Published online Jan 14, 2027. doi: 10.3748/wjg.123112
Revised: June 17, 2026
Accepted: July 1, 2026
Published online: January 14, 2027
Processing time: 187 Days and 12.3 Hours
As colorectal endoscopic submucosal dissection (ESD) is increasingly used, post-ESD electrocoagulation syndrome (PECS) has become an important adverse event.
To compare the incidence of PECS between intermittent electrocoagulation (I-ESD) technique and conventional continuous electrocoagulation (C-ESD) during colorectal ESD.
This retrospective cohort study included patients who underwent colorectal ESD at the First Affiliated Hospital of Ningbo University between November 2023 and November 2024. Procedures were performed by experienced endoscopists, with one using I-ESD and the others using C-ESD. The primary outcome was the incidence of PECS. Secondary outcomes included procedural time, lesion size, resection quality, and adverse events.
The cohort included 199 patients, with technical success achieved in all cases. Baseline characteristics were comparable between groups (P > 0.05). The incidence of PECS was significantly lower in the I-ESD group than the C-ESD group (8.5% vs 19.0%; P = 0.033). The median procedural time [42.0, interquartile range (IQR): 30.0-60.0 minutes vs 49.0, IQR: 35.0-62.0 minutes; P = 0.057], mean lesion size (20.2 ± 9.4 mm vs 20.4 ± 7.4 mm; P = 0.176), and en bloc and R0 resection rates (P > 0.05) did not differ significantly between the groups. The overall adverse event rate was notably lower in the I-ESD group (P = 0.031).
As a potentially safer alternative to conventional continuous coagulation, the I-ESD technique significantly reduced the risk of PECS without compromising resection efficiency or safety.
Core Tip: Post-endoscopic submucosal dissection electrocoagulation syndrome (PECS) is a notable adverse event after colorectal endoscopic submucosal dissection and is closely related to thermal injury. This study compared intermittent electrocoagulation with conventional continuous electrocoagulation in 199 patients undergoing colorectal endoscopic submucosal dissection. Intermittent electrocoagulation was associated with fewer cases of postoperative PECS and remained independently associated with lower PECS risk after adjustment. Resection efficiency, en bloc resection, and R0 resection were not compromised. These findings suggests that intermittent electrocoagulation is a simple, safe, and clinically practical strategy for PECS prevention.
- Citation: Wang JW, Hu KF, Xu Z, Pan YR, Miao M, Ye GL, Xu EP. Novel intermittent electrocoagulation technique reduces post-endoscopic submucosal dissection electrocoagulation syndrome in colorectal neoplasms. World J Gastroenterol 2027; 33(2): 123112
- URL: https://www.wjgnet.com/1007-9327/full/v33/i2/123112.htm
- DOI: https://dx.doi.org/10.3748/wjg.123112
The widespread implementation of endoscopic screening programs has led to the increased detection of colorectal neoplasms and submucosal tumors[1]. Endoscopic submucosal dissection (ESD) has emerged as the preferred method for en bloc resection of such lesions[2].
While the widespread implementation of electrocoagulation hemostasis has substantially reduced the incidence of postoperative bleeding after ESD[3], the incidence of post-ESD electrocoagulation syndrome (PECS) has concurrently increased to 4.8%-40.2%[4-8]. As a critical clinical challenge, PECS adversely affects both the trajectory of patient recovery and utilization of healthcare resources.
PECS, first described in 1981 by Waye[9] as a complication of colonic interventions, is characterized by localized abdominal pain and a systemic inflammatory response in the absence of perforation. Previous studies have proposed two primary contributors to the development of PECS: (1) Transmural thermal injury during ESD, which induces aseptic inflammation of the serosa, resulting in localized peritonitis; and (2) Local bacterial infection.
