Colorectal endoscopic submucosal dissection in Japan and Western countries

Efficacy and safety of endoscopic submucosal dissection for colorectal dysplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND/AIMS

In this meta-analysis, we studied the safety and efficacy of endoscopic submucosal dissection (ESD) for colorectal dysplasia in patients with inflammatory bowel disease (IBD).

METHODS

Multiple databases were searched, and studies were retrieved based on pre-specified criteria until October 2022. The outcomes assessed were resection rates, procedural complications, local recurrence, metachronous tumors, and the need for surgery after ESD in IBD. Standard meta-analysis methods were followed using the random-effects model, and I2% was used to assess heterogeneity.

RESULTS

Twelve studies comprising 291 dysplastic lesions in 274 patients were included with a median follow-up of 25 months. The pooled en-bloc resection, R0 resection, and curative resection rates were 92.5% (95% confidence interval [CI], 87.9%-95.4%; I2=0%), 81.5% (95% CI, 72.5%-88%; I2=43%), and 48.9% (95% CI, 32.1%-65.9%; I2=87%), respectively. The local recurrence rate was 3.9% (95% CI, 2%-7.5%; I2=0%). The pooled rates of bleeding and perforation were 7.7% (95% CI, 4.5%-13%; I2=10%) and 5.3% (95% CI, 3.1%-8.9%; I2=0%), respectively. The rates of metachronous recurrence and additional surgery following ESD were 10% (95% CI, 5.2%-18.2%; I2=55%) and 13% (95% CI, 8.5%-19.3%; I2=54%), respectively.

CONCLUSIONS

ESD is safe and effective for the resection of dysplastic lesions in IBD with an excellent pooled rate of en-bloc and R0 resection.

Efficacy and Safety of Endoscopic Submucosal Dissection for Rectal Tumors Extending Versus Not to the Dentate Line: A Systematic Review and Meta-Analysis

GOALS

To evaluate the outcomes of endoscopic submucosal dissection (ESD) for rectal tumors extending to the dentate line (RTDLs) compared with rectal tumors not extending to the dentate line (non-RTDLs).

BACKGROUND

There is limited composite data on the outcomes of ESD for RTDLs versus non-RTDLs.

STUDY

We performed a systematic review and meta-analysis of studies that reported the clinical outcomes of ESD for RTDLs and non-RTDLs. Main outcomes were pooled estimated rates of en bloc/complete/curative resection, local recurrence, and incidence of bleeding, perforation, stricture, anal pain, and fever.

RESULTS

Six studies were enrolled, including 265 cases of RTDLs and 788 cases of non-RTDLs. The en bloc resection rate was comparable for RTDLs and non-RTDLs [odds ratio (OR), 1.04; 95% confidence interval (CI), 0.55-1.95; P=0.90]. The complete resection rate was significantly lower for RTDLs (OR, 0.59; 95% CI, 0.41-0.83; P=0.003), as well as the curative resection rate (OR, 0.57; 95% CI, 0.38-0.87; P=0.010). The rates of stricture, postoperative anal pain and local recurrence were significantly higher for RTDLs than non-RTDLs (OR, 3.07; 95% CI, 1.01-9.31; P=0.05) (OR, 42.10; 95% CI, 4.73-374.97; P=0.0008) (OR, 3.00; 95% CI, 1.13-7.96; P=0.03), but the higher rates of postoperative bleeding and fever for RTDLs were not significantly (OR, 1.33; 95% CI, 0.53-3.30; P=0.54) (OR, 2.23; 95% CI, 0.55-9.07; P=0.26), as well as its lower perforation rate (OR, 0.85; 95% CI, 0.27-2.63; P=0.78).

CONCLUSIONS

Despite its inferior outcomes than non-RTDLs, ESD is still a feasible and safe treatment for RTDLs if appropriate lesions are treated by experienced operators.

Self-completion method of endoscopic submucosal dissection using the Endosaber for treating colorectal neoplasms (with video)

Endoscopic submucosal dissection (ESD) is effective for the treatment of colorectal neoplasms. We have developed a self-completion ESD (S-ESD) using Endosaber without requiring additional instruments or assistance. This prospective cohort study was conducted to investigate the feasibility of S-ESD for colorectal neoplasms. Patients with colorectal neoplasms measuring 20–40 mm in size were enrolled. A single operator, without assistance, performed ESD using only the Endosaber. The primary outcome was the success rate of S-ESD. Secondary outcomes included procedure time, the rates of en bloc, complete, and curative resection, and complication rates, including the incidence of perforation and delayed bleeding. In total, 15 patients with 15 lesions were enrolled. The median size of the resected lesions was 28 mm (interquartile range 25–29 mm). S-ESD success rate of 100% was achieved. The median procedure time was 44 min (29.5–53.5 min). We observed en bloc, complete, and curative resection rates of 100%, 93.3%, and 86.7%, respectively, and a complication rate of 6.7% (perforation: 0%, delayed bleeding: 6.7%). S-ESD for colorectal neoplasms was successfully performed with favorable treatment outcomes and low complication rates. S-ESD reduces the number of devices and extent of assistance, making S-ESD a simple and cost-effective procedure.

