 150 sek. The average percentage difference between immediate bleeding versus total number of resected polyps using the cold snare method is not statistically significant (p<0.05) (Difference test, p=0.0000). Delayed bleeding was not registered using this method. In the second investigated group (HSP), one patient had delayed bleeding. This was stopped with 2 clips. Immediate bleeding was not registered. Conclusion: CSP is safer than HSP in resecting colon polyps sized 4-10 mm, without risk of delayed bleeding.

Effectiveness and safety of endoscopic submucosal dissection using the pocket creation method in the Japanese population: a systematic review and meta-analysis

Background and study aims  Endoscopic submucosal dissection (ESD) is a standard method for minimally invasive resection of superficial gastrointestinal tumors. The pocket creation method (PCM) facilitates ESD regardless of location in the gastrointestinal tract. The aim of this systematic review and meta-analysis is to evaluate the effectiveness and safety of ESD for superficial neoplasms in the upper and lower gastrointestinal tract comparing the PCM to the non-PCM. Methods  Randomized controlled, prospective, and retrospective studies comparing the PCM with the non-PCM were included. Outcomes included en bloc resection, R0 resection, dissection speed, delayed bleeding and perforation. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) using the Mantel-Haenszel random effect model were documented. Results  Eight studies including gastric, duodenal, and colorectal ESD were included. The en bloc resection rate was significantly higher in the PCM group than the non-PCM group (OR 3.87, 95 %CI 1.24-12.10 P  = 0.020). The R0 resection rate was significantly higher in the PCM group than the non-PCM group (OR 2.46, 95 %CI 1.14-5.30, P  = 0.020). The dissection speed was significantly faster in the PCM group than the non-PCM group (mean difference 3.13, 95 % CI 1.35-4.91, P  < 0.001). The rate of delayed bleeding was similar in the two groups (OR 1.13, 95 %CI 0.60-2.15, P =  0.700). The rate of perforation was significantly lower in the PCM group than the non-PCM group (OR 0.34, 95 %CI 0.15-0.76, P =  0.009). Conclusions  The PCM facilitates high-quality, fast and safe colorectal ESD. Further studies are needed regarding the utility of PCM in ESD of the upper gastrointestinal tract.

Comparison of the Effectiveness and Safety of Different Methods of Colorectal Endoscopic Submucosal Dissection: A Systematic Review and Network Meta-Analysis

BACKGROUND

Traditional endoscopic submucosal dissection (ESD) has developed different methods, such as pocket method (P-ESD), traction-assisted method (T-ESD), and hybrid method (H-ESD). In this meta-analysis, the benefits and drawbacks of different ESD methods were discussed and ranked.

STUDY DESIGN

Studies comparing different methods of colorectal ESD were searched by using PubMed, EMBASE, and Cochrane Library databases. The study was conducted for five endpoints: en bloc resection rate, R0 resection rate, operation time, dissection speed, and adverse events rate. Pairwise and network meta-analyses were performed through Rev Man 5.4 and Stata 16.0. The quality of all included studies was assessed using the Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale.

RESULTS

Twenty-six studies met the inclusion criteria, including 7 RCTs and 19 non-RCTs, with a total of 3,002 patients. The pooled analysis showed that the en bloc resection rate of H-ESD was significantly lower than that of C-ESD, P-ESD, and T-ESD (RR = 0.28, 95% CI [0.12, 0.65]; RR = 0.11, 95% CI [0.03, 0.44]; RR = 8.28, 95% CI [2.50, 27.42]). Compared with C-ESD, the operation time of H-ESD and T-ESD was significantly shorter (MD = -21.83, 95% CI [-34.76, -8.90]; MD = -23.8, 95% CI [-32.55, -15.06]). Meanwhile, the operation time of T-ESD was also significantly shorter than that of P-ESD (MD = -18.74, 95% CI [-31.93, -5.54]). The dissection speed of T-ESD was significantly faster than that of C-ESD (MD = 6.26, 95% CI [2.29, 10.23]).

CONCLUSION

P-ESD and T-ESD are probably the two best methods of colorectal ESD at present. The advantages of P-ESD are high en bloc resection rate and low incidence of adverse events. The advantages of T-ESD are rapid dissection and short operation time.

