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Khalaf MA, Ayoub F, Staggers KA, El-Haj JW, Jawaid S, Othman MO. Learning curve for endoscopic submucosal dissection (ESD) in the United States: Large, untutored, single-operator experience. Endosc Int Open 2024; 12:E905-E913. [PMID: 39055261 PMCID: PMC11272410 DOI: 10.1055/a-2337-3865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 05/29/2024] [Indexed: 07/27/2024] Open
Abstract
Background and study aims Endoscopic submucosal dissection (ESD) allows removal of tumors en-bloc. Western adoption of ESD has been hindered by its steep learning curve. Western data regarding ESD learning curve are limited. We analyzed the learning curve of a single endoscopist at a tertiary referral center in the United States. Patients and methods All consecutive ESDs performed by a single endoscopist at a tertiary referral center in the United States from 2015 through 2022 were identified. Descriptive statistics and CUSUM analysis were used to describe the learning curve for en-bloc, R0 resection, and resection speed. Results In our study, 503 patients with 515 lesions were included. Severe submucosal fibrosis was found in 17% of the lesions. The rates of en-bloc, R0, and curative resections were 81.9%, 71.1%, and 68.4%, respectively. CUSUM analysis showed that the learning curve plateaued at 268, 347, and 170 cases for en-bloc resection, R0 resection, and achieving a resection speed > 9 cm 2 /hr. Fibrosis significantly affected the R0 resection rate in the regression analysis (95% confidence interval 0.21-0.55). In colonic ESD curve analysis, the learning plateau was reached after 185 cases for both en-bloc and R0 resection. Conclusions Following ex-vivo training in an animal model, an untutored expert operator achieved competency in ESD between 250 and 350 procedures. Our data can inform development of future training programs in the West.
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Affiliation(s)
- Mai A Khalaf
- Gastroenterology, Baylor College of Medicine, Houston, United States
- Tropical Medicine and infectious diseases, Tanta University Faculty of Medicine, Tanta, Egypt
| | - Fares Ayoub
- Gastroenterology, Baylor College of Medicine, Houston, United States
| | - Kristen A Staggers
- Department of Medicine, Baylor College of Medicine, Houston, United States
| | - Johanna W El-Haj
- College of Liberal Arts and Social Sciences, University of Houston, Houston, United States
| | - Salmaan Jawaid
- Gastroenterology, Baylor College of Medicine, Houston, United States
| | - Mohamed O. Othman
- Gastroenterology, Baylor College of Medicine, Houston, United States
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Chiba H, Ohata K, Ashikari K, Tachikawa J, Okada N, Hayashi A, Ebisawa Y, Kobayashi M, Arimoto J, Kuwabara H, Nakaoka M. Effectiveness of Strategy-Focused Training in Colorectal Endoscopic Submucosal Dissection: A Retrospective Observational Study. Dig Dis Sci 2024; 69:2370-2380. [PMID: 38662160 DOI: 10.1007/s10620-024-08430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Colorectal ESD, an advanced minimally invasive treatment, presents technical challenges, with globally varying training methods. We analyzed the learning curve of ESD training, emphasizing preoperative strategies, notably gravity traction, to guide ESD instructors and trainee programs. METHOD This retrospective study included 881 cases guided by an experienced supervisor. Six trainees received "strategy-focused" instruction. To evaluate the number of ESD experiences in steps, the following phases were classified based on ESD experiences of each trainees: Phase 0 (0-50 ESD), Phase 1 (51-100 ESD), Phase 2 (101-150 ESD), and Phase 3 (151-200 ESD). Lesion background, outcomes, and safety were compared across phases. Factors contributing to technical difficulty in early (Phase 0 and 1) and late phases (Phase 2 and 3) were identified, along with the utility of traction ESD with device assistance. RESULT Treatment outcomes were favorable, with 99.8% and 94.7% en bloc resection and curative resection rates, respectively. Approximately 90% self-completion rate could be achieved after experiencing about 50 cases (92.7% in Phase 1), signifying proficiency growth despite increased case difficulty. In early phases, factors such as left-sided colon, LST-NG morphology, and severe fibrosis pose challenges. In late phases, LST-NG morphology, mild and severe fibrosis remained significant. Traction-assisted ESD, utilized in 3% of cases, comprised planned (1.1%) and rescue (1.9%) methods. Planned traction aided specific lesions, while rescue traction was common in the right colon. CONCLUSION "Strategy-focused" ESD training consistently yields successful outcomes, effectively adapting to varying difficulty factors in different proficient stages.