A novel endoscopic purse-string suture technique, "loop 9", for gastrointestinal defect closure: a pilot study

BACKGROUND : This study aimed to assess the feasibility and efficacy of the novel loop 9 method of gastrointestinal (GI) defect closure. METHODS : 20 patients underwent a GI procedure that required defect closure. Loop 9 can be delivered through a single instrument channel (3.2 mm) and released at the defect site. After it has been anchored by two clips positioned on opposite sides of the defect edge, the loop 9 is tightened by pulling the end of the suture intraluminally using biopsy forceps. Additional clips are placed to achieve complete closure. The primary outcome was complete closure rate. The secondary outcomes were closure time, sustained closure rate, and adverse events. RESULTS : Complete closure was achieved in 100 % of cases. The mean size of the mucosal defects was 17.5 mm (range 10-55 mm). The median closure time was 14 minutes. The sustained closure rate was 90 %. No adverse events were noted. CONCLUSIONS : The loop 9 technique is feasible and effective in achieving complete and sustained closure of therapeutic endoscopy-related GI defects.

Efficacy and Safety of Endoscopic Submucosal Dissection for Dysplasia in Ulcerative Colitis Patients: A Systematic Review and Meta-Analysis

Background and Aims. Ulcerative colitis (UC) is associated with an increased risk of colorectal cancer. Current guidelines recommend endoscopic resection if the lesion is visible with distinct margins and a complete resection can be achieved. However, submucosal fibrosis due to chronic inflammation may increase the procedural risk and reduce the complete resection rate. The aim of this study is to assess the efficacy and safety of endoscopic submucosal dissection (ESD) for dysplasia in UC patients. Materials and Methods. A systematic search of databases was performed until May 30, 2021. Studies that reported the resection rates and complication rates of ESD for dysplasia in UC patients were included. A random-effects model was used to generate conservative estimates of the prevalence of the outcome variables. All data analyses were performed using software Stata (version 15). Results. 8 studies were enrolled in the meta-analysis, with a total of 203 dysplastic lesions in 192 UC patients. The mean lesion size was 26.7 mm. About 83% of the lesions were located in the left-side colon, and 90% of the lesions were nonpolypoid, and about 71% of the lesions had submucosal fibrosis. The mean procedural time of ESD was 83 minutes. The en bloc resection rate, complete resection rate, and curative resection rate were 94%, 84%, and 81%, respectively, with a local recurrence rate of 5%. The pooled prevalence of bleeding and perforation were 8% and 6%, respectively. The rates of metachronous tumors and additional surgery after ESD were 6% and 10%, respectively. Conclusion. Despite some limitations, our study suggests that ESD is an effective and safe treatment for dysplasia in UC patients. However, randomized controlled multicenter studies with less heterogeneity and longer follow-up are needed to better assess the clinical outcomes of ESD in UC patients.

Predictors of lymph-node metastasis in surgically resected T1 colorectal cancer in Western populations

Background

The risk of lymph-node metastasis (LNM) in T1 colorectal cancer (CRC) has not been well documented in heterogeneous Western populations. This study investigated the predictors of LNM and the long-term outcomes of patients by analysing T1 CRC surgical specimens and patients’ demographic data.

Methods

Patients with surgically resected T1 CRC between 2004 and 2014 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with multiple primary cancers, with neoadjuvant therapy, or without a confirmed histopathological diagnosis were excluded. Multivariate logistic-regression analysis was used to identify the predictors of LNM.

Results

Of the 22,319 patients, 10.6% had a positive lymph-node status based on the final pathology (nodal category: N1 9.6%, N2 1.0%). Younger age, female sex, Asian or African-American ethnicity, poor differentiation, and tumor site outside the rectum were significantly associated with LNM. Subgroup analyses for patients stratified by tumor site suggested that the rate of positive lymph-node status was the lowest in the rectum (hazard ratio: 0.74; 95% confidence interval: 0.63–0.86).

Conclusion

The risk of LNM was potentially lower in Caucasian patients than in API or African-American patients with surgically resected T1 CRC. Regarding the T1 CRC site, the rectum was associated with a lower risk of LNM.

Endoscopic resection for non-polypoid dysplasia in inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aims to evaluate efficacy and safety of endoscopic treatment for the non-polypoid dysplasia in patients with long-standing IBD.