Pocket-creation method versus conventional method of endoscopic submucosal dissection for superficial colorectal neoplasms: a meta-analysis

BACKGROUND AND AIMS

The pocket-creation method (PCM) is a newly developed strategy for colorectal endoscopic submucosal dissection (ESD). However, its superiority over the conventional method (CM) has not been established. The aim of this meta-analysis was to evaluate the efficacy and safety of PCM-ESD compared with CM-ESD for superficial colorectal neoplasms (SCNs).

METHODS

Literature searches were conducted using the Pubmed, Embase, and Cochrane Library databases, and a meta-analysis was performed. The primary outcome was the R0 resection rate, and the secondary outcomes were the en bloc resection rate, dissection speed, procedure time, and adverse event rate.

RESULTS

Five studies (2 randomized controlled trials and 3 retrospective studies) with 1481 patients were included in our meta-analysis. The pooled analysis showed that PCM-ESD achieved a higher R0 resection rate (93.5% vs 78.1%; odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.9; I² = 58%), a higher en bloc resection rate (99.8% vs 92.8%; OR, 9.9; 95% CI, 2.7-36.2; I² = 0), a shorter procedure time (minutes) (mean difference [MD], -11.5; 95% CI, -19.9 to -3.1; I² = 72%), a faster dissection speed (mm²/min) (MD, 3.6; 95% CI, 2.8-4.5; I² = 0), and a lower overall adverse event rate (4.4% vs 6.6%; OR, 0.6; 95% CI, 0.3-1.0; I² = 0) compared with CM-ESD.

CONCLUSIONS

This meta-analysis showed that PCM-ESD improves the efficacy and safety compared with CM-ESD for superficial colorectal neoplasms.

New modality for the quantitative evaluation of tissue elasticity using a forward-viewing radial-array echoendoscope for colorectal neoplasms

PURPOSE

Sound speed correction (SSC) is a non-invasive modality that quantifies the hardness of neoplasms. The aim of our study was to evaluate the usefulness of SSC for the diagnostic accuracy of colorectal neoplasms and to differentiate the depth of invasion.

METHODS

Forty colorectal neoplasms, contributed by 40 patients, were included in the analysis. The primary outcome was the diagnostic ability of SSC for the depth of invasion of colorectal neoplasms, with the secondary endpoint being the clinical efficacy of SSC to distinguish between a neoplasm and normal mucosa.

RESULTS

The median sound speeds for colorectal neoplasms and normal mucosa were 1580 m/s and 1515 m/s, respectively (p < 0.001), with a median sound speed of 1583 m/s for lesions with a depth shallower than that of the muscularis propria and 1610 m/s for depths deeper than that of the muscularis propria (p = 0.002). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80.0%, 100%, 100%, 83.3%, 90.0%, and 100%, respectively, for the diagnosis of neoplasms (using a cut-off sound speed of 1557 m/s) and 100%, 77.8%, 33.3%, 100%, 80.0%, respectively, for the diagnosis of the depth of invasion (using a cut-off of 1590 m/s).

CONCLUSION

We identified absolute sound speeds for colorectal neoplasms and the depth of invasion of neoplasms which yielded a good diagnostic performance. SSC provides an objective evaluation of colorectal neoplasms and the depth of invasion of neoplasms and, thus, might be a useful modality in practice.

TRIAL REGISTRATION

UMIN000038235 , Date of registration; October 8, 2019.

ESD and Pit Pattern Diagnosis: Lessons from a Japanese Endoscopist Working in the United States

Endoscopic submucosal dissection (ESD) was developed in 2000s to overcome the limitations of endoscopic mucosal resection (EMR), especially to accomplish en-bloc resection, and it has been accepted worldwide in the past decades. Many ESD devices and diagnosis modalities are currently available, which include pit pattern and narrow band imaging (NBI) diagnoses to evaluate the depth of the tumor preoperatively with sensitivities of 70 to 90%. Depending on the Japanese colorectal guideline, the intramucosal cancer and shallow invasion of the submucosal layer are the main good indications of ESD; however, the ESD practices between Japan and Western countries still vary, including pathologic definition of cancer, tumor/node/metastasis classification, and handling of ESD specimen. In the United States, despite the large demand for treatment of colorectal neoplasm, pit pattern and magnified NBI diagnoses are not widely accepted yet, and piecemeal EMR is still the major method in most of the institutions. Moreover, the specific guideline of ESD is also not available yet. More new technologies are being developed other than conventional ESD methods in Eastern and Western countries, and ESD is now expected to change in the next generation. It is recommended that not only gastroenterologists but also colorectal surgeons have appropriate knowledge of colorectal lesions and their management to ensure current treatments is applied to patients.