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Affiliation(s)
- Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan.
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Keiichi Ashikari
- Ashikari Endoscopy Clinic, 1-12-13 Kamiooka Higashi, Konan-ku, Yokohama, Kanagawa, 233-0001, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan
| | - Naoya Okada
- Department of Gastroenterology, Yokohama Rosai Hospital, 3211 Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, 222-0036, Japan
| | - Akimichi Hayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Yu Ebisawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Mikio Kobayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
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Wang L, Liu ZQ, Zhang JY, Li QL, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Ma LL, Zhou PH. Feasibility and safety of endoscopic resection for the jejunoileal lesions. J Gastroenterol Hepatol 2024; 39:527-534. [PMID: 37974384 DOI: 10.1111/jgh.16413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Endoscopic resection (ER) for jejunoileal lesions (JILs) has been technically challenging. We aimed to characterize the clinicopathologic characteristics, feasibility, and safety of ER for JILs. METHOD We retrospectively investigated 52 patients with JILs who underwent ER from January 2012 to February 2022. We collected and analyzed clinicopathological characteristics, procedure-related parameters, outcomes, and follow-up data. RESULTS The mean age was 49.4 years. Of the 52 JILs, 33 ileal tumors within 20 cm from the ileocecal valve were resected with colonoscopy, while 19 tumors in the jejunum or the ileum over 20 cm from the ileocecal valve received enteroscopy resection. The mean procedure duration was 49.0 min. The en bloc resection and en bloc with R0 resection rates were 86.5% and 84.6%, respectively. Adverse events (AEs) included one (1.9%) major AE (delayed bleeding) and five (9.6%) minor AEs. During a median follow-up of 36.5 months, two patients had local recurrence (3.8%), while none had metastases. The 5-year recurrence-free survival (RFS) and disease-specific survival (DSS) were 92.9% and 94.1%, respectively. Compared with the enteroscopy group, overall AEs were significantly lower in the colonoscopy group (P < 0.05), but no statistical differences were observed in RFS (P = 0.412) and DSS (P = 0.579). There were no significant differences in AEs, RFS, and DSS between the endoscopic submucosal dissection (ESD) and the endoscopic mucosal resection (EMR) group. CONCLUSIONS ER of JILs has favorable short-term and long-term outcomes. Both ESD and EMR can safely and effectively resect JILs in appropriately selected cases.
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Affiliation(s)
- Li Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ji-Yuan Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Li Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Kouladouros K, Centner M, Reissfelder C, Belle S, Kähler G. The role of the multidisciplinary tumor board after endoscopic resection of malignant tumors: is it worth it? Surg Endosc 2024; 38:607-613. [PMID: 37991571 PMCID: PMC10830656 DOI: 10.1007/s00464-023-10555-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/20/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVES The value of multidisciplinary tumor boards (MTBs) in the treatment of gastrointestinal cancer patients is well known. Most of the current evidence focuses on advanced cancer cases, whereas little is known about the effect of MTBs on early tumors, especially after endoscopic resection. The aim of our study is to evaluate the value of the MTB after endoscopic resection of malignant tumors of the gastrointestinal tract. METHODS We retrospectively analyzed all endoscopically resected malignant tumors in our department between 2011 and 2019, focusing on the existence of an MDT recommendation after endoscopic resection, the MDT adherence to the current guidelines, and the implementation of the recommendation by the patients. RESULTS We identified 198 patients fulfilling our inclusion criteria, of whom 168 (85%) were discussed in the MDT after endoscopic resection. In total, 155 of the recommendations (92%) were in accordance with the current guidelines, and 147 (88%) of them were implemented by the patients. The MDT discussion itself did not influence the overall survival, whereas the implementation of the MTB recommendation was associated with a significantly better prognosis. Deviations of the MDT recommendation from the guidelines had no effect on the overall survival. CONCLUSIONS The discussion of endoscopically resected malignant tumors in the MTB is crucial for the treatment of patients with this type of cancer, since the implementation of the MTB recommendation, even if it deviates from the current guidelines, improves the prognosis.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Maximilian Centner
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Sebastian Belle
