Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal tumors: A meta-analysis

Prospective feasibility study of a novel rigidizing stabilizing overtube in the resection of complex gastrointestinal polyps

BACKGROUND

A novel rigidizing overtube (ROT) was developed to facilitate endoscopic removal of complex gastrointestinal polyps. We aimed to prospectively evaluate the efficacy and safety of the device in the management of large gastrointestinal polyps.

METHODS

A prospective, single-center study, conducted between May 2021 and April 2023, enrolled patients undergoing endoscopic resection of colon/duodenal polyps ≥25 mm. Primary outcomes were safety, technical success, and clinical success defined as the ability of ROT to facilitate endoscopic polyp removal without changing the initial resection method.

RESULTS

97 patients (98 polyps), with a mean polyp size of 33.2 mm (median 31.1), were evaluated. Technical and clinical success rates were 100% and 84%, respectively. Ileocecal valve location was the only predictor of clinical failure (P = 0.02). The mean time to reach the lesion was 7.2 minutes (95%CI 5-8), with overall resection and procedure times of 53.6 minutes (95%CI 48-61) and 88.9 minutes (95%CI 79-95), respectively. No device-related adverse events occurred. Lower technical (67%) and clinical (67%) success rates were seen for duodenal polyps (n = 6).

CONCLUSION

The novel ROT was safe, with high technical and clinical success during resection of complex colon polyps. Future studies will determine timing of implementation during routine endoscopic resection.

Outcomes of Colorectal Endoscopic Submucosal Dissection for Elderly Patients: A Multicenter Study by the Honam Association for the Study of Intestinal Disease (HASID)

BACKGROUND/AIM

The aging population has been growing gradually; therefore, the proportion of elderly patients undergoing colorectal endoscopic submucosal dissection (ESD) has also been increasing. However, there is a lack of large-scale studies on the efficacy and safety of colorectal ESD in elderly patients.

PATIENTS AND METHODS

This retrospective analysis evaluated colorectal ESDs performed at five tertiary medical institutions between January 2015 and December 2020. Patients were categorized into the following four age groups: Middle-aged (<65 years), young-elderly (≥65 to <75 years), mid-elderly (≥75 to <85 years), and very elderly (≥85 years). Of the 1,446 patients included, 668 (46.2%), 466 (32.2%), 293 (20.3%), and 19 (1.3%) were in the middle-aged, young-elderly, mid-elderly, and very-elderly groups, respectively.

RESULTS

Compared to younger patients, more older patients used aspirin, clopidogrel, and anti-thrombotic agents. Additionally, the Charlson comorbidity index increased significantly with increasing age. However, no significant differences were observed in the complete resection rates nor the rates of complications, such as perforation, bleeding, and post-ESD coagulation syndrome, among the different age groups. A restricted cubic spline curve was used to construct predictive models for complete resection and major complications based on age and showed that the need for complete resection did not decrease with increasing age. Furthermore, major complications did not significantly differ with age progression.

CONCLUSION

Colorectal ESD should be actively considered as a relatively safe and effective treatment method for elderly patients.

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.

Characteristics of positive horizontal margins in patients who underwent colorectal endoscopic submucosal dissection

Objectives

Endoscopic submucosal dissection (ESD) enables en bloc resection of colorectal neoplasms, but occasionally results in positive horizontal margins (HMs). However, the site of the resected specimen that tends to be positive for HM has not been investigated. We aimed to clarify the characteristics associated with HMs in lesions resected en bloc with ESD.

Methods

Patients with colorectal neoplasms who underwent en bloc resection with ESD were included in this study. The patients were divided into negative HMs (HM0) and positive or indeterminate HMs (HM1) groups. The characteristics associated with HM1 resection were investigated. In addition, the local recurrence rate during endoscopic follow-up for >6 months after ESD was observed.

Results

In total, 201 lesions were analyzed in 189 patients (HM0, 189 lesions; HM1, 12 lesions). The HM1 group had a significantly larger median lesion diameter (25 vs. 55 mm; p < 0.001) and more lesions with >50% circumference than did the HM0 group (p < 0.001). Furthermore, the prevalence of severe fibrosis was significantly higher in the HM1 group than in the HM0 group (p < 0.001). Positive horizontal sites of the resected specimens were more frequent at the oral and anal sites than at the lateral sites. No local recurrences were observed in either group.

Conclusions

The characteristics associated with HM1 depended on lesion size, particularly lesions with >50% circumference, and submucosal fibrosis.

Endoscopic Submucosal Dissection Is Safe and Effective for Lesions Located at the Anorectal Junction: Analysis from Two Referral European Centers

Introduction

Endoscopic submucosal dissection (ESD) is a well-established resection technique for colorectal superficial tumors, but its role in the treatment of anorectal junction (ARJ) lesions still remains to be determined. With this study, we aimed to evaluate the feasibility, safety, and efficacy of ESD for the resection of ARJ lesions, in comparison to more proximal rectal lesions.

Methods

We performed a retrospective analysis of prospectively collected data concerning all consecutive rectal ESD procedures performed in two European centers, from 2015 to 2021.

Results

A total of two hundred and fifty-two rectal lesions were included. Sixty (24%) were ARJ lesions, and the remaining 192 (76%) were located proximally. Technical success was achieved in 248 procedures (98%), and its rate was similar in both locations (p = 0.246). Most of the lesions presented high-grade dysplasia/Tis adenocarcinoma (54%); 36 (15%) had submucosal adenocarcinoma, including 20 superficial (sm1) and 16 deeply invasive (>SM1) T1 cancers. We found no differences between ARJ and rectal lesions in regard to en bloc resection rate (100% vs. 96%, p = 0.204), R0 resection rate (76% vs. 75%, p = 0.531), curative resection rate (70% vs. 70%, p = 0.920), procedures' median duration (120 min vs. 90 min, p = 0.072), ESD velocity (14 vs. 12 mm2/min, p = 0.415), histopathology result (p = 0.053), and the need for surgery due to a non-curative ESD (5% vs. 3%, p = 0.739). Also, there was no statistically significant difference that concerns delayed bleeding (7% vs. 8%, p = 0.709), perforation (0% vs. 5%, p = 0.075), or the need for readmission (2% vs. 2%, p = 0.939). Nevertheless, anorectal stenosis (5% vs. 0%, p = 0.003) and anorectal pain (9% vs. 1%, p = 0.002) were significantly more frequent in ARJ lesions.

Conclusion

ESD is a safe and efficient resection technique for the treatment of rectal lesions located in the ARJ.

Endoscopic intermuscular dissection for locally advanced rectal cancer: A case report

BACKGROUND

Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is < 1000 microns with favourable histopathological features. Recent data suggests even deeper submucosal invasion can potentially be curative if R0 resection can be achieved and when no high-risk histopathological features are seen in the resected specimen. To achieve R0 resection, deeper dissection is required.

