Randomized controlled trial comparing conventional and traction endoscopic submucosal dissection for early colon tumor (CONNECT-C trial)

Comparative efficacy of different techniques for colonic endoscopic submucosal dissection: A network meta-analysis of randomized controlled trials

BACKGROUND

Endoscopic submucosal dissection (ESD) is an advanced technique that can provide successful 'en-bloc' and R0 resection rate for large gastrointestinal lesions. To date, several ESD techniques have been proposed, but their comparative efficacy is still unclear.

METHODS

Major databases were systematically searched for RCTs comparing the efficacy and safety of different ESD techniques for the resection of colonic lesions. The primary outcomes were 'en-bloc' and R0 resection rates. The secondary outcome was the incidence of procedure-related AEs.

RESULTS

After selection of studies, 9 RCTs were included in the systematic review. On network meta-analysis for 'en-bloc' resection, pocked with traction ESD (PT-ESD) (RR=1.02; 95%CI=0.96-1.07) and pocket ESD (P-ESD) (RR=1.02; 95%CI=0.98-1.05) showed higher efficacy, whereas hybrid ESD (H-ESD) (RR=0.94; 95%CI=0.87-1.02) lower efficacy compared to conventional ESD (C-ESD). With regard to R0 resection, PT-ESD (RR=1.05; 95%CI=0.96-1.16) showed higher efficacy, and H-ESD (RR=0.97; 95%CI=0.84-1.13) lower efficacy compared to C-ESD. Concerning safety PT-ESD (RR=0.35; 95%CI=0.05-2.48) was associated with lower incidence of AEs, and H-ESD (RR=1.22; 95%CI=0.30-5.01) with higher incidence of AEs, compared to C-ESD.

CONCLUSIONS

The results of this network meta-analysis show a trend towards greater effectiveness and safety of PT-ESD for the removal of colonic lesions. H-ESD was associated with worse results and should be reserved as a rescue treatment, preferring other techniques.

Prospective, randomized controlled study evaluating a double-balloon interventional endoscopic platform for colorectal endoscopic submucosal dissection (with video)

BACKGROUNDS AND AIMS

Endoscopic submucosal dissection (ESD) can be challenging and time-consuming. A double-balloon interventional platform (DBIP) was designed to assist with navigation, stabilization, traction, and device delivery during complex colorectal polypectomy. We compared traditional ESD (T-ESD) with DBIP-assisted ESD (DBIP-ESD) in a prospective, randomized trial.

METHODS

Patients with colorectal polyps ≥2 cm were randomly assigned (1:1) to DBIP-ESD or T-ESD. The primary study endpoint was the mean total procedure time difference between groups. Secondary endpoints were intraprocedural time points, en bloc resection rate, procedure cost, adverse events, and 3-month assessment. A sample size of 200 subjects for ≥80% power was calculated. Interim analysis for early study termination was planned at 70% enrollment if the primary endpoint was met (P ≤ .05).

RESULTS

One hundred forty-seven patients were enrolled between February 2019 and February 2020. Seven patients dropped out, and the interim analysis was performed on 140 patients (71 DBIP-ESD, 69 T-ESD). Demographics, comorbidities, and lesion size, location, and classification were similar between groups. The mean procedure time decreased with DBIP-ESD (88.6 ± 42.7 minutes) versus T-ESD (139.5 ± 83.2 minutes; difference of ∼51 minutes [36.5%]; P < .001], with procedural savings of $610.16 (11.4%) per patient after DBIP cost. The DBIP increased dissection speed by 49.0% (15.1 ± 8.0 vs 7.7 ± 6.6 cm2/h, P < .001). En bloc resection was superior with the addition of DBIP (97.2% vs 87.0%, P = .030). The mean navigation time with DBIP-ESD for sutured defect closure decreased by 7.7 minutes (P < .001). There were no adverse events in the DBIP-ESD group.