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- Department of Internal Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Steinbrück I, Faiss S, Dumoulin FL, Oyama T, Pohl J, von Hahn T, Schmidt A, Allgaier HP. Predictive Factors for the Outcome of Unsupervised Endoscopic Submucosal Dissection During the Initial Learning Curve with Prevalence-Based Indication. Dig Dis Sci 2023; 68:3614-3624. [PMID: 37421512 DOI: 10.1007/s10620-023-08026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/26/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND For an adequate educational strategy of ESD in non-Asian settings with prevalence-based indication it is essential to define adequate lesions, suitable for the beginner without on-site expert-supervision. AIMS We analyzed possible predictors for outcome parameters of effectiveness and safety during the initial learning curve. METHODS The first 120 ESDs of four operators (n = 480), performed between 2007 and 2020 in four tertiary hospitals, were enrolled. Uni-/multivariable regression analysis was done with sex, age, pretreated lesion, lesion size, organ, and organ-based localization as possible independent predictors for en bloc resection (EBR), complication, and resection speed. RESULTS Rates of EBR, complication, and resection speed were 84.5%, 14.2%, and 6.20 (± 4.45) cm2/h. Independent predictors for EBR were pretreated lesion (OR 0.27 [0.13-0.57], p < 0.001) and non-colonic ESD (OR 2.29 [1.26-4.17] (rectum)/5.72 [2.36-13.89] (stomach)/7.80 [2.60-23.42] (esophagus), p < 0.001), for complication pretreated lesion (OR 3.04 [1.46-6.34], p < 0.001) and lesion size (OR 1.02 [1.004-1.04], p = 0.012) and for resection speed pretreated lesion (RC - 3.10 [- 4.39 to - 1.81], p < 0.001), lesion size (RC 0.13 [0.11-0.16], p < 0.001) and male patient (RC - 1.11 [- 1.85 to - 0.37], p < 0.001). We found no significant difference in the incidence of technically unsuccessful resections in esophageal (1/84), gastric (3/113), rectal (7/181), and colonic (3/101) ESDs (p = 0.76). Technical failure was mainly caused by complication and fibrosis/pretreatment. CONCLUSION During the initial learning curve of an unsupervised ESD program with prevalence-based indication, pretreated lesions and colonic ESDs should be avoided. In contrast, lesion size and organ-based localizations have less predictive value for the outcome.
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Affiliation(s)
- Ingo Steinbrück
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital of University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany.
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Academic Teaching Hospital of University of Berlin, Fanningerstraße 32, 10365, Berlin, Germany
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic teaching Hospital of University of Bonn, Prinz-Albert-Straße 40, 53113, Bonn, Germany
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, 3400-28 Nakagomi, Saku, Nagano, 3850051, Japan
| | - Jürgen Pohl
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital of University of Hamburg, Paul-Ehrlich-Straße 1, 22763, Hamburg, Germany
| | - Thomas von Hahn
- Department of Gastroenterology, Hepatology and Endoscopy, Asklepios Klinik Barmbek, Academic Teaching Hospital of University of Hamburg, Rübenkamp 220, 22307, Hamburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Hans-Peter Allgaier
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital of University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany
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Wang L, Liu ZQ, Liu JZ, Ma LY, Li XQ, Yao L, Li QL, Zhou PH. Endoscopic submucosal dissection for anastomotic lesions after colorectal surgery. J Gastroenterol Hepatol 2023; 38:424-432. [PMID: 36398853 DOI: 10.1111/jgh.16063] [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: 09/07/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging. We aimed to characterize the clinicopathologic characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the lower gastrointestinal tract. METHOD We retrospectively investigated 55 patients with anastomotic lesions of the lower gastrointestinal tract who underwent ESD from February 2008 to January 2021. The lesions involving one or both sides of anastomoses were classified into the unilaterally involving anastomosis (UIA) or straddling anastomosis (SA) group, respectively. We collected clinicopathological characteristics, procedure-related parameters and outcomes, and follow-up data and analyzed the impact of anastomotic involvement. RESULTS The mean age was 62.5 years, and the median procedure duration was 30 min. The rates of en bloc resection and R0 resection were 90.9% and 85.5%, respectively. Four patients (7.3%) experienced major adverse events (AEs). During a median follow-up of 66 months (range 14-169), seven patients had local recurrence, and six patients had metastases. The 5-year disease-free survival and overall survival rates were 82.4% and 90.7%, respectively. The 5-year disease -specific survival (DSS) rate was 93.3%. Compared with the UIA group, the SA group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and R0 resection, and shorter disease-free survival (all P < 0.05). However, rates of AEs did not differ significantly between the two groups. CONCLUSIONS The short-term and long-term outcomes of ESD for colorectal anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for lesions at the anastomoses.