CASE SUMMARY

A 66 year old New Zealand European male presented with 3 mo history of per rectal bleeding. He was referred for a colonoscopy test to investigate this further. This revealed a malignant appearing lesion in the rectum. Biopsies however showed high grade dysplasia only. Given endoscopic appearances suspicious for deep submucosal invasion, patient was consented for endoscopic intermuscular dissection (EID). The case was successfully performed, and the presence of muscularis propria was confirmed in the resected specimen. There were no complications and total procedure time was 124 min. Lesion was clear of radial margins however deep margins were positive confirming it was at least a pT2 cancer. Patient was recommended to have further treatment but could not have radical surgery due to comorbidities and instead was referred for long course chemoradiotherapy.

CONCLUSION

EID is a safe and feasible option for management of rectal cancer in highly selected patients.

Usage trends of colorectal endoscopic submucosal dissection according to hospital types based on nationwide claims data

Although the use of colorectal endoscopic submucosal dissection (ESD) for colorectal lesions has increased, there is a lack of analysis of the recent usage trends of ESD. Thus, this study aimed to identify changes in the annual utilization of ESD and determine the proportion of surgeries after ESD according to hospital types. Using Health Insurance Review and Assessment data from 2012 to 2019, 26,502 colorectal ESD cases were analyzed to assess the annual usage trends of ESD according to hospital type, additional early and late surgeries after ESD, changes in the distribution of colorectal lesions, and factors associated with early and late surgery. Trend analysis was performed using the chi-squared test for trend in proportions. Colorectal ESD increased from 2046 in 2012 to 5319 in 2019. Additional early and late surgeries rose from 135 (6.6%) in 2012 to 441 (8.2%) in 2019 (P < .05) and from 9 (0.3%) in 2013 to 52 (1.0%) in 2019 (P < .05), respectively. In tertiary and general hospitals, the proportion of submucosal cancers decreased, whereas the proportion of intramucosal cancers increased. Submucosal cancer was associated with early (odds ratio: 108.90, 95% confidence interval: 61.67-192.35) and late surgery (odds ratio: 3.55, 95% confidence interval: 2.27-5.56). Using nationwide data, our study identified the clinical usage trends of colorectal ESD based on the annual increase in utilization and the proportion of additional surgeries after ESD.

pT1 colorectal cancer: A treatment dilemma

The implementation of population screening programs for colorectal cancer (CRC) has led to a considerable increase in the prevalence pT1-CRC originating on polyps amenable by local treatments. However, a high proportion of patients are referred for unnecessary oncological surgeries without a clear benefit in terms of survival. Selecting the appropriate endoscopic resection technique in the moment of diagnosis becomes crucial to provide the best treatment alternative to each individual polyp and patient. For this, it is imperative to increase the optical diagnostic skill for differentiating pT1-CRCs and decide the appropriate initial therapy. En bloc resection is crucial to obtain an adequate histological specimen that might allow organ preserving therapeutic management. In this review, we address key challenges in T1 CRC management, explore the efficacy and safety of the available diagnostic and therapeutic approaches, and shed light on upcoming advances in the field.

Endoscopic mucosal resection and endoscopic submucosal dissection with an external additional working channel (EMR+ and ESD+) are equivalent to using a double-channel endoscope: a systematic evaluation in a porcine ex vivo model

BACKGROUND AND AIMS

With an external additional working channel (AWC) endoscopic mucosal resection (EMR) as well as endoscopic submucosal dissection (ESD) can be extended to techniques termed "EMR+" and "ESD+." These novel techniques are systematically compared to EMR and ESD under the use of a double-channel endoscope (DC).

METHODS

Our trial was conducted prospectively in a pre-clinical porcine animal model (EASIE-R simulator) with standardized gastric lesions measuring 3 or 4 cm.

RESULTS

EMR+ and EMR DC showed both good results for 3 cm lesions with no adverse events and an en bloc resection rate of 73.33% (EMR+) and 60.00% (EMR DC, p = 0.70). They came to their limits in 4 cm lesions with muscularis damages of 20.00% (EMR+), 13.33% (EMR DC, p ≥ 0.99) and decreasing en bloc resection rates of 60.00% (EMR+) and 46.67% (EMR DC, p = 0.72). ESD+ and ESD DC were both reliable concerning en bloc resection rates (100% in all groups) and adverse events (0.00% in 3 cm lesions, 12.50% muscularis damages in both ESD+ and ESD DC in 4 cm lesions). Resection time was slightly shorter in all groups with the AWC compared to DC although only reaching significance in 3 cm ESD lesions (p < 0.05*).

CONCLUSIONS

With the AWC, a standard endoscope can easily be transformed to double-channel functionality. We could show that EMR+ and ESD+ are non-inferior to EMR and ESD under the use of a double-channel endoscope. Consequently, the AWC presents an affordable alternative to a double-channel endoscope for both EMR and ESD.

Comparing endoscopic mucosal resection with endoscopic submucosal dissection in colorectal adenoma and tumors: Meta-analysis and system review

AIMS

This study aimed to evaluate the safety, efficacy, and long-term outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for treating colorectal adenomas and tumors.

METHODS

A systematic literature review was conducted using databases including PubMed, Web of Science, and Embase. Parameters such as number of patients or lesions, histological diagnosis, lesion size, surgery time, en-bloc resection, R0 resection, severe postoperative complications, and local recurrence were extracted and pooled for analysis.

RESULTS

A total of 12 retrospective studies involving 1289 patients and 1850 lesions were included in the analysis. EMR was found to have a shorter operation time by 53.6 minutes (95% CI: 51.3, 55.9, P<0.001) and fewer incidences of severe postoperative complications such as perforation and delayed bleeding (OR = 0.40, 95%CI: 0.23, 0.71, P<0.001). On the other hand, ESD had higher rates of en-bloc resection (OR = 0.15, 95%CI: 0.07, 0.30, P<0.001) and R0 resection (OR = 0.32, 95%CI: 0.16, 0.65, P<0.001). Recurrence after EMR was found to be significantly higher than that after ESD surgery (OR = 5.88, 95%CI: 2.15, 16.07, P = 0.037).

CONCLUSIONS

The study suggests that the choice of surgical method may have a greater impact on recurrence compared to the pathological type, and that ESD may be more suitable for the treatment of malignant lesions despite its higher rates of severe postoperative complications and longer operation time.