Comparison of dissection speed during colorectal ESD between the novel Multiloop (M-loop) traction method and ESD methods without traction

Background and study aims  We previously reported on a novel traction method called Multiloop (M-loop) for faster colorectal endoscopic submucosal dissection (ESD). In this study, we retrospectively compared the difference in submucosal dissection time (SDT), and submucosal dissection speed (SDS) between groups of patients who were treated using traction with the M-loop method, and with non-traction methods of colorectal ESD. Patients and methods  We reviewed and timed duration of colorectal ESD by the non-traction method from videos recorded between June 2016 and December 2017. From January 2018 onward, we used the M-loop method during all colorectal ESDs and timed it until August 2018. Outcomes of colorectal ESD with the M-loop method and non-traction methods were compared. The study involved two experts and eight non-experts and was carried out at a tertiary endoscopic center in Japan. Results  The study included 50 patients who treated with the M-loop method and 115 patients treated with the non-traction method. Submucosal dissection time (SDT) was not significantly different (M-loop group, 42.1  ±  4.2 min, non-traction ESD group, 51.9 ± 3.3 min) ( P  = 0.098), but submucosal dissection speed (SDS) was significantly greater (M-loop group, 28.0 ± 2.9 mm ²  /min, non-traction ESD group, 19.9 ± 2.0 mm ² /min) ( P  = 0.0014) in the M-loop method group. Multivariate analysis showed that the M-loop method increased SDS by odds ratio of 1.46 ( P  = 0.001) when compared to the non-traction ESD method. A significant difference was also observed for SDT and SDS when the two methods were compared after propensity score matching ( P  = 0.001). No differences in unfavorable outcomes were observed. Conclusions  The M-loop method improved SDS compared to non-traction methods of ESD. The method is an effective tool to assist colorectal ESD.

Clinical utility of the pocket-creation method with a traction device for colorectal endoscopic submucosal dissection

BACKGROUND

Colorectal endoscopic submucosal dissection (ESD) is technically demanding while ensuring safety, especially in cases with fibrosis and/or poor maneuverability. To overcome such difficulties, we developed a novel method called the pocket-creation method with a traction device (PCM with TD). We then evaluated the effectiveness and safety of PCM with TD in colorectal ESD compared to other conventional methods.

METHODS

In total, 324 colorectal lesions treated with ESD from July 2018 to June 2019 were included. The following three treatment strategies were used: conventional ESD (CE), CE with TD, and PCM with TD. Patient backgrounds and treatment outcomes were retrospectively compared and analyzed.

RESULTS

As ESD methods, CE, CE with TD, and PCM with TD account for 58% (187/324), 24% (78/324), and 18% (59/324), respectively. No significant difference was observed among the three groups in en bloc and R0 resection rates or adverse events. The rate of lesions with fibrosis and poor maneuverability was significantly higher in the PCM with TD group (CE group vs CE with TD group vs PCM with TD group: fibrosis, 24% vs 47% vs 64%, p < 0.001; poor maneuverability, 5.3% vs 13% vs 20%, p = 0.002). Dissection speed was significantly higher in the PCM with TD than in the CE with TD group (p = 0.003).

CONCLUSIONS

PCM with TD can achieve a stable en bloc resection rate and R0 dissection rate without adverse events even in the hands of trainees, irrespective of the size and location of the lesion, presence of fibrosis, and under poor maneuverability conditions.

Multiloop as a novel traction method in accelerating colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Traction methods have been reported to speed up endoscopic submucosal dissection (ESD). We used the multiloop (M-loop) method as a traction method for colorectal ESD and recorded the submucosal dissection time (SDT) and submucosal dissection speed (SDS).

METHODS

From January to August 2018, we used the M-loop method for colorectal ESD procedures and timed the duration and recorded the outcomes. Two experts and eight nonexperts performed the procedures, which were carried out at a tertiary endoscopic center in Japan.

RESULTS

A total of 50 patients were treated by colorectal ESD using the M-loop method. The mean SDT was 42.1 ± 4.16 minutes and the mean SDS was 28.0 ± 2.89 mm²/minutes. The mean SDS was 38.9 ± 6.9 mm²/minutes for experts and 25.3 ± 3.1 mm²/minutes for nonexperts. En bloc resection was achieved in 100% of cases. There were 3 adverse events and unfavorable outcomes.