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Affiliation(s)
- Li Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Zheng Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Yun Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Qing Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lu Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Zandanell S, Gensluckner S, Wolkersdoerfer G, Berr F, Dienhart C, Gantschnigg A, Singhartinger F, Wagner A. Feasibility of Continuous Monitoring of Endoscopy Performance and Adverse Events: A Single-Center Experience. Cancers (Basel) 2023; 15:cancers15030725. [PMID: 36765682 PMCID: PMC9913416 DOI: 10.3390/cancers15030725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record. METHODS This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020. RESULTS A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%). CONCLUSIONS The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.
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Affiliation(s)
- Stephan Zandanell
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Sophie Gensluckner
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Gernot Wolkersdoerfer
- Department of Internal Medicine, Rotthalmünster Hospital, 94094 Rotthalmünster, Germany
| | - Frieder Berr
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- Laboratory for Tumour Biology and Experimental Therapies (TREAT), Institute of Physiology and Pathophysiology, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christiane Dienhart
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Antonia Gantschnigg
- Department of Surgery, University Clinics Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Franz Singhartinger
- Department of Surgery, University Clinics Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Andrej Wagner
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- Correspondence: ; Tel.: +43-57255-57561
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Tatar C, Ozgur I, Justiniano CF, Bhatt A, Liska D, Hull T, Steele SR, Gorgun E. Is Endoscopic Submucosal Dissection for Colorectal Lesions Performed in the Endoscopy Suite Safe and Cost Saving? Surg Laparosc Endosc Percutan Tech 2022; 32:688-691. [PMID: 36468893 DOI: 10.1097/sle.0000000000001118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/11/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND We aimed to compare the outcomes and the cost differences of endoscopic submucosal dissection (ESD) procedures in the endoscopy suite (ES) versus the operating room (OR). MATERIALS AND METHODS The procedures in the OR were compared with procedures performed in the ES for demographics, lesion characteristics, procedure outcome, and procedure charges. The study included 163 procedures in the ES and 73 in the OR. RESULTS Both were similar in age, sex, body mass index, and intraprocedural and postoperative 30-day (late) complications. ES cases had significantly greater polyp size, were more commonly right-sided polyps, and had shorter hospital stays, with similar en bloc and margin-negative resection rates. The overall cost ratio of ESD procedures in ES to OR was 0.47 ( P <0.001). CONCLUSIONS Colorectal ESD procedures performed in the ES have similar efficacy and safety as those in the OR. Procedures performed in the ES were associated with a shorter length of stay and significant periprocedural cost savings.
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Affiliation(s)
| | | | | | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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9
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Kouladouros K, Baral J. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases. Langenbecks Arch Surg 2022; 407:2423-2430. [PMID: 35652960 DOI: 10.1007/s00423-022-02562-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas. METHODS We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients. RESULTS We identified 145 cases matching our criteria. The median size of the lesions was 4.2 cm, and the median operating time was 45 min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24 months, there was a local recurrence in 4.8% of the cases. CONCLUSIONS TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Department of Surgery, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany. .,Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany.