METHODS

Medline, Embase, Cochrane, and clinicaltrials.gov registry were comprehensively searched. Pooled estimates of curative, R0, en-bloc resection rates, CRC, metachronous dysplasia, and local recurrence rates were calculated. Subgroup analysis according to areas, lesion size, endoscopic resection techniques, and grades of dysplasia were conducted. Data synthesis was completed in R using the package "meta".

RESULTS

Of the 973 studies initially identified, 7 met the inclusion/exclusion criteria. These were all single-arm cohorts and included a total of 202 patients with IBD and non-polypoid dysplasia. The combined R0 and en-bloc resection rate were 0.70 (95% CI 0.55-0.81) and 0.86 (95% CI 0.65-0.95), respectively, with a recurrence rate of 0.08 (95% CI 0.05-0.13). CRC and metachronous dysplasia incidences were pooled as 32.53 (95% CI 12.21-86.67) and 90.24 (95% CI 44.91-181.33) per 1000 patient years.

CONCLUSIONS

Non-polypoid dysplasia associated with IBD can be resected endoscopically, especially by ESD. However, these patients have higher CRC and metachronous dysplasia incidence rates than patients with polypoid dysplasia, indicating a closer endoscopic surveillance.

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.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect

BACKGROUND

Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD.

METHODS

We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques.

RESULTS

A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed.

CONCLUSIONS

Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Feasibility of endoscopic mucosa-submucosa clip closure method (with video)

Background and study aims We developed a new endoscopic closure technique using just conventional endoclips. The feasibility of endoscopic mucosa-submucosa clip closure method was evaluated in this clinical pilot study.

Patients and methods This study involved consecutive 25 patients who underwent colorectal endoscopic submucosal dissection. Endoclips were placed at the edge of the mucosal defect. Each arm of the endoclip gripped the mucosa and submucosa, respectively. The direction in which the endoclip grips were placed was parallel to the short axis of the defect. Several endoclips were applied in this way. As a result, the mucosal defect was significantly reduced in size. Additional clips were placed to achieve complete closure.

Results Mean size of resected specimen was 31.2 ± 11 mm. The success rate was 96 % (24/25). Mean procedure time was 9.6 ± 4.4 minutes. Mean number of endoclips was 9.3 ± 3.7. No complications were observed in any of the patients after the procedure.

Conclusion Endoscopic mucosa-submucosa clip closure method could close mucosal defect of size around 2 – 4 cm completely using just conventional endoclips, and it seems easy, simple and low cost.

Combining eastern and western practices for safe and effective endoscopic resection of large complex colorectal lesions

BACKGROUND

Endoscopic resection of large colorectal polyps is well established. However, significant differences in technique exist between eastern and western interventional endoscopists. We report the results of endoscopic resection of large complex colorectal lesions from a specialist unit that combines eastern and western techniques for assessment and resection.

PATIENTS AND METHODS

Endoscopic resections of colorectal lesions of at least 2 cm were included. Lesions were assessed using magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion-specific approach to resection with endoscopic mucosal resection or endoscopic submucosal dissection (ESD) was used. Surveillance endoscopy was performed at 3 (SC1) and 12 (SC2) months.

RESULTS

Four hundred and sixty-six large (≥20 mm) colorectal lesions (mean size 54.8 mm) were resected. Three hundread and fifty-six were resected using endoscopic mucosal resection and 110 by ESD or hybrid ESD. Fifty-one percent of lesions had been subjected to previous failed attempts at resection or heavy manipulation (≥6 biopsies). Nevertheless, endoscopic resection was deemed successful after an initial attempt in 98%. Recurrence occurred in 15% and could be treated with endoscopic resection in most. Only two patients required surgery for perforation. Nine patients had postprocedure bleeding; only two required endoscopic clips. Ninety-six percent of patients without invasive cancer were free from recurrence and had avoided surgery at last follow-up.

CONCLUSION

Combining eastern and western practices for assessment and resection results in safe and effective organ-conserving treatment of complex colorectal lesions. Accurate assessment before and after resection using magnification chromoendoscopy and a lesion-specific approach to resection, incorporating ESD where appropriate, are important factors in achieving these results.

Endoscopic string clip suturing method: a prospective pilot study (with video)

BACKGROUND AND AIMS

We developed a suturing method with string and clips for a single-channel endoscope. The feasibility of the string clip suturing method is evaluated in this prospective pilot study.

METHODS

This study involved 10 consecutive patients who underwent endoscopic submucosal dissection (ESD) for a duodenal tumor. Polyester string was tied to the arm of a partially out thrust clip. The clip and string can be passed through the instrument channel (3.2 mm) of a single-channel endoscope. The clip with string was placed at the distal edge of the large mucosal defect. A second clip was hooked on the string and placed on the opposite side. Both clips were gathered by pulling the free end of the string, and additional clips were placed to achieve complete closure. This method was compared with that for the previous 10 patients without mucosal closure after duodenal ESD.