Based on these mechanisms, various technical and perioperative strategies have been proposed to reduce the incidence of PECS. For the infection-related pathway, the effectiveness of prophylactic antibiotic administration remains controversial[5,10]. Notably, Nomura et al[11] reported that prophylactic clipping closure after colorectal ESD, intended to prevent intestinal bacteria and fecal exposure, did not reduce the onset of PECS, suggesting that the pathogenic role of bacterial infection is uncertain. In contrast, strategies targeting thermal injury appear more promising. Underwater ESD, which involves filling the lumen with water to limit transmural heat transfer, has shown preventive effects in multiple studies[12,13]. Likewise, several clinical studies have identified Joule heat generated by electrocoagulation as an independent risk factor for PECS, due to the capacity to deeply penetrate into the bowel wall, which causes inflammation of the muscularis propria and serosal layers, resulting in abdominal pain and fever[14,15]. Together, these findings underscore that prevention of transmural thermal injury is a key strategy to mitigate PECS, which is the specific focus of our ongoing research.
Based on the principle of controlling thermal exposure, we developed a novel intermittent electrocoagulation (I-ESD) technique, in which short coagulation activations were separated by brief intervals to reduce cumulative heating of tissue to prevent deep thermal injury without altering the standard application of ESD. Hence, the aim of this retrospective cohort study was to evaluate the comparative effectiveness of the I-ESD technique vs the conventional continuous electrocoagulation (C-ESD) method in reducing the incidence of PECS and improve patient outcomes.
The cohort of this retrospective study included consecutively patients with colorectal epithelial lesions or submucosal tumors who underwent ESD at the First Affiliated Hospital of Ningbo University from November 2023 to November 2024. Specific inclusion and exclusion criteria were used to select eligible participants. All procedures were performed by experienced endoscopists, with one (Ye GL) using an innovative I-ESD technique, while others used the conventional
The inclusion criteria were: (1) Confirmed diagnosis of colorectal epithelial neoplasms or submucosal tumors; (2) Lesions resected by ESD; and (3) Absence of any exclusion criteria. The exclusion criteria were: (1) Age < 18 years or > 90 years; (2) Pregnancy; (3) Intraprocedural adverse events necessitating surgical intervention or aborted endoscopic procedures due to technical infeasibility; (4) Intraoperative perforation; (5) Declined informed consent; and (6) Incomplete clinical, procedural, pathological, or documentation data.
The study protocol was approved by the Institutional Review Board of the First Affiliated Hospital of Ningbo University (No. 2025-127RS) and conducted in accordance with the ethical principles for medical research involving human subjects described in the Declaration of Helsinki (6th revision, Fortaleza, 2008).
All procedures were performed by senior endoscopists (≥ 100 prior ESD cases[16]), with one operator (Ye GL) pioneering an innovative I-ESD strategy tailored to minimize thermal injury, while others adhered to conventional continuous techniques. All patients were hospitalized preoperatively and received a low-residue dietary regimen and standardized bowel preparation with polyethylene glycol electrolyte solution. Endoscopic procedures were conducted under continuous intravenous anesthesia with real-time hemodynamic monitoring, including heart rate, noninvasive blood pressure, and peripheral oxygen saturation. A standard video colonoscope (CF-HQ290I; Olympus Corporation, Tokyo, Japan) was equipped with a transparent distal attachment (D-201-13404; Olympus Corporation) to optimize submucosal visualization and maintain tissue traction. A high-frequency generator (ERBE VIO 200D; Erbe Elektromedizin GmbH, Tübingen, Germany) was set to Endo cut Q (effect, 3; duration, 2; interval, 3) for mucosal incision, swift coagulation
The standardized protocol for conventional C-ESD included: (1) Submucosal injection with diluted epinephrine-saline at the lesion margins; (2) Circumferential incision from the anal aspect using a high-frequency electrosurgical knife (VDK-KM-15-200-D; Jiangsu Vedkang Medical Science and Technology Co., Ltd., Changzhou, Jiangsu Province, China) with 1.5-mm tip exposure, followed by submucosal dissection with the same device; (3) Hemostasis during dissection and post-resection wound management performed in a continuous coagulation mode. Small vessels were coagulated directly with the knife tip, whereas larger vessels were grasped with hot biopsy forceps (FD-410 LR; Olympus Corporation) and treated with sustained coagulation until complete hemostasis was achieved[3,17,18]. The duration and interval of coagulation were adjusted manually based on the experience of the operator and real-time bleeding response, without a fixed activation-pause rhythm; and (4) Systematic documentation of lesion characteristics (location, size, morphology) and procedural metrics (duration, intraoperative bleeding). Cases requiring surgical conversion were excluded.