Effect of Sarcopenia on Pneumonia after Endoscopic Submucosal Resection in Patients Aged ≥65 Years: A Retrospective Study

We aimed to investigate the association between sarcopenia and incidence of pneumonia after endoscopic submucosal dissection (ESD) in patients aged ≥65 years. Patients with (n = 1571) and without sarcopenia (n = 1718) who underwent ESD for gastric neoplasm were included. Propensity score matching (PSM) was performed between the groups (n = 785) at a 1:1 ratio. The primary endpoint was the effect of sarcopenia on the incidence of pneumonia after ESD. Among the included patients, 2.2% (n = 71) developed pneumonia after ESD. After PSM, the incidence rate of pneumonia was significantly higher in patients with sarcopenia than that in patients without sarcopenia (p = 0.024). Sarcopenia and age ≥73 years were significantly associated with the incidence of pneumonia (sarcopenia and age <73 years, odd ratio (OR) = 1.22 [95% confidence interval (CI): 0.46-3.22]; sarcopenia and age ≥73 years, OR = 3.92 [95% CI: 1.79-8.74]). Patients with sarcopenia had an increased risk of developing pneumonia after ESD, even after adjusting for other factors, resulting in a higher incidence of leukocytosis and a longer duration of post-ESD hospitalization. The combination of sarcopenia and age ≥73 years could be an effective predictive factor for screening high-risk groups for pneumonia after ESD.

Short‐term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions

Objectives

Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients.

Methods

Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events.

Results

A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors.

Conclusions

No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.

The Perioperative and Operative Management of Esophageal and Gastric Cancer

Optimal management of esophageal and gastric cancer during the perioperative period requires a coordinated multidisciplinary treatment effort. Accurate staging guides treatment strategy. Advances in minimally invasive surgery and endoscopy have reduced risks associated with resection while maintaining oncological standards. Although the standard perioperative chemo-and radiotherapy regimens have not yet been established, randomized control trials exploring this subject show promising results.

Advances in Imaging of Inflammation, Fibrosis, and Cancer in the Gastrointestinal Tract

Gastrointestinal disease is prevalent and broad, manifesting itself in a variety of ways, including inflammation, fibrosis, infection, and cancer. However, historically, diagnostic technologies have exhibited limitations, especially with regard to diagnostic uncertainty. Despite development of newly emerging technologies such as optoacoustic imaging, many recent advancements have focused on improving upon pre-existing modalities such as ultrasound, computed tomography, magnetic resonance imaging, and endoscopy. These advancements include utilization of machine learning models, biomarkers, new technological applications such as diffusion weighted imaging, and new techniques such as transrectal ultrasound. This review discusses assessment of disease processes using imaging strategies for the detection and monitoring of inflammation, fibrosis, and cancer in the context of gastrointestinal disease. Specifically, we include ulcerative colitis, Crohn's disease, diverticulitis, celiac disease, graft vs. host disease, intestinal fibrosis, colorectal stricture, gastric cancer, and colorectal cancer. We address some of the most recent and promising advancements for improvement of gastrointestinal imaging, including unique discussions of such advancements with regard to imaging of fibrosis and differentiation between similar disease processes.

Is Endoscopic Submucosal Dissection for Colorectal Lesions Performed in the Endoscopy Suite Safe and Cost Saving?

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.

Endoscopic Management of Colitis-Associated Neoplasia

This article reviews the latest data concerning the use of advanced therapeutic techniques for endoscopically treating colitis-associated neoplastic lesions and discusses factors associated with improved outcomes.

Development and validation of a nomogram based on neutrophil-to-lymphocyte ratio and fibrinogen-to-lymphocyte ratio for predicting recurrence of colorectal adenoma

Background

There are many risk factors for the recurrence of colorectal adenoma (CRA). The purpose of this study was to explore the predictive performance of fibrinogen-to-lymphocyte ratio (FLR) and neutrophil-to-lymphocyte ratio (NLR) on the recurrence of CRA and to construct a predictive model.

Methods

This study analyzed the clinicopathological features of 421 CRA patients who underwent colonoscopy and adenectomy, and evaluated the recurrence of polyps under colonoscopy. Among them, 301 were training cohort and 120 were validation cohort. Multivariate logistic regression was used to identify independent risk factors associated with CRA recurrence. Established a nomogram model to predict the risk of recurrence in CRA patients using independent risk factors. The receiver operating characteristic (ROC) curves were used to verify the nomogram model discrimination. Calibration curves were used to verify the model calibration degree. The decision curve analysis (DCA) curves were used to verify the clinical efficacy of the nomogram model.

Results

Totally, six independent predictors, including smoking, diabetes, adenoma number, adenoma size, NLR, and FLR, were enrolled in the nomogram. In the training cohort and validation cohort, the area under the curve (AUC) of the nomogram for predicting the risk of CRA recurrence was 0.846 and 0.841, respectively. The calibration curves displayed a good agreement. DCA curves showed that this model had a high net clinical benefit.

Conclusions

Smoking, diabetes, adenoma number, adenoma size, NLR, and FLR were influencing factors for CRA recurrence.

Clinical effectiveness of short course oral prednisone for stricture prevention after semi-circumferential esophageal endoscopic submucosal dissection

Background and study aims  Esophageal strictures (ES) occur frequently after semi-circumferential endoscopic submucosal dissection (ESD) for the eradication of superficial esophageal neoplasms and negatively impact a patient's quality of life. Oral corticosteroids have been shown to be clinically effective, but the most appropriate drug, dose and duration is yet to be determined. The aim of the study was to investigate the clinical effectiveness and safety of 30 mg prednisone with a shortened tapering schedule on ES after semi-circumferential ESD. Patients and methods  This was a retrospective observational study that analyzed consecutive patients with esophageal neoplasms who underwent semi-circumferential ESD with a resection defect greater than 75 % of the circumference that received a protocol of oral steroids for stricture prevention. On postoperative day 3, 30 mg prednisone was prescribed, tapering weekly to 20 mg/10 mg/5 mg over 4 weeks. Follow-up included clinic consultation and endoscopic review at weeks 2 and 4. Effectiveness outcomes included ES rates, safety, tolerability, resection, dilatation and recurrence rates. Results  Ninety ESD procedures were carried out during the specified time period and 18 patients met the inclusion criteria for the final analysis. The mean age was 61.5 years, lesion size was 52.5 mm, and final histology was squamous cell carcinoma in all patients. Incidence of intra-procedure complications was: bleeding 5.5 % (1/18) and ES 5.5 % (1/18), requiring a median two endoscopic dilatations. En bloc, R0 and curative resection rates were 88.8 %, 72.2 %, and 55.5 %, respectively. Conclusions  The short tapering schedule of 30 mg oral prednisone is clinically efficacious and safe for prevention of ES after semi-circumferential ESD in Latin American patients.

Combined endoscopic robotic surgery for complex colonic polyp resection: case series

BACKGROUND

The study objective was to evaluate combined endoscopic and robotic surgery, a novel surgical technique modifying traditional combined endoscopic laparoscopic surgery through robotic assistance, and characterize a series of patients who underwent the modified operative technique.