CONCLUSIONS

Traction by the M-loop method improved SDS in colorectal ESD. The method can be an effective tool to assist colorectal ESD. Further evaluation of the usefulness of the M-loop method is required in direct comparison with conventional ESD.

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.

Advanced Treatment and Imaging in Colonoscopy: The Pocket-Creation Method for Complete Resection and Linked Color Imaging for Better Detection of Early Neoplastic Lesions by Colonoscopy

Early detection and resection of neoplastic lesions are key objectives to diminish colorectal cancer mortality. Resection of superficial colorectal neoplasms, cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection have all been developed and used worldwide. The pocket-creation method facilitates the resection of tumors in difficult and routine locations. Early detection is the most important first step to maximize the benefits of recent advancements in endoscopic techniques. However, the detection of small, flat-shaped, or faded color lesions remains difficult. Linked color imaging, a novel multi-light technology, facilitates the recognition of minor differences in tissue by enhancing the color contrast between early colorectal neoplasms and surrounding normal mucosa in a bright field of view. The most striking feature of linked color imaging is its ability to display the color of early neoplastic lesions as distinct from inflammatory changes, both of which have similar “redness” when viewed using white light imaging. To increase the detection rate of neoplasms, linked color imaging should be used from the outset for endoscopic observation. Early detection of superficial colorectal tumors can result in decreased mortality from colorectal cancer and maintain a good quality of life for patients.

Comparison of Endoscopic Submucosal Dissection for Primary and Recurrent Colorectal Lesions: A Single-Center European Study

INTRODUCTION

Endoscopic submucosal dissection (ESD) is an acknowledged endoscopic technique for the management of early gastrointestinal neoplasia. The clinical experience and the research from the Eastern ESD centers show that experienced endoscopists can successfully treat even the most demanding recurrent colorectal lesions.

AIM

The aim of this study was to analyze the clinical outcomes of the management of recurrent colorectal lesions in comparison with those of primary lesions in the setting of high-volume European center.

METHODS

A retrospective analysis of 298 cases (228 primary lesions and 70 recurrent lesions) performed by a single endoscopist was carried out. Evaluating learning curves for both primary and recurrent lesions, cumulative sum analysis was performed.

RESULTS

Primary lesions had ∼9% higher R0 resection rate (86.84% versus 78.51%). Yet, this difference did not reach statistical significance (P = .091). The presence of recurrent lesion and lengthy procedure (≥150 min) are risks factors of R1 resection, whereas rectal localization of the lesion was associated with lower risk of R1 resection. The cumulative R0 of 80% was achieved at 36th procedure in the primary lesions group, whereas for the recurrent lesions it was reached at 50th procedure (overall 229 procedures).

CONCLUSIONS

Our study underlines the importance of proper experience in ESD before the management of recurrent lesions. Even after the completion of high volume of primary lesions, first recurrent lesions can pose a challenge. Nevertheless, the final outcomes are promising, as the complications do not pose a serious risk to the patients and high R0 resection rate can be achieved in a reasonable timeframe.

Efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps: Systematic review and meta-analysis

BACKGROUND AND AIM

Safety and effectiveness of cold snare polypectomy (CSP) compared with hot snare polypectomy (HSP) has been reported. The aim of the present study is to carry out a meta-analysis of the efficacy and safety of HSP and CSP.

METHODS

Randomized controlled trials were reviewed to compare HSP with CSP for resecting small colorectal polyps. Outcomes reviewed include complete resection rate, polyp retrieval, delayed bleeding, perforation and procedure time. Outcomes were documented by pooled risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel random effect model.

RESULTS

Eight studies were reviewed in this meta-analysis, including 1665 patients with 3195 polyps. Complete resection rate using HSP was similar to CSP (RR: 1.02, 95% CI: 0.98-1.07, P = 0.31). Polyp retrieval after HSP was similar to CSP (RR: 1.00, 95% CI: 1.00-1.01, P = 0.60). Delayed bleeding rate after HSP was higher than after CSP, although not significantly (patient basis: RR: 7.53, 95% CI: 0.94-60.24, P = 0.06; polyp basis: RR: 7.35, 95% CI: 0.91-59.33, P = 0.06). Perforation was not reported in all eight studies. Total colonoscopy time for HSP was significantly longer than CSP (mean difference 7.13 min, 95% CI: 5.32-8.94, P < 0.001). Specific polypectomy time for HSP was significantly longer than CSP (mean difference 30.92 s, 95% CI: 9.15-52.68, P = 0.005).