The procedural steps for the I-ESD group were identical except for the hemostatic method. I-ESD was standardized to 0.5-second activation followed by a 1-2 seconds pause per cycle to allow consistent control of thermal exposure and localized heat dissipation between activations. Minor bleeding points were treated directly with the knife tip using this rhythm, whereas larger vessels were clamped with hot biopsy forceps (FD-410 LR; Olympus Corporation) and treated under identical intermittent parameters. Procedural documentation was consistent with the control group.
Tissue specimens were fixed in 40 g/L of neutral-buffered formaldehyde solution and embedded in paraffin following standard histological procedures. Subsequent histopathological evaluation was performed to determine the tumor subtype and malignancy based on the World Health Organization classification criteria. If the tumor architecture was not clearly defined, immunohistochemical analysis was utilized to assist in diagnosis[19].
All food, liquids, and oral medications were withheld for 24 hours after the ESD procedure, followed by a liquid diet for 24 hours before gradual dietary advancement under clinical supervision. Patients without complications were discharged within 48-72 hours.
Systematic monitoring included assessments for fever (≥ 37.8 °C), abdominal pain intensity [numeric rating scale (NRS) ≥ 4], and gastrointestinal bleeding manifestations (hematemesis or melena). Postprocedural abdominal pain was routinely assessed and documented in nursing records, and ward nurses were not informed of the electrocoagulation method used during ESD. Patients presenting with abdominal pain (NRS ≥ 4) underwent further assessment, including routine blood tests and C-reactive protein (CRP) measurement, and those with concomitant tenderness and rebound tenderness underwent urgent radiologic evaluation (abdominal X-ray or contrast-enhanced computed tomography) to exclude perforation[20]. Subcutaneous emphysema or hemodynamic instability triggered emergent surgical consultation.
Structured endoscopic surveillance was conducted at 3-, 6-, and 12-month intervals post-ESD, with annual follow-up thereafter to evaluate mucosal integrity, residual neoplasia, and recurrence patterns. For rectal neuroendocrine tumors (NETs), follow-up was tailored to the lesion characteristics. Routine surveillance was omitted for completely resected lesions ≤ 10 mm with low risk. For lesions > 10 mm, endoscopic reassessment was performed at 1 year and 3 years, then every 5 years. In cases with high-risk features or non-curative resection, rectoscopy or endoscopic ultrasound was conducted every 6 months for 3 years, then annually thereafter. Radical surgery was recommended for lesions with lymphovascular invasion[21].
The primary outcome was the incidence of PECS following the procedure, defined as post-ESD localized abdominal pain (NRS ≥ 4) within 3 days, accompanied by fever (≥ 37.8 °C) or systemic inflammation (white blood cell count ≥ 10000/μL or CRP ≥ 1 mg/dL), without radiologic evidence of perforation[6,22].
Secondary outcomes included procedural time, lesion size, en bloc and R0 resection rates, and procedure-related adverse events. Procedural time was defined as the interval from the initiation of submucosal injection to the completion of colorectal neoplasm resection[23]. Lesion location was categorized as the right colon, left colon, and rectum[24]. The right colon included the cecum, ascending colon, hepatic flexure, and transverse colon, whereas the left colon included the splenic flexure, descending colon, and sigmoid colon[25]. Rectal lesions were defined as those located distal to the sigmoid take-off[26]. The long and short diameters (mm) of the resected lesion were measured after fixation on a specimen board, with lesion size defined as the length of the longest diameter. The mucosal defect area (mm2) was calculated as (short axis length/2) × (long axis length/2) × π[27]. En bloc resection was defined as removal of the lesion in a single piece. R0 resection was defined as en bloc resection with histologically negative lateral and vertical margins[28]. Intraoperative bleeding was defined in accordance with the Endoscopic Resection Bleeding classification as c2 or c3[29]. Postoperative bleeding was defined as hematemesis, melena, or a hemoglobin drop > 2 g/dL following ESD[30]. Postoperative perforation was diagnosed endoscopically or by detection of free air on postoperative computed tomography[20].