METHODS

A retrospective case series was performed. The first thirty-seven consecutive patients who underwent combined endoscopic robotic surgery by a single colorectal surgeon from March 2018 to October 2019 were included. Main outcome measures included operative time, intra-operative complication, 30-day post-operative complication, and hospital length of stay.

RESULTS

Combined endoscopic and robotic surgery was performed in 37 cases, 32 (86.5%) of which saw the technique through to completion. Median operative room time was 73 min (range 31-184 min). No intraoperative complications occurred and 2 (6.3%) experienced 30-day post-operative complications. Median hospital length of stay was 1.1 days (range 0.2-2.0 days). Median polyp size was 35 mm (range 20-130 mm). Polyps were resected from the following locations: cecum (37.5%), ascending colon (28.1%), transverse colon (21.9%), descending colon (3.1%), sigmoid colon (6.3%), and rectum (3.1%). Pathology demonstrated 77.4% tubular adenoma, 12.9% sessile serrated adenoma, 6.5% dysplasia, and 3.2% signet cell adenocarcinoma.

CONCLUSION

Combined endoscopic robotic surgery was associated with decreased operative time, complication rates, and hospital length of stay compared to literature-reported statistics for combined endoscopic laparoscopic surgery. Increased confidence with 3-dimensional visualization and intracorporeal suturing using combined endoscopic and robotic surgery was noted. Additional studies are needed to further define the role of robotics in combined endoscopic surgery.

Risk Stratification of Endoscopic Submucosal Dissection in Colon Tumors

Background: Endoscopic submucosal dissection (ESD) is a technique proven effective in the treatment of early neoplastic lesions in the gastrointestinal tract. However, in the case of colon lesions, many doubts remain. The purpose of our study is to stratify the success rates of the ESD procedure in the colon. Materials and Methods: A retrospective analysis of 601 patients who underwent ESD procedure for colorectal neoplasm from 2016 to 2019 in Center of Bowel Treatment, Brzeziny, Poland. Excluding 335 rectal neoplasms, we selected 266 patients with lesions located in the colon. Results: Lesions located in the left colon were characterized by the statistically higher en bloc resection and success rate, compared with the right colon—87.76% vs. 73.95% (p = 0.004) and 83.67% vs. 69.75% (p = 0.007), respectively. The success rate was significantly lower in lesions with submucosal cancer, compared to low- and high-grade dysplasia (p < 0.001). Polyps located in the right colon were characterized by a slightly higher complication rate compared to the left colon, without statistical significance—13.45% vs. 9.52% (p = 0.315). Conclusions: Our results show that colonic ESD has a high success rate, especially in the left colon, with a low risk of complications, slightly higher than in the right colon.

Minimally Invasive Endoscopic and Surgical Management of Rectal Neoplasia

Rectal cancer demonstrates a characteristic natural history in which benign rectal neoplasia precedes malignancy. The worldwide burden of rectal cancer is significant, with rectal cancer accounting for one-third of colorectal cancer cases annually. The importance of early detection and successful management is essential in decreasing its clinical burden. Minimally invasive treatment of rectal neoplasia has evolved over the past several decades, which has led to reduced local recurrence rates and improved survival outcomes. The approach to diagnosis, staging, and selection of appropriate treatment modalities is a multidisciplinary effort combining interventional endoscopy, surgery, and radiology tools. This review examines the currently available minimally invasive endoscopic and surgical management options of rectal neoplasia.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

Endoscopic mucosal resection of colorectal polyps: results, adverse events and two-year outcome

Background and study aims

Endoscopic mucosal resection (EMR) is the first-line treatment for large sessile and flat colorectal polyps in Western centres, however recurrence after EMR continues to be a challenge. The aim of this study is to assess efficacy, safety and recurrence rate of EMR in a tertiary centre and to identify risk factors for recurrence at first surveillance endoscopy (SE1).

Patients and methods

We performed a retrospective study of 165 sessile and flat colorectal lesions ≥15 mm, treated by EMR between 2017-2019. We used multivariate logistic regression to identify independent risk factors for recurrence at SE1.

Results

EMR was performed for 165 colorectal polyps in 142 patients with technical success in 158 cases (95,2%). SE1 data for 117 of 135 eligible cases (86,7%) showed recurrent adenoma in 19 cases (16,2%) after a median time of 6,2 months (IQR 5-9,9). This was primarily treated endoscopically (78,9%). Independent risk factors for recurrence at SE1 were lesion size ≥40 mm (OR 4,03; p=0,018) and presence of high-grade dysplasia (HGD) (OR 3,89; p=0,034). Early adverse event occurred in 4 patients (2,4%), with 3 bleeding complications and one perforation. Twelve patients (7,2%) presented with delayed bleeding of which 3 required transfusion, with radiological intervention in one case. All other complications were managed either conservatively (n=8) or endoscopically (n=5).

Conclusions

EMR is a safe and effective treatment for large sessile and flat colorectal lesions with low recurrence rates. Lesion size ≥40 mm and presence of HGD were identified as risk factors for early recurrence, highlighting the importance of compliance to follow-up in these cases.

Current Endoscopic Resection Techniques for Gastrointestinal Lesions: Endoscopic Mucosal Resection, Submucosal Dissection, and Full-Thickness Resection

Background

Endoscopic resection of dysplastic lesions in early stages of cancer reduces mortality rates and is recommended by many national guidelines throughout the world. Snare polypectomy and endoscopic mucosal resection (EMR) are established techniques of polyp removal. The advantages of these methods are their relatively short procedure times and acceptable complication rates. The latter include delayed bleeding in 0.9% and a perforation risk of 0.4-1.3%, depending on the size and location of the resected lesion. EMR is a recent modification of endoscopic resection. A limited number of studies suggest that larger lesions can be removed en bloc with low complication rates and short procedure times. Novel techniques such as endoscopic submucosal dissection (ESD) are used to enhance en bloc resection rates for larger, flat, or sessile lesions. Endoscopic full-thickness resection (EFTR) is employed for non-lifting lesions or those not easily amenable to resection. Procedures such as ESD or EFTR are emerging standards for lesions inaccessible to EMR techniques.

Summary

Endoscopic treatment is now regarded as first-line therapy for benign lesions.

Key Message

Endoscopic resection of dysplastic lesions or early stages of cancer is recommended. A plethora of different techniques can be used dependent on the lesions.

Role of hospitalization for inflammatory bowel disease in the post-biologic era

Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.