RESULTS

Mean size of resected specimens was 39.1 ± 12.4 mm. The success rate of the string clip suturing method was 100% (10/10). The mean procedure time was 23.4 ± 13.8 minutes. Perforation during ESD occurred in 1 patient and was successfully closed by this method. None of the treated patients developed serious adverse events after the procedure. Compared with the no-suture group, the length of stay was significantly shorter (P = .038).

CONCLUSION

The string clip suturing method appears to be a safe and effective method for closure of large mucosal defects. (Clinical trial registration number: UMIN000023698.).

The role of colorectal endoscopic submucosal dissection in patients with ulcerative colitis

BACKGROUND AND AIM

Patients with ulcerative colitis have an increased risk of colorectal dysplasia. Endoscopic submucosal dissection (ESD) for neoplastic lesions in ulcerative colitis remains controversial. The aim of this study was to clarify the role of ESD in the treatment strategy for ulcerative colitis.

METHODS

We retrospectively investigated 25 patients with ulcerative colitis in clinical remission who underwent colorectal ESD at 2 referral centers. We analyzed short-term and long-term outcomes. Preoperative diagnoses based on biopsy or endoscopy were also compared with the histologic diagnoses of resected specimens.

RESULTS

The mean size of the resected specimens was 34.9 ± 17.1 mm. The mean procedure time for ESD was 71.3 minutes. En bloc resection and R0 resection rates were achieved in 100% (25/25) and 76% (19/25), respectively. Postoperative bleeding and perforation during the procedure occurred in 0% and 4%, respectively. Five patients with noncurative resection underwent additional surgery. During a median 21 months (range, 8-80 months) follow-up, local recurrence did not occur. Metachronous high-grade dysplasia occurred in 1 case (4%). The biopsy predicted a final histologic diagnosis of carcinoma with a sensitivity of 72.2% (95% confidence interval [CI], 46.5-90.3), accuracy of 78.2% (95% CI, 56.3-92.5). The endoscopic findings predicted a final histologic diagnosis of carcinoma with a sensitivity of 72.2% (95% CI, 46.5-90.3), accuracy of 76% (95% CI, 54.9-90.6).

CONCLUSION

ESD for neoplasms in ulcerative colitis is feasible by expert endoscopists and may avoid unnecessary surgery. Because the biopsy and endoscopic findings had relatively low accuracy for the final histology, ESD could have a curative as well as a diagnostic purpose.

Efficacy, Safety, and Overall Quality of Life of Endoscopic Submucosal Dissection for Early Colorectal Cancer in Elderly Patients

Purpose

Studies reporting the treatment of early colorectal cancer (ECC) by endoscopic submucosal dissection (ESD) in elderly patients are lacking in China. The aim was to evaluate the efficacy, safety and overall quality of life of elderly patients with ECC who undergoing ESD.

Methods

Three hundred and seventy-nine patients with 401 colorectal lesions entered into our study from March 2013 to March 2016 (Patients with an age 70 years old or older were divided into the elderly group and those who were less than 70-year-old entered the non-elderly group).

Results

No significant differences were found in sex ratio, body mass index, location, endoscopic classification, pathological pattern, lesion size, mean procedure time, hospitalization days, complete excision, and en bloc resection rate between the two groups (P > 0.05). No significant differences were observed between the groups in terms of complications during and after ESD procedure (P > 0.05). There were no statistical differences between two groups in Quality of life index (QL-Index) and European Organization for Research and Treatment quality of life version 3.0 questionnaire (EORTC QLQ-C30) scores (P > 0.05).

Conclusion

ESD was relatively safe and effective for elderly patients with ECC, and it may be an recommended first-line treatment.

Endoscopic slip-knot clip suturing method: prospective pilot study (with video)

BACKGROUND AND AIMS

We developed a suturing method with a slip-knot string and clips for a single-channel endoscope. The feasibility of the slip-knot clip suturing method was evaluated in this clinical pilot study.

METHODS

Ten patients underwent endoscopic submucosal dissection for colorectal and duodenal tumors 5 cm or less. A slip-knot loop can be tightened when tension is applied to the free end of the string. A clip and string can be passed through an instrument channel (3.2 mm) of a single-channel endoscope. The slip-knot loop is anchored onto the mucosal defect's proximal margin with the clip. Additional clips anchoring the slip-knot loop are placed at the opposite side of the margin. The slip-knot loop is tightened by pulling the string. Additional clips are placed to achieve complete closure.

RESULTS

The mean size of resected specimen was 34.4 ± 10.0 mm. The success rate of the slip-knot clip suturing method was 90% (9/10). In the first patient, the string was cut because of friction, and the patient dropped out of the study. After the failure of the first patient, we used wet string to reduce friction, and slip-knot string worked effectively. The mean procedure time was 18.2 ± 3.3 minutes.