All statistical analyses were performed using R software (version 4.5.0; R Foundation for Statistical Computing, Vienna, Austria). Data normality was assessed prior to analysis. Normally distributed variables were compared using the independent-samples t-test and are expressed as the mean ± SD, whereas non-normally distributed variables were compared using the Mann-Whitney U test and are reported as the median [interquartile range (IQR)]. Categorical variables were compared using the χ2 or Fisher’s exact test, as appropriate, and are presented as n (%). Variables with a probability P value < 0.10 by univariate analysis were entered into a multivariable logistic regression model to identify independent predictors of PECS, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses were performed to explore interactions between the electrocoagulation modality and clinical covariates. In subgroup comparisons, ORs were calculated using I-ESD as the reference group, such that OR > 1 indicated a higher risk of PECS with C-ESD. A two-sided P value < 0.05 was considered statistically significant.
Data from 230 patients who underwent colorectal ESD between November 2023 and November 2024 were retrospectively collected. Of these 230 patients, 31 were excluded according to the predefined exclusion criteria, thus 199 were included in the final analysis (Figure 1). All procedures were performed by experienced endoscopists at the First Affiliated Hospital of Ningbo University, with one endoscopist (Ye GL) utilizing I-ESD and others applying C-ESD. All ESD procedures were technically successful, with no major intraoperative adverse events.
The I-ESD and C-ESD groups included 94 patients and 105 patients, respectively (Table 1). The median age was 62 (IQR: 53-68) years in the I-ESD group and 60 (IQR: 53-67) years in the C-ESD group (P = 0.395). There was no significant difference in sex distribution, body mass index, history of prior malignancy, American Society of Anesthesiologists classification, lesion location, or depth of lesion origin between groups (all P > 0.05).
| I-ESD (n = 94) | C-ESD (n = 105) | P value | |
| Age, years | 62 (53-68) | 60 (53-67) | 0.3952 |
| Sex | 0.196 | ||
| Male | 46 (48.9) | 61 (58.1) | |
| Female | 48 (51.1) | 44 (41.9) | |
| Body mass index, kg/m2 | 23.5 (21.3-25.1) | 23.9 (21.5-25.5) | 0.366 |
| History of malignancy | 12 (12.8) | 9 (8.6) | 0.336 |
| ASA | 1.0001 | ||
| 1 | 46 (48.9) | 52 (49.5) | |
| 2 | 48 (51.1) | 53 (50.5) | |
| 3 | 0 | 0 | |
| Location | 0.115 | ||
| Right side of colon | 48 (51.1) | 47 (44.8) | |
| Left side of colon | 20 (21.3) | 15 (14.3) | |
| Rectum | 26 (27.7) | 43 (41.0) | |
| Origination | 0.8551 | ||
| Mucosa | 78 (83.0) | 86 (81.9) | |
| Submucosa | 16 (17.0) | 19 (18.1) | |
| Muscularis propria | 0 | 0 | |
| Macroscopic type | |||
| LST classification | 0.002 | ||
| LST-G | 6 (11.8) | 22 (37.3) | |
| LST-NG | 45 (88.2) | 37 (62.7) | |
| Paris classification | 0.359 | ||
| 0-I | 22 (28.2) | 30 (28.6) | |
| 0-II | 56 (71.8) | 56 (65.1) | |
| NICE classification | 0.2581 | ||
| 1 | 6 (7.7) | 4 (4.7) | |
| 2 | 66 (84.6) | 69 (80.2) | |
| 3 | 6 (7.7) | 13 (15.1) |
Morphologically, the granular subtype of laterally spreading tumors was significantly less prevalent in the I-ESD group than the C-ESD group (11.8% vs 37.3%; P = 0.002). No significant differences were observed in the Paris classification (P = 0.359) or narrow-band imaging international colorectal endoscopic classification (P = 0.258) between groups.