| | - Jörg Baral
- Central Interdisciplinary Endoscopy Department, Department of Surgery, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
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Rashid MU, Alomari M, Afraz S, Erim T. EMR and ESD: Indications, techniques and results. Surg Oncol 2022; 43:101742. [DOI: 10.1016/j.suronc.2022.101742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/21/2022] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
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Kouladouros K, Warkentin V, Kähler G. Transanal endoscopic microsurgical submucosal dissection: Are there advantages over conventional ESD? MINIM INVASIV THER 2021; 31:720-727. [PMID: 34469273 DOI: 10.1080/13645706.2021.1967999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a technique that has been recently described for the treatment of large rectal adenomas and early rectal cancer. The purpose of our study is to compare TEM-ESD with flexible endoscopic submucosal dissection (ESD) in an experimental, ex vivo porcine model. MATERIAL AND METHODS We used TEM-ESD and flexible ESD to resect a total of 100 standardized 4 × 4cm lesions in an ex vivo porcine stomach model, performing 50 resections with each technique. Total procedure time, en bloc resection rate, injuries of the muscularis propria, perforation rate and learning curve were analysed. RESULTS TEM-ESD was associated with a significantly shorter total procedure time in comparison to ESD (19 min vs. 33 min, p < .001). The rates of en bloc resection, injury of the muscularis propria layer, and perforation were the same in both groups. The learning curve of TEM-ESD was shallower than that of ESD. CONCLUSION TEM-ESD showed an advantage over ESD in terms of procedure time and learning curve, with similar en bloc resection rates and safety profile in our experimental model.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Viktor Warkentin
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
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Hybrid endoscopic submucosal dissection: An alternative resection modality for large laterally spreading tumors in the cecum? BMC Gastroenterol 2021; 21:203. [PMID: 33952206 PMCID: PMC8097794 DOI: 10.1186/s12876-021-01766-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/14/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Endoscopic resection for large, laterally spreading tumors (LSTs) in the cecum is challenging. Here we report on the clinical outcomes of hybrid endoscopic submucosal dissection (ESD) in large cecal LSTs. METHODS We retrospectively reviewed data from patients with cecal LSTs ≥ 2 cm who underwent ESD or hybrid ESD procedures between January of 2008 and June of 2019. We compared the baseline characteristics and clinical outcomes, including procedure time, the en bloc and complete resection rates, and adverse events. RESULTS A total of 62 patients were enrolled in the study. There were 27 patients in the ESD group and 35 patients in the hybrid ESD group, respectively. Hybrid ESD was more used for lesions with submucosal fibrosis. No other significant differences were found in patient characteristics between the two groups. The hybrid ESD group had a significantly shorter procedure time compared with the ESD group (27.60 ± 17.21 vs. 52.63 ± 44.202 min, P = 0.001). The en bloc resection rate (77.1% vs. 81.5%, P = 0.677) and complete resection rate (71.4% vs. 81.5%, P = 0.359) of hybrid ESD were relatively lower than that of the ESD group in despite of no significant difference was found. The perforation and post-procedure bleeding rate (2.9% vs. 3.7%, P = 0.684) were similar between the two groups. One patient perforated during the ESD procedure, which was surgically treated. One patient in the hybrid ESD group experienced post-procedure bleeding, which was successfully treated with endoscopic hemostasis. Post-procedural fever and abdominal pain occurred in six patients in the ESD group and five patients in the hybrid ESD group. One patient in the ESD group experienced recurrence, which was endoscopically resected. CONCLUSION The results of this study indicate that hybrid ESD may be an alternative resection strategy for large cecal LSTs with submucosal fibrosis.
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Akahoshi K, Shiratsuchi Y, Oya M, Koga H, Kubokawa M, Nakama N, Akahoshi K, Ihara E. Endoscopic submucosal dissection with a grasping-type scissors for early colorectal epithelial neoplasms: a large single-center experience. VideoGIE 2019; 4:486-492. [PMID: 31709338 PMCID: PMC6831854 DOI: 10.1016/j.vgie.2019.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Background and aims The Clutch Cutter (CC) can grasp, pull, coagulate, and incise targeted tissue with the use of electrosurgical current. It was developed as a biopsy technique to reduce the technical difficulty of endoscopic submucosal dissection (ESD) with knives. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early colorectal epithelial neoplasms (ECENs). Methods In this prospective study, we enrolled 437 consecutive patients with a diagnosis of ECEN between January 2009 and January 2018. They all satisfied the Japanese colorectal cancer treatment guidelines for ESD; namely, confirmation by preliminary endoscopy, EUS, and endoscopic biopsy. The CC was used for all steps of ESD (mucosal incision, submucosal dissection, and hemostatic treatment); therapeutic efficacy and safety were assessed. Results The en bloc resection rate was 99.3% (434/437), and the R0 resection rate was 87.0% (380/437). The mean operating time was 88.3 minutes. Perforation occurred in 10 cases (2.3%) and was managed with conservative medical treatment. Post-ESD-CC bleeding occurred in 10 cases (2.3%) and was successfully treated by endoscopic hemostatic treatment. Conclusions ESD-CC is a technically efficient, safe, and easy method for resecting ECEN.