CONCLUSION

The slip-knot clip suturing method could close large mucosal defects completely using a single-channel endoscope. (Clinical trial registration number: UMIN000017583.).

Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia

BACKGROUND AND AIMS

Colorectal EMR for nonpolypoid neoplasia achieves better outcomes when performed by expert endoscopists. The time point at which the endoscopist achieves expert level remains to be defined. The objective of this study was to establish a learning curve of colorectal EMR for nonpolypoid neoplasia based on residual tissue on surveillance colonoscopy and adverse event rate.

METHODS

Five hundred seventy-eight consecutive patients underwent EMR of colorectal neoplasia by 1 of 3 primary endoscopists between December 2004 and September 2013 in a tertiary academic center. Primary analyses focused on the largest lesion for patients with more than 1 lesion (median age, 69 years; median polyp size, 30 mm; 51% en bloc resection). Data on surveillance colonoscopy were available for 74%. Learning curves were calculated for each of the 3 main outcome measurements: the presence of residual neoplasia on surveillance colonoscopy, endoscopic assessment of incomplete EMR, and the occurrence of an immediate bleeding adverse event.

RESULTS

Residual neoplasia on surveillance colonoscopy was present for 23.2% of patients, the rate of endoscopist-assessed incomplete EMR was 27.6%, and immediate bleeding adverse events occurred in 6.9% of patients. Although there was between-endoscopist variability, the overall rates of residual neoplasia and incomplete EMR decreased to below 20% to 25% after 100 EMRs; initial decreases in both rates were observed for earlier EMRs. Immediate bleeding adverse events occurred at a low frequency for each endoscopist across all EMRs. Perforation requiring surgical intervention occurred in 1 patient (0.2%).

CONCLUSIONS

This study demonstrated that an unexpectedly high number of 100 colorectal EMR procedures for large nonpolypoid colorectal neoplasia are required to achieve a plateau phase for crucial outcomes.

Endoscopic submucosal dissection and its potential role in the management of early colorectal neoplasia in UK

In Europe, colorectal cancer is the most common newly diagnosed cancer and the second most common cause of cancer deaths, accounting for approximately 436 000 incident cases and 212 000 deaths in 2008. National screening programmes will increase the number of early (pT1) cancers detected. pT1 cancers are those showing invasion through the muscularis mucosae into the submucosa but not into the muscularis propria. Microstaging of pT1 cancer is crucial in predicting those cases less likely to cause nodal disease and that will be cured with endoscopic resection alone. The submucosal extent and other histological features predict the risk of nodal disease, and for this reason, en bloc resection is highly desirable. Endoscopic submucosal dissection enables en bloc resection of mucosal and submucosal disease and could reduce the need for surgery in some cases by definitive initial resection.

Colorectal endoscopic submucosal dissection: Recent technical advances for safe and successful procedures

Endoscopic submucosal dissection (ESD) is very useful in en bloc resection of large superficial colorectal tumors but is a technically difficult procedure because the colonic wall is thin and endoscopic maneuverability is poor because of colonic flexure and extensibility. A high risk of perforation has been reported in colorectal ESD. To prevent complications such as perforation and unexpected bleeding, it is crucial to ensure good visualization of the submucosal layer by creating a mucosal flap, which is an exfoliated mucosa for inserting the tip of the endoscope under it. The creation of a mucosal flap is often technically difficult; however, various types of equipment, appropriate strategy, and novel procedures including our clip-flap method, appear to facilitate mucosal flap creation, improving the safety and success rate of ESD. Favorable treatment outcomes with colorectal ESD have already been reported in many advanced institutions, and appropriate understanding of techniques and development of training systems are required for world-wide standardization of colorectal ESD. Here, we describe recent technical advances for safe and successful colorectal ESD.

Effects of preoperative proton pump inhibitor administration on bleeding after gastric endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND AND AIM

The efficacy of using proton pump inhibitors (PPIs) prior to gastric endoscopic submucosal dissection (ESD) to reduce gastric bleeding remains controversial. This study aimed to systematically review the literature to evaluate the efficacy of preoperative PPI use to reduce post-ESD bleeding.

METHODS

PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched to identify randomized trials eligible for inclusion in the systematic review. Data from four studies (406 patients) were combined to calculate a pooled risk difference (RD) for developing post-ESD bleeding.

RESULTS

Compared with patients who received no premedication, the pooled RD for post-ESD bleeding in patients who received preoperavive PPI was -0.027 (95% confidence interval: -0.070-0.017, p = 0.228), without significant heterogeneity. Preoperavive PPI use significantly increased gastric pH (weighted mean difference: 1.289, 95% CI: 0.227-2.352, p = 0.0174).

CONCLUSIONS

This systematic review and meta-analysis showed that premedication with PPI had no advantage for the prevention of post-ESD bleeding, despite increasing gastric pH.

Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis

AIM: To summarize the clinical impact of a formal training for the effectiveness and safety of endoscopic submucosal dissection for gastrointestinal cancer.

METHODS: We searched databases including PubMed, EMBASE and the Cochrane Library and Science citation Index updated to August 2014 to include eligible articles. In the Meta-analysis, the main outcome measurements were en bloc resection rate, local recurrence rate (R0) and the incidence of procedure-related complications (perforation, bleeding).

RESULTS: En bloc resection was high for both, dissecting stomach tumors with an overall percentage of 93.2% (95%CI: 90.5-95.8) and dissecting colorectal tumors with an overall percentage of 89.4% (95%CI: 85.1-93.7). Although the number of studies reporting R0 resection (the dissected specimen was revealed free of tumor in both vertical and lateral margins) was small, the overall estimates for R0 resection were 81.4% (95%CI: 72-90.8) for stomach and 85.9% (95%CI: 77.5-95.5) for colorectal tumors, respectively. The analysis showed that the percentage of immediate perforation and bleeding were very low; 4.96 (95%CI: 3.6-6.3) and 1.4% (95%CI: 0.8-1.9) for colorectal tumors and 3.1% (95%CI: 2.0-4.1) and 4.8% (95%CI: 2.8-6.7) for stomach tumors, respectively.

CONCLUSION: In order to obtain the same rate of success of the analyzed studies it is a necessity to create training centers in the western countries during the “several years” of gastroenterology residence first only to teach EGC diagnose and second only to train endoscopic submucosal dissection.

Second-look endoscopy after endoscopic submucosal dissection for gastric neoplasms

Routine second-look endoscopy after gastric endoscopic submucosal dissection (ESD) remains controversial. The aim of the present study was to systematically evaluate the efficacy of second-look endoscopy for gastric ESD. PubMed, the Cochrane library, and the Igaku-chuo-zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data were combined to calculate a pooled odds ratio (OR) for developing post-ESD bleeding. The database search yielded three randomized trials (854 patients). Compared with second-look endoscopy, the pooled OR for post-ESD bleeding without second-look endoscopy was 0.69 (95% confidence interval [CI]: 0.38-1.26, P = 0.228), without significant heterogeneity. There were no significant differences between second-look endoscopy and no second-look endoscopy with regard to large tumor size (>20 mm). This systematic review and meta-analysis showed that second-look endoscopy had no advantage for the prevention of post-ESD bleeding in patients without a high risk of bleeding.

Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video)

BACKGROUND

Conventional endoscopic treatment of a recurrent adenoma after piecemeal EMR (PEMR) of a colorectal laterally spreading tumor (LST) is technically difficult with low en bloc resection rates because of the inability to snare fibrotic residual.

OBJECTIVE

To assess the feasibility of salvage underwater EMR (UEMR) for the treatment of recurrent adenoma after PEMR of a colorectal LST.

DESIGN

Retrospective, cross-sectional study.

SETTING

Single, tertiary-care referral center.

PATIENTS

Patients who have recurrent adenoma after PEMR of colorectal LST (≥2 cm).

INTERVENTIONS

UEMR versus EMR.

MAIN OUTCOME MEASUREMENT

En bloc resection rate, endoscopic complete removal rate, recurrence rate on follow-up colonoscopy, adjunctive ablation rate with argon plasma coagulation (APC) during salvage procedure, and independent predictive factors for successful en bloc resection and endoscopic complete removal.

RESULTS

Eighty salvage procedures (36 UEMRs vs 44 EMRs) were analyzed. En bloc resection rate (47.2% vs 15.9%, P = .002) and endoscopic complete removal rate (88.9% vs 31.8%, P < .001) were higher in the UEMR group than in the EMR group. APC ablation of visible residual during salvage procedure was lower in UEMR group than EMR group (11.1% vs 65.9%, P < .001). Recurrence rate on follow-up colonoscopy was significantly lower in the UEMR group than the EMR group (10% vs 39.4%, P = .02). UEMR was an independent predictor of successful en bloc resection and endoscopic complete removal.

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

UEMR can be a useful and feasible technique as a salvage procedure for recurrent colorectal adenoma after PEMR.

Propofol versus traditional sedative agents for endoscopic submucosal dissection

BACKGROUND AND AIM

Propofol has been suggested to be superior to benzodiazepines when used as a sedative agent for endoscopic examination. The aim of the present study was to systematically evaluate the safety and efficacy of propofol sedation for endoscopic submucosal dissection (ESD).

METHODS

PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data from the eligible studies were combined to calculate pooled odds ratios (OR) of developing restlessness, full awakening at 1 h post-ESD, hypoxia, and hypotension.