The incidence of PECS was significantly lower in the I-ESD group than the C-ESD group (8.5% vs 19.0%; P = 0.033) (Table 2). Correspondingly, patients in the I-ESD group had a lower incidence of abdominal pain (NRS ≥ 4) after the procedure (9.6% vs 22.9%; P = 0.012) and exhibited a lower median peak body temperature [37.0 °C (IQR: 36.9-37.2) vs 37.1 °C (IQR: 37.0-37.4); P = 0.003]. The proportion of patients with fever ≥ 37.8 °C was also significantly reduced (6.4% vs 18.1%; P = 0.013). Similarly, reduced frequencies of leukocytosis (2.1% vs 7.6%; P = 0.106) and elevated CRP (4.3% vs 14.3%; P = 0.016) were observed in this group.
| I-ESD (n = 94) | C-ESD (n = 105) | P value | |
| Size, mm | 20.2 ± 9.4 | 20.4 ± 7.4 | 0.1762 |
| Procedural time, minute | 42.0 (30.0-60.0) | 49.0 (35.0-62.0) | 0.0572 |
| Procedural speed, mm2/minute | 4.9 (2.9-7.6) | 4.6 (3.0-7.4) | 0.6472 |
| En bloc resection | 93 (98.9) | 104 (99.0) | 1.0001 |
| R0 resection | 87 (92.6) | 98 (93.3) | 0.830 |
| Histopathology | 0.8881 | ||
| Serrated lesion | 23 (24.5) | 29 (27.6) | |
| Adenoma | 54 (57.4) | 54 (51.4) | |
| Carcinoma | |||
| Tis | 1 (1.1) | 2 (1.9) | |
| SM1 | 0 | 1 (1.0) | |
| Others | 16 (17.0) | 19 (18.1) | |
| Adverse events | 0.031 | ||
| Bleeding | 2 (2.1) | 6 (5.7) | |
| Perforation | 0 | 0 | |
| PECS | 8 (8.5) | 20 (19.0) | 0.033 |
| Abdominal pain (NRS ≥ 4) | 9 (9.6) | 24 (22.9) | 0.012 |
| Postoperative max temperature, °C | 37.0 (36.9-37.2) | 37.1 (37.0-37.4) | 0.0032 |
| 0.013 | |||
| ≥ 37.8 | 6 (6.4) | 19 (18.1) | |
| < 37.8 | 88 (93.6) | 86 (81.9) | |
| WBC ≥ 10000/μL | 2 (2.1) | 8 (7.6) | 0.1061 |
| CRP ≥ 1 mg/dL | 4 (4.3) | 15 (14.3) | 0.016 |
| Intraoperative adverse event | 0 | 0 | |
| Muscle layer exposure | 6 (6.4) | 6 (5.7) | 0.843 |
| NPO duration, days | 1 (1-1) | 1 (1-1) | 0.2362 |
| Length of hospital stay, days | 5 (4-6) | 5 (4-7) | 0.4572 |
Comparisons between the I-ESD and C-ESD groups revealed no significant difference in the median procedural time [42.0 (IQR: 30.0-60.0) minutes vs 49.0 (IQR: 35.0-62.0) minutes; P = 0.057], mean lesion size (20.2 ± 9.4 mm vs 20.4 ± 7.4 mm; P = 0.176), or procedural speed [4.9 (IQR: 2.9-7.6) mm2/minutes vs 4.6 (IQR: 3.0-7.4) mm2/minutes; P = 0.647].
Rates of en bloc resection were comparably high between groups, with 98.9% and 99.0% in the I-ESD and C-ESD groups, respectively, achieving complete single-piece resection (P = 1.000). Likewise, the R0 resection rates did not differ significantly (92.6% vs 93.3%, P = 0.830), indicating comparable resection quality between the two techniques. Histopathologic evaluation showed a similar distribution of lesion subtypes between the I-ESD and C-ESD groups (P = 0.888). Adenomas accounted for the majority of lesions in both cohorts (57.4% vs 51.4%), followed by serrated lesions.
Regarding procedure-related adverse events, no perforation occurred in either group, and the I-ESD group demonstrated both a lower incidence of bleeding (2.1% vs 5.7%) and a significantly reduced overall rate of procedure-related adverse events (P = 0.031). Other postoperative clinical parameters, including the duration of withholding all food, liquids, and oral medications (median, 1 day for both groups; P = 0.236) and length of hospital stay (median, 5 days vs 5 days; P = 0.457), showed no significant differences.