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Affiliation(s)
- Kazuya Akahoshi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Yuki Shiratsuchi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Masafumi Oya
- Department of Pathology, Aso Iizuka Hospital, Iizuka, Japan
| | - Hidenobu Koga
- Department of Health Information Management, Aso Iizuka Hospital, Iizuka, Japan
| | - Masaru Kubokawa
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Naotaka Nakama
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Kazuaki Akahoshi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Cost Analysis of Endoscopic Submucosal Dissection for the Treatment of Colorectal Lesions in China. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6983896. [PMID: 31032359 PMCID: PMC6457293 DOI: 10.1155/2019/6983896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/19/2022]
Abstract
Aim The aim of the study was to evaluate costs associated with colonic endoscopic submucosal dissection (ESD) for treatment of colorectal cancer. Methods The study is a retrospective analysis of data on 395 patients treated by colonic ESD. Results The operation, consumable items, and medication accounted for 71% of the total costs for colonic ESD treatment. Medication and consumable items' costs were higher if lesions occurred in the transverse colon and right hemicolon compared to the left hemicolon. Medication, consumable items, and total costs were higher for larger lesions. Lesion numbers and carcinoma were associated with higher medication, consumable items, operation, and total costs. Positive surgical margins and complications of hemorrhage or perforation were positively correlated with higher costs for medication, consumable items, and total costs. Conclusion Labor costs for doctors and nurses remain low in China. Costs for medication and consumable items were higher for treatment involving the transverse colon or right hemicolon (vs. the left hemicolon), larger lesions, carcinoma, and a positive surgical margin. A benchmark cost estimate for ESD treatment including 4 days of postoperative hospitalization was determined to be approximately 5400 USD.
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Mocker L, Hildenbrand R, Oyama T, Sido B, Yahagi N, Dumoulin FL. Implementation of endoscopic submucosal dissection for early upper gastrointestinal tract cancer after primary experience in colorectal endoscopic submucosal dissection. Endosc Int Open 2019; 7:E446-E451. [PMID: 30931376 PMCID: PMC6428673 DOI: 10.1055/a-0854-3610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Current guidelines recommend endoscopic submucosal dissection (ESD) as a treatment option for early cancers of the upper gastrointestinal tract with absent or minimal risk of lymph node metastasis. However, due to the low prevalence of these entities, it is difficult to achieve a competence level for ESD of upper gastrointestinal tract cancers in the Western World. Here, we present single-center data on the implementation of upper gastrointestinal ESD after previous experience with 89 colorectal ESD cases. Methods Retrospective case series of 39 consecutive patients with early cancers of the esophagus (n = 13) or cardia and stomach (n = 26) treated with ESD over a 4-year period. Results ESD was technically feasible in all cases with en bloc, R0, and curative resection rates of 100 %, 76.9 %, and 71.8 %, respectively, and a mean procedure time of 100 minutes (30 - 360 minutes). After an initial 20 procedures, the R0 and curative resection rates increased from 65.0 % to 89.5 %, and from 60.0 % to 84.2 %, respectively. Complications were observed in four patients (10.3 %): three perforations, one case of delayed bleeding, and one esophageal stricture. No case required emergency surgery; the 30-day mortality rate was 0 %. Conclusion In this modest case series from Europe, we observed an effectiveness and complication rate for ESD for early esophageal and gastric cancer that are comparable to other series from Europe but also to more abundant data from Asia. The results indicate that even small numbers of upper gastrointestinal cancers can be managed adequately in centers with expertise in colorectal ESD.
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Affiliation(s)
- Lena Mocker
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | | | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Bernd Sido
- Department of General and Abdominal Surgery, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
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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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