CONCLUSION

This meta-analysis shows significantly shorter procedure time using CSP compared with HSP. CSP tends toward less delayed bleeding compared with HSP. We recommend CSP as the standard treatment for resecting small benign colorectal polyps.

Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center

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.

Characteristics of Patients with Colonic Polyps Requiring Segmental Resection

BACKGROUND

It is unclear if the availability of new techniques for removal of large colonic polyps has affected the use of segmental colon resection. We sought to evaluate the characteristics of polyps undergoing surgical resection, including involvement of therapeutic gastroenterologists (TG).

METHODS

484 patients had a colonic resection; 165 (34%) were identified from the pathology database with polyp, adenoma, or mass in the clinical history field; these charts were reviewed.

RESULTS

128 patients (mean age 68 yrs, 72% male) were included. The mean polyp size was 2.9 cm (0.4 cm-12.0 cm). Adenocarcinoma was diagnosed in 50 (39.1%). 97 (75.8%) patients had a polyp that was felt to be unresectable by EMR, and 31 (24.2%) underwent successful EMR followed by surgery for adenocarcinoma (n = 29). The indication for surgery in those with unresectable polyps was variable and was not clearly documented in 51 (52.6%); only 17 of these patients (17.5%) had a TG involved.

CONCLUSION

A high proportion of polyps managed by segmental resection did not contain adenocarcinoma. This data suggests that even in a tertiary care center where advanced endoscopic techniques are easily available, they are not always utilized. Educational endeavors to ensure that ideal pathways of intervention are utilized require implementation.

Extended cold snare polypectomy for small colorectal polyps increases the R0 resection rate

BACKGROUND AND STUDY AIMS

 Despite widespread use of cold snare polypectomy (CSP), the R0 resection rate is not well documented. We perform extended CSP, resecting polyps with a > 1 mm circumferential margin. The aim of this study is to compare the R0 resection rate of extended CSP with conventional CSP and to assess safety.

PATIENTS AND METHODS

From April 2014 to September 2016, 712 non-pedunculated colorectal polyps, < 10 mm in size, resected using CSP from 316 patients were retrospectively analyzed.

RESULTS

 We divided lesions into conventional CSP (n = 263) and extended CSP groups (n = 449). The baseline characteristics of these two groups were not significantly different in univariate or multivariate analyses. Sessile polyps comprised 94 % (668/712), and the remaining were flat-elevated polyps. Mean size of polyps (±standard deviation) was 4.2 ± 1.5 mm. The most frequent pathology was low grade adenoma (97 %, 689/712). The R0 resection rate was significantly higher in the extended CSP group (439/449 [98 %]) than in the conventional CSP group (222/263 [84 %], P  < 0.001). There was no delayed bleeding or perforation in either group (conventional CSP group, 0/263, 95 % confidence interval: 0.0 - 1.4 % and extended CSP group, 0/449, 95 % confidence interval: 0.0 - 0.8 %).

CONCLUSIONS

 Extended CSP results in a higher R0 resection rate compared with conventional CSP. Extended CSP did not result in a higher rate of delayed bleeding or perforation. Extended CSP is a safe and promising procedure for endoscopic resection of non-pedunculated colorectal polyps < 10 mm in size.

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.

Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type

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.

Endoscopic Approach for Superficial Colorectal Neoplasms

BACKGROUND

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females, with an estimated 1.4 million cases and 693,900 deaths in 2012. Colonoscopy is the cornerstone for the detection and prevention of CRC. In addition, endoscopic treatment for CRC at an early stage can effectively improve patients' quality of life and cure rate.

SUMMARY

This review focuses on endoscopic approaches, including white light endoscopy, chromoendoscopy, magnifying endoscopy and therapeutic endoscopy, for the evaluation and treatment of superficial colorectal neoplasms.

KEY MESSAGE

Understanding the preoperative evaluation, indications and techniques of endoscopic mucosal resection/endoscopic submucosal dissection as well as postoperative surveillance for superficial colorectal neoplasms is critical for providing appropriate management to the patients.

PRACTICAL IMPLICATIONS

Endoscopic therapy, a method preserving organ function and improving quality of life, is a widely applied microinvasive treatment for superficial colorectal neoplasms. This review describes the basics and developments of endoscopic approaches and may facilitate daily practice for superficial colorectal neoplasms.