Indications and outcomes of endoscopic resection for non-pedunculated colorectal lesions: A narrative review

In the last years, endoscopic techniques gained a crucial role in the treatment of colorectal flat lesions. At the same time, the importance of a reliable assessment of such lesions to predict the malignancy and the depth of invasion of the colonic wall emerged. The current unsolved dilemma about the endoscopic excision techniques concerns the necessity of a reliable submucosal invasive cancer assessment system that can stratify the risk of the post-procedural need for surgery. Accordingly, this narrative literature review aims to compare the available diagnostic strategies in predicting malignancy and to give a guide about the best techniques to employ. We performed a literature search using electronic databases (MEDLINE/PubMed, EMBASE, and Cochrane Library). We collected all articles about endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) registering the outcomes. Moreover, we analyzed all meta-analyses comparing EMR vs ESD outcomes for colorectal sessile or non-polypoid lesions of any size, preoperatively estimated as non-invasive. Seven meta-analysis studies, mainly Eastern, were included in the analysis comparing 124 studies and overall 22954 patients who underwent EMR and ESD procedures. Of these, eighty-two were retrospective, twenty-four perspective, nine case-control, and six cohorts, while three were randomized clinical trials. A total of 18118 EMR and 10379 ESD were completed for a whole of 28497 colorectal sessile or non-polypoid lesions > 5-10 mm in size. In conclusion, it is crucial to enhance the preoperative diagnostic workup, especially in deciding the most suitable endoscopic method for radical resection of flat colorectal lesions at risk of underlying malignancy. Additionally, the ESD necessitates further improvement because of the excessively time-consuming as well as the intraprocedural technical hindrances and related complications. We found a higher rate of en bloc resections and R0 for ESD than EMR for non-pedunculated colorectal lesions. Nevertheless, despite the lower local recurrence rates, ESD had greater perforation rates and needed lengthier procedural times. The prevailing risk for additional surgery in ESD rather than EMR for complications or oncologic reasons is still uncertain.

Endoscopic submucosal dissection is safe and feasible, allowing for ongoing surveillance and organ preservation in patients with inflammatory bowel disease

AIM

Experience of endoscopic submucosal dissection (ESD) for colorectal lesions in the setting of inflammatory bowel disease (IBD) remains limited. The aim of this work was to determine the safety, feasibility and oncological outcomes of ESD in patients with IBD.

METHOD

A retrospective review of all adult patients (≥18 years) with a known diagnosis of either ulcerative colitis (UC) or Crohn's disease (CD) who underwent advanced colonoscopy and ESD between 1 January 2014 and 1 October 2020. Data collected included patient demographics, disease characteristics, pathological variables and procedure-related complication rates.

RESULTS

A total of 25 patients were included: 19 (76%) were male with a median age of 63 years and disease duration of more than 10 years. Sixteen had UC and nine had CD; the majority were taking corticosteroids, immunomodulators or monoclonal antibodies at the time of ESD. The median procedure time was 41 min and the majority (n = 18; 72%) utilized chromoendoscopy. The median lesion size was 30 mm: eight had low-grade dysplasia, nine had high-grade dysplasia and three had adenocarcinoma and underwent oncological resection. None had surgical intervention for complication of ESD or perforation. A total of 23 (88%) had a complete R0 resection. Over a median follow-up of 19 months, three were found to have dysplasia excised in polyps and none had subsequent adenocarcinoma.

CONCLUSION

ESD in the setting of IBD is safe and effective for complete removal of large neoplastic lesions, allowing for ongoing endoscopic surveillance and organ preservation rather than surgical intervention.

New Closure Method Using Loop and Open-Close Clips after Endoscopic Submucosal Dissection of Stomach and Colon Lesions

Endoscopic submucosal dissection (ESD) and en bloc resection of stomach and colon tumors have become common. However, mucosal defects resulting from ESD may cause delayed bleeding and perforation. To prevent adverse events, we developed a new clip closure technique, namely, the loop and open–close clip closure method (LOCCM), and aimed to examine its efficacy after ESD for stomach and colon tumors. The LOCCM uses loop and open–close clips. Here, the open–close clip was used to grasp the loop to bring it to the edge of the post-ESD mucosal defect. Another clip with a loop was then inserted into the opposite edge and clipped to the contralateral mucosa to pull both edges together. Once apposed, additional clips facilitated complete closure. The LOCCM was performed in 19 patients after ESD at Tottori University between October 2020 and March 2021. The outcomes retrospectively analyzed were the LOCCM success and adverse event rates. The complete closure rate using LOCCM was 89.5% and none of the patients had post-ESD bleeding or perforation. The results show that LOCCM is an effective and safe closure technique for mucosal defects after stomach and colon ESD to prevent bleeding and perforation.

Emerging therapies in translational endoscopy: new frontiers in endoscopic submucosal dissection

Video 1New frontiers in endoscopic submucosal dissection.

Colonic endoscopic submucosal dissection using a novel robotic system (with video)

BACKGROUND AND AIMS

One of the difficulties in performing endoscopic submucosal dissection (ESD) is the lack of retraction during submucosal dissection. The development of the EndoMaster EASE System (EndoMaster Pte Ltd, Singapore) aims to enhance the safety and efficacy of ESD through 2 flexible robotic arms for tissue retraction and dissection. This is a preclinical animal study to evaluate the performance of colorectal ESD using the latest version of the EndoMaster EASE System.

METHODS

The latest version of the EndoMaster EASE System consists of an independently designed, flexible platform with a built-in endoscopic imaging system and 3 working channels, 2 for the passage of robotic arms and 1 for accessories. In this animal study, the outcome measures were operating time (from starting incision to finishing dissection), completeness of resection, procedure-related adverse events, and limitations of arm manipulation in a narrow working space as assessed by counting the frequency of blind cutting.

RESULTS

Five ESD procedures were performed in a 66.7-kg porcine model with the animal under general anesthesia. The mean operative time was 73.8 minutes, and the mean size of the specimen resected was 1340 mm². There was no perforation, although profuse bleeding was encountered during 1 robotic ESD procedure.

CONCLUSIONS

The current preclinical study confirmed the feasibility of performing colorectal ESD using the latest version of the EndoMaster EASE System. The system was also tested for the ability to manage adverse events including bleeding and perforation. This study provided important preclinical experience for clinical trial.

Endoscopic Management of Complex Lesions in Patients With Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) have a higher risk of developing colitis-associated dysplastic lesions. Surveil-lance colonoscopy with endoscopic imaging techniques such as chromoendoscopy has been suggested. However, complex dysplastic lesions of larger size, challenging location behind folds, and nonpolypoid morphology defy standard polypectomy techniques and require advanced management with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). When technically feasible for visible dysplasia with distinct margins, these endoscopic procedures have replaced the traditional approach of surgical management. Recent guidelines support careful endoscopic inspection of the colonic mucosa with high-definition colonoscopes and the application of imaging techniques such as chromoendoscopy to enhance lesion detection and characterization as well as to help determine whether endoscopic management is an effective alternative to colectomy. Endoscopic resection techniques such as EMR and ESD have become key modalities in the management of endoscopically resectable dysplasia in patients with IBD.