RESULTS

We identified three randomized trials (298 patients) from the database search. Compared with traditional sedative agents, the pooled OR of restlessness and full awakening at 1 h post-ESD with propofol sedation were 0.41 (95% confidence interval [CI]: 0.21-0.81) and 8.59 (95% CI: 4.29-17.2), respectively, without significant heterogeneity. Compared with traditional sedative agents, the pooled OR of hypoxia and hypotension with propofol sedation were 1.13 (95% CI: 0.58-2.21) and 0.92 (95% CI: 0.25-3.41), respectively, indicating no significant differences between the groups.

CONCLUSION

Propofol sedation during ESD is more effective as compared with traditional sedative agent. The risk of complications is similar.

Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort

BACKGROUND

Colorectal endoscopic submucosal dissection (C-ESD) is a promising but challenging procedure. We aimed to evaluate the factors associated with technical difficulties (failure of en bloc resection and procedure time, ≥2 h) and adverse events (perforation and bleeding) of C-ESD.

METHODS

We conducted a retrospective exploratory factor analysis of a prospectively collected cohort in 15 institutions. Eight-hundred sixteen colorectal neoplasms larger than 20 mm from patients who underwent C-ESD were included. We assessed the outcomes of C-ESD and risk factors for technical difficulties and adverse events.

RESULTS

Of the 816 lesions, 767 (94 %) were resected en bloc, with a median procedure time of 78 min. Perforation occurred in 2.1 % and bleeding in 2.2 %. Independent factors associated with failure of en bloc resection were low-volume center (<30 neoplasms), snare use, and poor lifting after submucosal injection. Factors significantly associated with long procedure time (≥2 h) were large tumor size (≥4 cm), low-volume center, less-experienced endoscopist, CO2 insufflation, and use of two or more endoknives. Poor lifting was the only factor significantly associated with perforation, whereas rectal lesion and lack of a thin-type endoscope were factors significantly associated with bleeding. Poor lifting after submucosal injection occurred more frequently for nongranular-type laterally spreading tumors (LST) and for protruding and recurrent lesions than for granular-type LST (LST-G).

CONCLUSIONS

Poor lifting after submucosal injection was the risk factor most frequently associated with technical difficulties and adverse events on C-ESD. Less experienced endoscopists should start by performing C-ESDs on LST-G lesions.

Novel diagnostic and therapeutic techniques for surveillance of dysplasia in patients with inflammatory bowel disease

The risk for developing dysplasia and colorectal cancer in patients with longstanding inflammatory bowel disease (IBD) involving the colon is well documented. Random biopsies during white-light, standard-definition colonoscopy (33 to 50 biopsies) with or without dye spraying chromoendoscopy has been the recommended strategy in North America to detect dysplastic lesions in IBD. However, there are several limitations to this approach including poor physician adherence, poor sensitivity, increased procedure time and considerable cost. The new generation of high-definition endoscopes with electronic filter technology provide an opportunity to visualize colonic mucosal and vascular patterns in minute detail, and to identify subtle flat, multifocal, polypoid and pseudopolypoid neoplastic and non-neoplastic lesions. The application of these new technologies in IBD is slowly being adopted in clinical practice. In addition, the advent of confocal laser endomicroscopy provides an opportunity to explore real-time histology, thus redefining the understanding and characterization of the lesions in IBD. There is emerging evidence that serrated adenomas are also associated with longstanding IBD colitis and may be recognized as another important contributing factor to colorectal cancer development. The circumscribed neoplastic lesions can be treated using endoscopic therapeutic management such as mucosal resection or, especially, endoscopic submucosal dissection. This may replace panproctocolectomy in selected patients. The authors review the potential of these techniques to transform endoscopic diagnosis and therapeutic management of dysplasia in IBD.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms

AIM: To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms.

METHODS: We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD.

RESULTS: Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding.

CONCLUSION: Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

A novel opportunity in minimally invasive colorectal cancer therapy: defining a role for endoscopic submucosal dissection in the United States

Colorectal cancer is the third most common cancer among both men and women in the United States and the second leading cause of cancer death. Endoscopic submucosal dissection (ESD) is an innovative advanced endoscopic therapy for superficial gastrointestinal neoplasms which is rapidly becoming standard of care particularly in Asia. ESD was first developed for the resection of early gastric cancers; yet ESD for colon tumors has gained increasing attention in recent years. The advantage of ESD over conventional endoscopic resection lies in its potential to achieve en bloc resection regardless of tumor size, leading to more precise histological evaluation and greater potential for cure. Selecting appropriate patients for this procedure involves identifying colorectal cancers with nul risk of lymph node spread. For colorectal ESD to engraft in the United States, the prevalence of such early stage lesions must be defined so that centers of excellence can be developed for high volume clinical practice to offer patients the safest and most efficacious outcomes. This review discusses the endoscopic staging of colorectal neoplasms, indications for colorectal ESD, and the epidemiology of early stage ESD-amenable colorectal cancer in America to better define an opportunity for this important minimally invasive therapy.