CONCLUSIONS

DBIP-ESD decreased the total procedure time, improved the en bloc resection rate, and facilitated sutured defect closure, making DBIP a promising and cost-effective tool to improve colorectal ESD adoption. (Clinical trial registration number: NCT03846609.).

Learning curve of colorectal endoscopic submucosal dissection of an endoscopist experienced hands-on training in Japan

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection is a technically demanding procedure with a steep learning curve. In Japan, the National Cancer Center Hospital allows overseas doctors to participate in hands-on training. We aimed to assess the colorectal endoscopic submucosal dissection performance and learning curve of an endoscopist who participated in hands-on training.

METHODS

In this retrospective analysis using a prospectively collected database, 100 consecutive superficial colorectal tumors from 100 patients treated with endoscopic submucosal dissection by a colorectal surgeon between January 2020 and May 2024 were included. The cases were grouped into three learning periods: phase I (the initial 30 cases under local expert supervision before training in Japan), phase II (the middle 30 cases), and phase III (the last 40 cases). The primary outcome was resection speed.

RESULTS

The median resection speed was 5, 11.7, and 13.2 cm2/h in phases I, II, and III, respectively. In matched data, the resection speeds in phases II and III were higher than that in phase I (P = 0.02 and P < 0.001, respectively). En bloc and R0 resection rates were 99% and 95%, respectively. The en bloc resection, R0 resection, and complication rates were not different between phases. Cumulative sum analysis of the resection speed revealed that proficiency was achieved after 36 cases.

CONCLUSIONS

An endoscopist who underwent a tutored approach and hands-on training in Japan achieved the proficiency benchmarks for colorectal endoscopic submucosal dissection after 36 cases. However, the endoscopist's extensive experience before training may contribute to excellent outcomes.

Orthodontic Rubber Band Traction Improves Trainees' Learning Curve of Colorectal Endoscopic Submucosal Dissection: A Prospective Randomized Study

INTRODUCTION

Colorectal endoscopic submucosal dissection (ESD) is a technically demanding operation with a long learning curve. The aim of this study was to determine whether orthodontic rubber band (ORB)-assisted colorectal ESD could improve the trainees' learning curve as it was shown to shorten colorectal ESD procedure time in trainees and experts.

METHODS

This prospective, randomized, controlled clinical study involved 178 patients who underwent colorectal ESD, randomly divided into trainee ORB-assisted ESD (Trainee ORB-ESD; n = 60), trainee conventional ESD (Trainee C-ESD; n = 57), and expert conventional ESD (Expert C-ESD; n = 61) groups. The main outcome was procedure time.

RESULTS

Per Protocol analysis showed a similar operative time in the trainee ORB-ESD and expert C-ESD groups, which was shorter than in the trainee C-ESD group [28.0 (21.0-35.0) and 25.0 (15.0-35.0) vs 41.0 (31.0-52.5) min; ( P < 0.001)]. The trainee ORB-ESD, trainee C-ESD, and expert C-ESD groups differed significantly in resection speed (11.35, 9.07, and 12.56 mm 2 /min, respectively), good visual field exposure rate (96.7%, 80.7%, and 93.4%), and muscle injury rate (5.0%, 17.5%, and 6.6%). However, the trainee ORB-ESD and expert C-ESD groups were similar in these measures, and all 3 groups were similar in adverse events, en bloc resection, R0 resection, and pathology rates. The cumulative sum suggested that the learning inflection point of the trainee ORB-ESD group was earlier than that of the trainee C-ESD group.

DISCUSSION

ORB-ESD shortened colorectal ESD procedure time and improved efficiency in trainees to an expert level. ORB-ESD could shorten the learning curve, justifying its widespread application.

Conventional versus rubber band traction-assisted endoscopic submucosal dissection for rectal neuroendocrine tumors: a single-center retrospective study (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is a safe and effective technique for the treatment of gastrointestinal tumors, including rectal neuroendocrine tumors (r-NETs). However, the relative advantages of traction-assisted ESD for the treatment of small rectal lesions are still debated.