Univariate analysis identified the method of electrocoagulation, sex, lesion size, procedural time, and muscle layer exposure as potential factors associated with the development of PECS (P < 0.05; Table 3). In the multivariable logistic regression, I-ESD was independently associated with a lower risk of PECS as compared to C-ESD (OR = 0.38; 95%CI: 0.15-0.96; P = 0.041). Female sex (OR = 2.72; 95%CI: 1.12-6.61; P = 0.028), lesion size ≥ 20 mm (OR = 3.43; 95%CI: 1.22-9.61; P = 0.019), and muscle layer exposure (OR = 7.10; 95%CI: 1.65-30.57; P = 0.008) were all independently associated with an increased risk of PECS. Although prolonged procedural time (> 60 minutes) was significantly associated with an increased risk of PECS by univariate analysis (OR = 2.38; 95%CI: 1.04-5.44; P = 0.040), this association was not maintained in the multivariate model (OR = 1.72; 95%CI: 0.69-4.24; P = 0.242), suggesting that the procedural time may not have been independently predictive of PECS when adjusted for other covariates, such as lesion size. Other variables, including age, American Society of Anesthesiologists classification, history of malignancy, lesion location, histopathologic subtype, and laterally spreading tumor classification, were not significantly associated with an increased risk of PECS (all P > 0.05).
| Factors | Univariate analysis | Multivariate analysis | ||
| OR (95%CI) | P value | OR (95%CI) | P value | |
| Electrocoagulation method | 0.037 | 0.041 | ||
| C-ESD | 1.00 (reference) | 1.00 (reference) | ||
| I-ESD | 0.40 (0.17-0.95) | 0.38 (0.15-0.96) | ||
| Sex | 0.043 | 0.028 | ||
| Male | 1.00 (reference) | 1.00 (reference) | ||
| Female | 2.36 (1.03-5.41) | 2.72 (1.12-6.61) | ||
| Age, years | 0.543 | |||
| ≤ 60 | 1.00 (reference) | |||
| > 60 | 0.78 (0.35-1.74) | |||
| ASA | 0.467 | |||
| 1 | 1.00 (reference) | |||
| 2 | 1.35 (0.60-3.02) | |||
| History of malignancy | 0.976 | |||
| No | 1.00 (reference) | |||
| Yes | 1.02 (0.28-3.72) | |||
| Location | ||||
| Right side of colon | 1.00 (reference) | |||
| Left side of colon | 1.45 (0.53-3.95) | 0.471 | ||
| Rectum | 0.65 (0.25-1.72) | 0.387 | ||
| Size, mm | 0.016 | 0.019 | ||
| < 20 | 1.00 (reference) | 1.00 (reference) | ||
| ≥ 20 | 3.04 (1.23-7.51) | 3.43 (1.22-9.61) | ||
| Procedural time, minute | 0.040 | 0.242 | ||
| ≤ 60 | 1.00 (reference) | 1.00 (reference) | ||
| > 60 | 2.38 (1.04-5.44) | 1.72 (0.69-4.24) | ||
| LST classification | 0.964 | |||
| LST-G | 1.00 (reference) | |||
| LST-NG | 1.03 (0.30-3.49) | |||
| Histopathology | 0.801 | |||
| Serrated lesion | 1.00 (reference) | |||
| Adenoma | 0.89 (0.35-2.25) | |||
| Muscle layer exposure | 0.009 | 0.008 | ||
| No | 1.00 (reference) | 1.00 (reference) | ||
| Yes | 5.09 (1.49-17.39) | 7.10 (1.65-30.57) | ||
To further evaluate the differential impact of the electrocoagulation strategy on the risk of PECS, subgroup analyses were performed across selected clinical variables (Figure 2). Among all patients, I-ESD was associated with a significantly lower incidence of PECS as compared to C-ESD (8.5% vs 19.0%; OR = 2.53; 95%CI: 1.06-6.06; P = 0.037). This benefit was particularly evident in patients aged > 60 years, with a significantly reduced rate of PECS in the I-ESD group (5.6% vs 20.4%; OR = 4.36; 95%CI: 1.12-16.91; P = 0.033). Similarly, for lesions ≥ 20 mm, I-ESD was associated with a lower incidence of PECS than C-ESD (6.8% vs 29.0%; OR = 5.59; 95%CI: 1.53-20.40; P = 0.009). This pattern was also observed in patients with shorter procedural times (≤ 60 minutes), where PECS occurred in 5.6% vs 16.2% of cases, respectively (OR = 3.29; 95%CI: 1.01-10.74; P = 0.048). Among patients without muscle layer exposure, the percentage of PECS remained significantly lower in the I-ESD group (4.5% vs 19.2%; OR = 4.99; 95%CI: 1.63-15.30; P = 0.005). In contrast, among those with muscle layer exposure, PECS occurred in four of six patients in the I-ESD group and one of six in the C-ESD group (P = 0.099), although the small sample size limited interpretation. No statistically significant difference was observed in other subgroups, including patients aged ≤ 60 years (12.5% vs 17.9%; P = 0.478), lesion size < 20 mm (10.0% vs 4.7%; P = 0.341), or when stratified by sex (male: 2.2% vs 14.8%, P = 0.056; female: 14.6% vs 25.0%, P = 0.213).