Training in endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.

Training in endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient's quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee's background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.

Creation of simulated papillae for endoscopic sphincterotomy and papillectomy training by using in vivo and ex vivo pig model (with videos)

BACKGROUND

There are few in vivo and ex vivo models for training in endoscopic sphincterotomy (ES) and endoscopic papillectomy (EP).

OBJECTIVE

We describe in vivo and ex vivo training pig models that use a simulated papilla for hands-on teaching of ES and EP.

DESIGN

Animal experiment.

SETTING

A referral center.

MATERIALS AND INTERVENTIONS

Hyaluronate solution (0.4%) was injected submucosally using a 25-gauge sclerotherapy needle to create a submucosal bleb by using porcine in vivo stomach, ex vivo stomach, and ex vivo rectum. ES and EP were then performed by using a pull-type sphincterotome and snare, respectively.

MAIN OUTCOME MEASUREMENT

The feasibility of creating a simulated papilla for ES and EP procedures was tested by experienced and nonexperienced ERCP endoscopists.

RESULTS

Creation of a hemispheroidal bulge was successful in 13 of 17 (76%) areas within an in vivo stomach, 13 of 16 (81%) areas of an ex vivo stomach, and 16 of 16 (100%) areas in an ex vivo rectum. In the in vivo stomach model, ES was successfully and realistically performed on the anterior wall of the stomach rather than in other walls. In the ex vivo stomach model, endoscopists experienced in ERCP and trainees performed ES without difficulty, whereas it was difficult or impossible for nonexperienced trainees to perform ES. In the ex vivo rectum model, all 3 endoscopists were able to complete not only ES but also EP.

LIMITATIONS

Pilot study.

CONCLUSIONS

Although further studies are necessary to evaluate the reproducibility and cost-effectiveness, this novel pig model appears useful for ES and EP training.

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

Piecemeal endoscopic mucosal resection (EMR) is generally indicated for laterally spreading tumors (LST) >2 cm in diameter. However, the segmentation of adenomatous parts does not affect the histopathological diagnosis and completeness of cure. Thus, possible indications for piecemeal EMR are both adenomatous homogenous-type granular-type LST (LST-G) and LST-G as carcinoma in adenoma without segmentalizing the carcinomatous part. Diagnosis of the pit pattern using magnifying endoscopy is essential for determining the correct treatment and setting segmentation borders. In contrast, endoscopic submucosal dissection (ESD) is indicated for lesions requiring endoscopic en bloc excision, as it is difficult to use the snare technique for en bloc excisions such as in non-granular-type LST (LST-NG), especially for the pseudodepressed type, tumors with a type VI pit pattern, shallow invasive submucosal carcinoma, largedepressed tumors and large elevated lesions, which are often malignant (e.g. nodular mixed-type LST-G). Other lesions, such as intramucosal tumor accompanied by submucosal fibrosis, induced by biopsy or peristalsis of the lesion; sporadic localized tumors that occur due to chronic inflammation, including ulcerative colitis; and local residual early carcinoma after endoscopic treatment, are also indications for ESD. In clinical practice, an efficient endoscopic treatment with segregation of ESD from piecemeal EMR should be carried out after a comprehensive evaluation of the completeness of cure, safety, clinical simplicity, and cost-benefit, based on an accurate preoperative diagnosis.

Colorectal endoscopic submucosal dissection: is it suitable in western countries?

Endoscopic submucosal dissection (ESD) represents a significant advance in therapeutic endoscopy with the major advantage being the ability to achieve a higher en bloc resection rate for early stage lesions. Western endoscopists infrequently perform colorectal ESD (CR-ESD) because of the greater technical difficulty involved, longer procedure times, and increased risk of perforation. Specialized training and sufficient clinical experience are necessary to successfully perform ESDs, but a systematic education and training program has still not been established in Japan or elsewhere in the world. Experts generally acknowledge that the stomach is the first organ in which endoscopists should begin performing ESDs. The incidence and detection rates for early stage gastric cancer are significantly higher in Japan than in western countries, so Japanese endoscopists have a greater opportunity to perform gastric ESDs than their western counterparts. It is logical to ask, therefore, whether CR-ESD can be effectively applied in western countries. Based on a review of the relevant literature and our practical perspective, we have focused on the progress made in performing CR-ESD, its indications, training methods, and learning curve. Use of animal gastric and colon models is strongly recommended along with accumulating the necessary experience from the rectum to the colon on a step-by-step basis. It is reasonable to assume that an increasing number of CR-ESDs will be performed by western endoscopists in the foreseeable future given the continuing development of new techniques, and the refinement of instruments and other technologically advanced devices together with the creation of even more effective submucosal injection agents.