Analysis of 234 cases of colorectal polyps treated by endoscopic mucosal resection

BACKGROUND

Colorectal polyps refer to all neoplasms that protrude into the intestinal cavity. Researchers believe that 50%-70% of colorectal cancers originate from adenomatous polyps.

AIM

To investigate the endoscopic morphologic features, pathologic types, and clinical situation; evaluate the efficacy and safety of endoscopic mucosal resection (EMR); and guide clinicians in their daily practice.

METHODS

Two hundred thirty-four patients who underwent EMR in our hospital from January 1, 2018 to December 31, 2019 were recruited. Data including sex, age, endoscopic morphology of the polyps, and pathological characteristics were analyzed among groups.

RESULTS

A total of 295 polyps were resected from the 234 subjects enrolled in the study, of which 4 (1.36%) were Yamada type I. There were 75 (25.42%) type II, 101 (34.24%) type III, and 115 (38.98%) type IV adenomas. Among them, 41 were non-adenomas, 110 were low-risk adenomas, 139 were high-risk adenomas, and 5 were carcinomas. The differences in distribution were not statistically significant, with P values greater than 0.05. The risk of cancer significantly increased for polyps ≥ 1 cm in diameter (c² = 199.825, P = 0.00). Regarding the endoscopic morphological features, congestion, erosion, and lobulation were more common on the surface morphology of high-risk adenomas and cancerous polyps (c² = 75.257, P = 0.00), and most of them were Yamada types III and IV. In all, 6 of the 295 polyps could not be removed completely, with a one-time resection rate of 97.97%. There were two cases of postoperative bleeding and no cases of perforation, with an overall complication rate of 0.09%.

CONCLUSION

Colorectal polyps ranging from non-adenomatous polyps, low-risk adenomas, and high-risk adenomas to adenocarcinomas each has their own endoscopic features, while EMR, as a mature intervention, has good safety and operability and should be promoted clinically, especially at the primary care level.

Evaluation of recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions

BACKGROUND AND AIM

the process that leads to the development of colorectal cancer takes many years and most tumors originate from polyps and non-polypoid lesions. Techniques of endoscopic resection are surgical treatment options, even in case of large lesions or with initial invasion. This study aimed to evaluate the recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions.

METHODS

a retrospective, longitudinal and descriptive trial was performed via an analysis of colonoscopies with the resection of non-pedunculated lesions larger than 3 cm, performed between 2014 and 2017.

RESULTS

sixty-two lesions were included from 61 patients and 32 (52.5 %) were female. The age ranged from 36 to 89 years, with a mean age of 60.5 years. Lesions had an average diameter of 40.08 mm, ranging from 30 to 80 mm. Regarding the location of the lesions, the most frequent colonic segments were the ascending and rectum, both accounting for 22.6 %. Considering the morphologic endoscopic classification, 67.7 % were granular laterally spreading tumors (LST), 38.8 % were homogeneous granular and 29 % were mixed granular. The most frequent histological types were tubulovillous adenoma (30.7 %) and intramucosal adenocarcinoma (29 %). The resection technique was piecemeal mucosectomy in 85.5 %. Five lesions were removed by en bloc mucosectomy, two (3.2 %) by endoscopic submucosal dissection (ESD) and two (3.2 %) by a hybrid technique. The recurrence rate was 25.8 %. Three patients needed complementary surgical treatment and the clinical success of endoscopic treatment was 95.1 %.

CONCLUSION

recurrence rate after endoscopic resection of large colorectal lesions was 25.8 % and surgical complementation rate due to failure in the endoscopic treatment of recurrence was 4.8 %.

[Interventional endoscopy in the gastrointestinal tract : Indications and limitations]

The spectrum of endoscopic techniques has been greatly enlarged in recent years. Lesions and also (iatrogenic) complications that required surgical procedures in the past can now often be treated endoscopically. Advances in endoscopic mucosal resection and submucosal dissection also enable the resection of large or laterally spreading polyps in the gastrointestinal tract. Full-thickness resection is also possible by means of specially designed clips. By the creation of a submucosal tunnel submucosal lesions can be completely excised and the muscle fibers of the lower esophageal sphincter can be endoscopically severed in achalasia patients. Endosonography-guided interventions have developed into the standard procedure for complicated pancreatitis and the use of cholangioscopy offers new therapeutic procedures for the bile and pancreatic ducts. In this continuing medical education article interventional endoscopic techniques are presented and critically evaluated.

Endoscopic submucosal dissection with an additional working channel (ESD+): a novel technique to improve procedure time and safety of ESD

Background and aims

A new external additional working channel (AWC) was recently introduced by which endoscopic submucosal dissection (ESD) can be converted to a technique termed “ESD+ ”. We aim to systematically evaluate this novel technique in flat gastric lesions and compare it to classical ESD.

Methods

The study was prospectively conducted in a pre-clinical ex vivo animal model (EASIE-R simulator) with porcine stomachs. Prior to intervention, we set standardized lesions measuring 3 cm or 4 cm in antegrade as well as in retrograde positions.

Results

Overall, 64 procedures were performed by an experienced endoscopist. Both techniques were reliable and showed en bloc resection rates of 100%. Overall, ESD+ reduced time of procedure compared to ESD (24.5 vs. 32.5 min, p = 0.025*). Particularly, ESD+ was significantly faster in retrograde lesions with a median of 22.5 vs. 34.0 min in 3 cm retrograde lesions (p = 0.002*) and 34.5 vs. 41.0 min (p = 0.011*) in 4 cm retrograde lesions. There were 0 perforations with both techniques. In ESD+ , 1 muscularis damage occurred (3.13%) compared to 6 muscularis damages with ESD (18.75%, p = 0.045*).

Conclusions

By its grasp-and-mobilize technique, ESD+ allows potentially faster and safer resections of flat gastric lesions compared to conventional ESD in an ex vivo porcine model. The potential advantages of ESD+ in terms of procedure time may be particularly relevant for difficult lesions in retrograde positions.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07808-w) contains supplementary material, which is available to authorized users.

Early primary anorectal malignant melanoma treated with endoscopic submucosal dissection: a case report

BACKGROUND

Anorectal malignant melanoma (ARMM) is a rare disease accounting for less than 1% of primary anorectal malignancies. Here we first present a case of early primary anorectal malignant melanoma completely resected by endoscopic submucosal dissection (ESD).

METHODS AND RESULTS

A 43-year-old woman visited our hospital because of suspected anal melanoma found by routine colonoscopy in her local hospital. Following series of tests including CT, MRI, and whole-body PET-CT did not show any evidence of metastasis. The lesion was removed by the method of ESD in en bloc and no delayed bleeding or perforation occurred. The result of histopathologic examinations confirmed to be malignant melanoma. No recurrence or distant metastases were found during follow-up time (the latest follow-up was 2 years after ESD).