As summarized in Supplementary Table 1, 23 patients with rectal NETs underwent successful ESD. All lesions were located in the rectum, with 21 lesions (91.3%) classified as World Health Organization grade G1 and 2 lesions (8.7%) as grade G2. No lymphovascular invasion was identified. Invasion was confined to the mucosa in 1 lesion (4.3%), to the submucosa in 5 lesions (21.7%), and involved both the mucosa and submucosa in 17 lesions (73.9%). The median tumor size was 5 (IQR: 4-7) mm, and the median procedure time was 38 (IQR: 30-55) minutes. R0 resection was achieved in 69.6% of cases (16/23) and 91.3% of lesions had a Ki-67 index < 3%. I-ESD was applied in seven patients (30.4%) and C-ESD in 16 patients (69.6%). Post-procedural adverse events were infrequent, with two cases of delayed bleeding (8.7%) and one case of PECS (4.3%). No recurrence or tumor-related death occurred during a median follow-up period of 4 (IQR: 1-6) months.
The results of this retrospective cohort study demonstrated that the I-ESD technique significantly reduced the incidence of PECS, as compared to the C-ESD method. This difference was reflected in clinical manifestations, with lower percentages of abdominal pain, decreased leukocytosis, reduced CRP elevation, and lower postoperative fever in the
Importantly, because only the coagulation method was altered during the I-ESD technique without changing the overall procedural steps, the quality of resection was not compromised. The en bloc and R0 resection rates remained comparable between groups (98.9% vs 99.0%, P = 1.000; 92.6% vs 93.3%; P = 0.830, respectively). In addition, this approach did not increase the treatment-related economic burden, with no significant difference observed in postoperative fasting duration or total length of hospitalization (P > 0.05). Notably, there was no intraoperative adverse events, such as bleeding or perforation, in either group, confirming the safety of both techniques when performed by experienced endoscopists.
Univariate and multivariate logistic regression analyses identified I-ESD as independently associated with a lower risk of PECS (OR = 0.38; 95%CI: 0.15-0.96; P = 0.041). In contrast, female sex (OR = 2.72; 95%CI: 1.12-6.61; P = 0.028), lesion size ≥ 20 mm (OR = 3.43; 95%CI: 1.22-9.61; P = 0.019), and muscle layer exposure (OR = 7.10; 95%CI: 1.65-30.57; P = 0.008) were identified as independent risk factors. These findings were consistent with previous reports identifying female sex[4,7], older age[8], larger lesion size[8,30,31], and muscle injury[1,32] as key contributing factors to an increased risk of PECS. Ito et al[4] proposed that female patients may exhibit a higher incidence due to lower visceral pain thresholds, while Ma et al[1] emphasized the influence of subjective pain perception based on sex and age. However, in our study, older age (P = 0.543) was not significantly associated with the incidence of PECS. The lack of an association with age may have been attributable to the age distribution of our cohort, as most patients were older than 50 years, potentially reducing the ability to detect age-related differences.