AIMS

We conducted a study to compare the efficacy and safety of rubber band traction-assisted ESD (RBT-ESD) to conventional ESD (C-ESD).

METHODS

This study retrospectively analyzed consecutive patients with r-NET treated with ESD between October 2021 and October 2023. Our study assessed differences between the groups in the complete resection rate of lesions, muscular layer injury, surgical complications, operation time, resection speed, time to liquid diet, postoperative hospital stay, hospital cost, and recurrence rate.

RESULTS

A total of 119 patients with r-NETs participated in this study (RBT-ESD group, n = 27; C-ESD group, n = 92). The operation time in RBT-ESD group was shorter than in C-ESD group, but the difference was not statistically significant (16.0 min [9.0-22.0 min] vs. 18.0 min [13.3-27.0 min], P = 0.056). However, the resection speed was significantly faster in the RBT-ESD group (6.7 vs. 4.1 mm2/min, P = 0.005). Furthermore, the RBT-ESD group showed significantly less muscular layer injury (P = 0.047) and faster diet recovery (P = 0.035). No significant differences were observed in the complete resection rate, surgical complications, postoperative hospital stay, hospital cost, or recurrence rate between the two groups.

CONCLUSION

For r-NETs of < 2 cm in size, the RBT method did not significantly shorten the operation time but resulted in faster resection speed, less muscular layer injury, and earlier postoperative recovery to a liquid diet.

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Compared with conventional endoscopic submucosal dissection (C-ESD) for colorectal lesions, the traction method (T-ESD) allows the lesion to be stabilized with easier dissection. However, randomized controlled trials (RCTs) have reported conflicting results on the clinical outcomes of T-ESD as compared with C-ESD. We conducted a meta-analysis to compile the data.

METHODS

Multiple databases were searched for RCTs evaluating C-ESD versus T-ESD for colorectal tumors. The end points of interest were procedure time (min), resection speed (mm²/min), R0 resection, en bloc resection, delayed bleeding, and perforation. Standard meta-analysis methods were employed using the random-effects model.

RESULTS

Six RCTs with a total of 566 patients (C-ESD n=284, T-ESD n=282) were included. The mean age was 67±10 y and 60% were men. As compared with the T-ESD technique, the C-ESD group was associated with longer procedure time (SMD 0.91, 95% CI 0.58 to 1.23, P <0.00001) and lesser resection speed (SMD -1.03, 95% CI -2.01 to -0.06, P =0.04). No significant difference was found in the 2 groups with respect to R0 resection rate (RR 1.00, 95% CI 0.94 to 1.06, P =0.87), en bloc resection (RR 0.99, 95% CI 0.97 to 1.01, P =0.35), delayed bleeding (RR 0.66, 95% CI 0.17 to 2.59, P =0.55) and perforation (RR 2.16, 95% CI 0.75 to 6.27, P =0.16).

DISCUSSION

On meta-analysis, pooled procedure time was significantly faster with T-ESD compared with C-ESD. The clinical outcomes, however, were comparable.

Multicenter prospective randomized controlled clinical trial comparing the pocket-creation method with and without single-clip traction of colonic endoscopic submucosal dissection

BACKGROUND

The pocket-creation method (PCM) was developed to overcome the technical difficulties of endoscopic submucosal dissection (ESD), although opening the pocket remains challenging. We developed a novel technique of PCM with single-clip traction (PCM-CT), which uses a reopenable clip as a traction device to maintain stability during the procedure. No prospective study has compared the efficacy of PCM-CT and PCM. This study aimed to investigate the effectiveness of PCM-CT vs. PCM in a randomized controlled trial.

METHODS

This randomized controlled clinical trial was conducted at four Japanese institutions. Patients with superficial colorectal neoplastic lesions were included following Japanese guidelines for colorectal cancer. Seven moderately experienced endoscopists performed the ESD procedures using either PCM-CT or PCM.