CONCLUSION

The present case showed endoscopic submucosal dissection that can be an effective and safe alternative treating early primary anorectal malignant melanoma.

Pathologic Evaluation of Large Colorectal Endoscopic Submucosal Dissections: An Analysis of 279 Cases With Emphasis on the Importance of Multidisciplinary Work and Establishing Examination Protocols

Background. Endoscopic submucosal dissections (ESDs) allow removal of large gastrointestinal tumors and help patients avoid major oncologic surgery. In this study, the challenges and development of approaches toward successfully handling ESDs were analyzed in 279 colorectal specimens (114 rectal, 47 left, 118 right colonic; 90% adenoma with/without carcinoma). Methods. Each specimen was processed according to an established protocol including gross photography, mapping, and total submission for histopathologic examination. Results. Mean lesion size was 4.2 cm (range: 0.5-22 cm; 28% ≥5 cm; 6% ≥10 cm). Invasive carcinoma was present in 38 cases (14%), which had a mean overall tumor size of 3.8 cm (range: 1.1-17.5 cm), and mean largest size of the invasive component was 0.93 cm (range: 0.04-3 cm). Fifteen cases were staged as pT1a (submucosal invasion of <1000 µm) and 13 cases as pT1b (submucosal invasion of ≥1000 µm). En-bloc and R0 resection rates were 99.3% and 90.6%, respectively. Conclusion. Various histopathologic challenges were encountered, which were carefully evaluated by dedicated pathologists with familiarity to the subtleties in handling and reporting these specimens. We recommend these specimens to be prepared in the endoscopy suite, submitted to the Pathology Department oriented, pinned, and placed into copious amount of fixative. Total sampling, gross photography, mapping, and proper fixation are crucial components in the histopathologic evaluation. Micromeasurement of invasion depth and substaging per European/Japanese guidelines as well as accurate measurement of the distance from the resection margins are highly recommended. In conclusion, ESD is an adequate method that can be successfully implemented in a tertiary care center to perform en-bloc and margin-free resections of clinically selected large colorectal superficial lesions.

Endoscopic mucosal resection with an additional working channel (EMR+) in a porcine ex vivo model: a novel technique to improve en bloc resection rate of snare polypectomy

Background and study aims  Recently, a new external additional working channel (AWC) was introduced by which conventional endoscopic mucosal resection (EMR) can be improved to a technique termed "EMR+". We first evaluated this novel technique in comparison to classical EMR in flat lesions. Methods  The trial was prospectively conducted in an ex vivo animal model with porcine stomachs placed into the EASIE-R simulator. Prior to intervention, standardized lesions were set by coagulation dots, measuring 1, 2, 3 or 4 cm. Results  Overall, 152 procedures were performed. EMR and EMR+ were both very reliable in 1-cm lesions, each showing en bloc resection rates of 100 %. EMR+ en bloc resection rate was significantly higher in 2-cm lesions (95.44 % vs. 54.55 %, P  = 0.02), in 3-cm lesions (86.36 % vs. 18.18 %, P  < 0.01) and also in 4-cm lesions (60.00 % vs. 0 %, P  < 0.01). Perforations occurred only in EMR+ procedures in 4-cm lesions (3 of 20; 15 %). Conclusions  With its grasp-and-snare technique, EMR+ facilitates en bloc resection of larger lesions compared to conventional EMR. In lesions 2 cm and larger, EMR+ has demonstrated advantages, especially concerning en bloc resection rate. At 3 cm, EMR+ reaches its best discriminatory power whereas EMR+ has inherent limits at 4 cm and in lesions of that size, other techniques such as ESD or surgery should be considered.

Lack of proper reimbursement is hampering adoption of minimally invasive gastrointestinal endoscopy in North America

Endoscopic submucosal dissection (ESD) and related procedures are minimally invasive and cost-effective alternates to surgery. However, there is no approved or listed current procedural terminology (CPT) for ESD. We aimed to review the current reimbursement process hurdles for ESD procedures in private practice model in United States. We reviewed the data of two advanced endoscopists (one in New York and other in Pennsylvania State) performing ESD in their private practice set-ups. We found the reimbursement process was complex, with number of refusals varied from 0-9 for ESD procedures. It was not paid at all in 8.3% of cases by the medical insurance. Endoscopic mucosal resection, which is considered inferior as compared to ESD, but has a listed CPT, was denied in only 0.83% cases. Our data highlights the billing hurdles by the endoscopists to adopt ESD-related procedures in private practice model.

Endoscopic submucosal dissection: an update on tools and accessories

Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.

Endoscopic Treatment of Intussusception From Massive Colonic Lipomas via Endoscopic Mucosal Resection: A Case Series

Although the safety and effectiveness of endoscopic resection of colonic lipomas has already been described, the ideal excisional technique continues to be debated. Notably, a majority of the proposed techniques focus on small, incidentally found lipomas. We report 3 patients with massive (≥8 cm) colonic lipomas presenting as intussusception that were successfully treated by piecemeal endoscopic mucosal resection. We propose endoscopic mucosal resection as the endoscopic treatment of choice and feasible alternative to surgery for the management of intussuscepting lipomas.

Endoscopic mucosal resection with anchoring of the snare tip: multicenter retrospective evaluation of effectiveness and safety

Background  Endoscopic mucosal resection (EMR) with snare is the recommended technique to resect non-invasive colorectal neoplastic lesions between 10 and 30 mm in diameter. The objective of EMR is to resect completely the neoplastic tissue en bloc and preferably with free margins (R0), avoiding recurrences. Anchoring the tip of the snare in the submucosa is a technical trick that allows snare sliding to be reduced and larger pieces to be caught. The aim of the present study was to evaluate the effectiveness and safety of anchoring-EMR (A-EMR). Methods  This was a retrospective analysis of A-EMR procedures for lesions of diameter between 10 and 30 mm (endoscopic evaluation) performed consecutively in four French centers between May 2017 and January 2018. A-EMR was routinely performed for all EMR using Olympus conventional snares (10 or 25 mm). The primary outcome was evaluation of the proportion of R0 resections. Results  A total of 141 A-EMR procedures were performed by 10 operators. Mean lesion size was 19.8 mm. Anchoring was feasible in 96.5 % of cases. There were 81.6 % en bloc resections and 70.2 % R0 resections, with the percentage of procedures decreasing with increasing lesion size (82.8 % < 20 mm, 55.3 % 21 - 30 mm, and 50.0 % > 30 mm, P  = 0.002). Complete perforations closed endoscopically occurred in 3/141 cases (2.1 %); none occurred in lesions < 20 mm in size (0 /87). Conclusion  The A-EMR technique appears to be promising with a high proportion of R0 for lesions of 10 - 20 mm in size without any perforations. It could also offer an alternative to endoscopic submucosal dissection (ESD), or to hybrid techniques to reach R0 for lesions between 20 and 30 mm in size.