Importantly, although both larger lesion size and longer procedural time were associated with an increased risk of PECS by univariate analysis, only lesion size ≥ 20 mm remained significant in the multivariate model. This shift suggested that the association between procedural time and an increased risk of PECS was largely mediated by lesion size. In clinical settings, larger lesions typically require more extensive dissection and longer durations of electrocoagulation, which prolong the procedure time[33,34] and increase the risk of thermal injury[35]. The procedural time partially reflects the impact of lesion size on an increased risk of PECS, serving more as a downstream indicator of lesion burden rather than an independent predictor of adverse outcomes. Muscle layer exposure was also independently associated with an increased risk of PECS, likely reflecting deeper dissection planes and more aggressive coagulation, as both may increase the risk of serosal inflammation[4]. These findings emphasize the importance of lesion size and depth in shaping procedural risk profiles and suggest that tailored intraoperative strategies may help mitigate thermal injury.
Subgroup analysis further revealed that the clinical benefit of the I-ESD technique was more pronounced in specific patient populations. Among patients older than 60 years, the incidence of PECS was significantly lower in the I-ESD group than the C-ESD group (5.6% vs 20.4%, OR = 4.36; P = 0.033), likely due to the lower mucosal repair capacity of older patients, which increases susceptibility to thermal injury. By limiting cumulative thermal exposure, the I-ESD technique may help mitigate this vulnerability in older adults. Similarly, for lesions ≥ 20 mm, PECS occurred in only 6.8% of patients in the I-ESD group, as compared to 29.0% in the C-ESD group (OR = 5.59; P = 0.009). Resection of larger lesions necessitates more extensive dissection and a longer duration of coagulation, thereby elevating the risk of transmural thermal injury[15]. The I-ESD technique may reduce this thermal burden and provide additional protection for such high-risk lesions. Notably, among patients with a procedural time ≤ 60 minutes, the incidence of PECS was also significantly lower in the I-ESD group (5.6% vs 16.2%; OR = 3.29; P = 0.048). This finding suggests that continuous coagulation may still cause cumulative tissue injury even during shorter procedures, whereas intermittent delivery permits thermal dissipation between activations. Overall, these findings indicate that the I-ESD technique may reduce the risk of PECS by limiting cumulative thermal injury in several clinically relevant settings.
In addition to its clinical benefits, the I-ESD technique is simple to adopt and cost-neutral. The technique requires no additional equipment and can be incorporated into standard ESD workflows. Endoscopists can perform intermittent coagulation by manually alternating activation and rest intervals on conventional electrosurgical generators. In high-volume endoscopy units or community hospitals, this approach may offer a practical way to improve procedural safety without increasing procedural complexity. Compared with other PECS prevention strategies, the I-ESD technique is non-invasive and avoids pharmacologic side effects. Its ease of implementation and low resource burden support further evaluation across different clinical settings.
This study included all colorectal lesions treated by ESD, including epithelial neoplasms and submucosal tumors such as rectal NETs. Because ESD indications cover a broad range of lesion types, NETs were included in the cohort. In this subgroup, the generally small lesion size and limited invasion depth were associated with shorter procedure times and smaller resection areas, which may explain the low incidence of PECS observed (1/23, 4.3%). No recurrence was detected during follow-up, which is consistent with the short-term safety and efficacy of ESD for low-grade rectal NETs.
Nonetheless, there were several limitations in this study. As a single-center retrospective analysis, potential selection bias and limited generalizability could not be excluded. Notably, all procedures were performed by experienced endoscopists; however, the I-ESD technique was exclusively performed by a single operator, while the C-ESD method was conducted by multiple others. As this “single-operator” implementation of the intervention was a major source of operator bias, it was impossible to disentangle the effect of the technique itself from the individual skill and experience of that specific endoscopist. We plan to conduct a prospective randomized controlled trial with clearly defined inclusion and exclusion criteria to further evaluate the efficacy of the I-ESD technique.
The I-ESD technique effectively mitigated key risk factors and significantly reduced the incidence of PECS. This simple, cost-effective technique was easily implementable across a wide range of clinical settings. Owing to its safety, practicality, and scalability, the I-ESD technique represents a promising strategy for incorporation into future protocols aimed at preventing PECS, with the potential to enhance patient outcomes and standardize endoscopic care.
The authors gratefully acknowledge all endoscopists from the Department of Gastroenterology, the First Affiliated Hospital of Ningbo University, for their support and assistance in performing the endoscopic procedures included in this study.
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