RESULTS

100 patients were enrolled in the study. Compared with PCM, PCM-CT achieved significantly faster mean (SD) dissection speed (21.4 [10.8] vs. 27.0 [14.5] mm2/min [95%CI 0.5 to 10.7], P = 0.03), and reduced the mean procedure time (81.8 [57.9] vs. 64.8 [47.6] minutes [95%CI -38.2 to 4.3], P = 0.12) and pocket-opening time (37.8 [33.0] vs. 30.0 [28.9] minutes [95%CI -20.2 to 4.6], P = 0.22). En bloc and R0 resection rates were not significantly different between the two groups (100% vs. 100%, P >0.99; 100% vs. 96%, P = 0.50, respectively). No significant differences were observed in adverse events between the two groups.

CONCLUSION

ESD facilitated by the novel PCM-CT method appeared to be significantly faster than PCM. Both methods achieved high R0 resection rates.

Traction Devices May Not Affect the Vertical Margin Distance in the Endoscopic Submucosal Dissection of Rectal Neuroendocrine Tumors

Introduction The usefulness of traction devices (TDs) in endoscopic submucosal dissection (ESD) for rectal neuroendocrine tumors (NETs) has not been reported. The aim of this study was to investigate the impact of using a TD on the vertical margin (VM) distance in the ESD of rectal NETs. Methods In this single-center, retrospective study, we included patients with rectal NETs who were treated with ESD during 2013-2023. They were divided into TD and non-TD groups. One pathologist remeasured the VM distance (primary outcome) and the depth of submucosal invasion (SM depth). Secondary outcomes were margins, resection time, delayed bleeding, and perforation. First, we performed propensity score matching (PSM) to assess the usefulness of TD for VM distance. Then, we used multiple regression analysis to identify factors affecting the VM distance. Results The TD and non-TD groups comprised 24 and 117 lesions, respectively. Patients in the TD group were significantly younger than those in the non-TD group (P = 0.003). In the TD and non-TD groups, the VM distance was 150 μm and 100 μm, respectively (P = 0.70). Only resection time significantly differed between groups, shorter in the TD group (P = 0.005). Twenty-two cases in each group were matched after PSM, yielding no significant differences in VM distance. The use of a TD was not an independent predictor of VM distance (P = 0.65), but age (P < 0.001) and SM depth (P = 0.003) were. Conclusion Using a TD does not seem to affect the VM distance in ESD for rectal NETs.

Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.

Device-assisted traction methods in colorectal endoscopic submucosal dissection and options for difficult cases

Endoscopic submucosal dissection (ESD) procedure has a longer procedure time and higher perforation rate than endoscopic mucosal resection owing to technical complications, including a poor field of vision and inadequate tension for the submucosal dissection plane. Various traction devices were developed to secure the visual field and provide adequate tension for the dissection plane. Two randomized controlled trials demonstrated that traction devices reduce colorectal ESD procedure time compared with conventional ESD (C-ESD), but they had limitations, including a single-center fashion. The CONNECT-C trial was the first multicenter randomized controlled trial comparing the C-ESD and traction device-assisted ESD (T-ESD) for colorectal tumors. In the T-ESD, one of the device-assisted traction methods (S–O clip, clip-with-line, and clip pulley) was chosen according to the operator’s discretion. The median ESD procedure time (primary endpoint) was not significantly different between C-ESD and T-ESD. For lesions ≥ 30 mm in diameter or in cases treated by nonexpert operators, the median ESD procedure time tended to be shorter in T-ESD than in C-ESD. Although T-ESD did not reduce ESD procedure time, the CONNECT-C trial results suggest that T-ESD is effective for larger lesions and nonexpert operators in colorectal ESD. Compared with esophageal and gastric ESD, colorectal ESD has some difficulties, including poor endoscope maneuverability, which may be associated with prolonged ESD procedure time. T-ESD may not effectively improve these issues, but a balloon-assisted endoscope and underwater ESD may be promising options and these methods can be combined with T-ESD.