EMR + with the AWC improves endoscopic resection speed compared to ESD: a porcine ex-vivo pilot study

INTRODUCTION

To improve resection speed and to reach higher en bloc resection rates in lesions ≥ 2 cm, a novel grasp and snare EMR technique termed "EMR+", accomplished by an additional working channel (AWC), was developed. Its use compared to endoscopic submucosal dissection (ESD) is evaluated for the first time.

MATERIAL AND METHODS

We prospectively conducted a randomized pre-clinical ex-vivo pilot study in explanted porcine stomachs for the comparison of EMR + with classical ESD of mucosal-based lesions. Prior to intervention, we set flat lesions with a standardized size of 3 × 3 cm.

RESULTS

The median time of procedure was significantly shorter in the EMR + group (median 10.5 min, range 4.4-24 min) than in the ESD group (median 32 min, range 14-61.6 min, p < .0001). The rate of en bloc resection was significantly lower in the EMR + group (38 % vs. 95 %) (p < .0001). Nevertheless, an improvement in the learning curve for EMR + was achieved after the first 12 procedures, with a subsequent en bloc resection rate of 100 %.

CONCLUSIONS

EMR + could improve the efficiency of mucosal resection procedures. Initial experience demonstrates a higher and satisfactory en bloc resection rate after going through the learning curve of EMR+.

Outcome of endoscopic resection of colonic polyps larger than 10 mm in patients with inflammatory bowel disease

Background and study aims  There are limited published data on endoscopic removal of colorectal polyps by endoscopic mucosal resection (EMR) and endoscopic mucosal dissection (ESD) in patients with inflammatory bowel disease (IBD). Patients and methods  We performed a retrospective review of patients with colonic IBD and colonic polyps >10mm who underwent EMR and/or ESD at our institution between January 1, 2012 and June 31, 2016. Results  Ninety-seven patients with pathology-confirmed IBD (median disease duration 16 years) were included. Mild or moderate active colitis (in background biopsies) was seen in 85 %. Of the total 124 polyps, location was ascending colon in 44 %, transverse in 15 % and sigmoid in 18.5 %; of the total, 55 % were < 20 mm and 45 % were ≥20mm in maximal diameter. Using the Paris classification, 56 % of polyps were polypoid sessile (Is) polyps, while 38 % were non-polypoid (IIa, IIb, IIc). EMR was used in 118 polyps, three required ESD, and three by combined EMR-ESD. Seventy-two percent were resected en-bloc; 28 % underwent piecemeal resection. Histology included low-grade dysplasia in 75, serrated adenoma in 31, and tubular adenoma in 14 polyps. Chromoendoscopy was used in 33 (26.6 %). Adverse events occurred in three patients. Colectomy was performed in 11 patients within 12 months. Recurrence was seen in 20 polyps, 11 of which were successfully resected en-bloc using EMR. Polyps ≥ 20 mm and polyps treated with APC were found to have a statistically significantly higher risk of recurrence. Conclusion  This study demonstrates the efficacy and safety of endoscopic resection of large polyps in patients with IBD, making them effective alternatives to colectomy.

Endoscopic submucosal dissection as excisional biopsy for anorectal malignant melanoma: A case report

BACKGROUND

Anorectal malignant melanoma (AMM) is a rare disorder with an extremely poor prognosis. Although there is currently no consensus on the treatment methods for AMM, surgical procedures have been the most common treatment methods used until now. We recently encountered a case of AMM that we diagnosed using endoscopic submucosal dissection (ESD). To our knowledge, this is the first case of ESD for AMM, suggesting that ESD can potentially be a diagnostic and treatment method for AMM.

CASE SUMMARY

A 77-year-old woman visited our hospital with a chief complaint of anal bleeding and a palpable rectal mass. Colonoscopy revealed a 20-mm protruded lesion in the lower rectum. After obtaining biopsy specimens from the lesion, although a malignant rectal tumor was suspected, a definitive diagnosis was not made. Endoscopic ultrasonography revealed tumor invasion into the submucosal layer but not the muscular layer. Therefore, we performed an excisional biopsy using ESD. Immunohistochemical examination of the ESD-resected specimen revealed tumor cells positive for Human Melanin Black-45, Melan-A, and S-100. Moreover, the tumor cells lacked melanin pigment; thus, a diagnosis of amelanotic AMM was made. Although the AMM had massively invaded the submucosal layer and both lymphatic and venous invasion were present, we closely monitored the patient without any additional therapy on the basis of her request. Six months after ESD, local recurrence was detected, and the patient consented to wide local excision.

CONCLUSION

It is suggested that ESD is a potential diagnostic and treatment method for AMM.

An internal magnet traction device reduces procedure time for endoscopic submucosal dissection by expert and non-expert endoscopists: ex vivo study in a porcine colorectal model (with video)

BACKGROUND

Efficacy of an internal magnet traction device (MTD) for gastric endoscopic submucosal dissection (ESD) by an expert endoscopist has been reported. We hypothesized that use of the MTD would enhance the performance of colorectal ESD in a non-expert endoscopist in ESD compared to the conventional technique. Primary aim of this study was to compare procedure times between conventional ESD (C-ESD) and MTD-assisted ESD (MTD-ESD) by expert and non-expert endoscopists in ESD. Secondary aims included rate of en bloc resection, iatrogenic injury, visualization score of the submucosal layer, and endoscopist satisfaction score.

METHODS

A total of 56 lesions were created in an ex vivo porcine colorectum. Two endoscopists completed C-ESD (n = 28) and MTD-ESD (n = 28). Lesions measured 3 cm in diameter and were located on either the anterior or posterior colorectal wall. The MTD consisted of a small neodymium magnet and nylon monofilament attached to a through-the-scope clip. The first MTD was deployed on the opposing colorectal wall of the target lesion and a second MTD was then deployed directly onto the distal margin of the lesion.

RESULTS

Total procedure time for MTD-ESD was significantly shorter than C-ESD for both expert (median: 15.8 vs. 19.3 min, p < 0.05) and non-expert (median: 21.3 vs. 33.9 min, p < 0.001) endoscopists. All lesions were resected en bloc. There was no iatrogenic muscularis propria injury in the MTD-ESD group. For both the expert and non-expert, scores for MTD-ESD were significantly higher for submucosal layer visualization (p < 0.05) and endoscopist satisfaction (p < 0.001) compared to C-ESD.

CONCLUSIONS

Use of the MTD significantly reduced procedure time for both expert and non-expert endoscopists performing ESD. Improving the efficiency, safety, and satisfaction of ESD with such a device particularly for non-expert endoscopists is appealing and could potentially minimize the complexity and duration of the procedure allowing for more widespread use of the technique.