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Le QD, Le NQ, Quach DT. Underwater vs conventional endoscopic mucosal resection for nonpedunculated colorectal neoplasms: A randomized controlled trial. World J Gastrointest Surg 2025; 17:103635. [DOI: 10.4240/wjgs.v17.i6.103635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 03/23/2025] [Accepted: 04/21/2025] [Indexed: 05/30/2025] Open
Abstract
BACKGROUND Underwater endoscopic mucosal resection (UEMR) has been shown to be a good treatment option for the management of nonpedunculated polyps ≥ 10 mm since its introduction. However, there is a paucity of randomized controlled trials (RCTs) in Asia.
AIM To compare the efficacy and safety of UEMR with those of conventional EMR (CEMR) in treating nonpedunculated colorectal lesions.
METHODS We carried out this RCT at a tertiary hospital from October 2022 to July 2024. Patients with nonpedunculated colorectal neoplasms ranging from 10 mm to 30 mm in size were randomly assigned to either the UEMR or CEMR group. The primary outcome was the curative resection (R0) rate. The secondary outcomes included en bloc resection, procedure time, adverse events, and the number of clips used for defect closure.
RESULTS A total of 260 patients with 260 lesions (130 in each UEMR and CEMR group) were recruited. The median age was 58 (27-85) years, the male/female ratio was 1.74, and the median lesion size was 20 (10-30 mm) mm. Compared with CEMR, UEMR was associated with a significantly greater curative resection (R0) rate (98.4% vs 90.3%; P = 0.007), greater en bloc resection rate (100% vs 94.6%; P = 0.014), shorter procedure time (65 vs 185 seconds; P < 0.001), lower rate of bleeding complications (1.5% vs 10%; P = 0.003), and fewer clips used (2 vs 3; P < 0.001). No perforations were observed in either group.
CONCLUSION Compared with CEMR, UEMR has a higher R0 rate, greater en bloc resection rate, shorter procedure time, fewer bleeding complications, and clips used in the management of nonpedunculated colorectal neoplasms.
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Affiliation(s)
- Quang D Le
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 70000, Viet Nam
| | - Nhan Q Le
- Department of Gastrointestinal Endoscopy, University Medical Center at Ho Chi Minh City, Ho Chi Minh City 70000, Viet Nam
| | - Duc T Quach
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 70000, Viet Nam
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Tawheed A, Ismail A, El-Kassas M, El-Fouly A, Madkour A. Endoscopic resection of gastrointestinal tumors: Training levels and professional roles explored. World J Gastrointest Oncol 2025; 17:101832. [PMID: 40235878 PMCID: PMC11995314 DOI: 10.4251/wjgo.v17.i4.101832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Revised: 01/26/2025] [Accepted: 02/11/2025] [Indexed: 03/25/2025] Open
Abstract
In this editorial, we provide commentary on a recently published study by Zhao et al in the World Journal of Gastrointestinal Oncology. The study discusses the clinical characteristics of patients undergoing endoscopic resection for gastric cancers. We feel it is important to engage our endoscopy community in a discussion on the current evidence in the literature on the necessary number of cases for training in endoluminal surgery techniques, particularly endoscopic submucosal dissection. This includes the latest recommendations from the European Society of Gastrointestinal Endoscopy, as well as a summary of key studies on the learning curve for these techniques. Additionally, we explore the impact of an endoscopist's specialty on endoscopy outcomes, drawing from current evidence in the literature to shape our perspective in this evolving field.
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Affiliation(s)
- Ahmed Tawheed
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Alaa Ismail
- Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Mohamed El-Kassas
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Amr El-Fouly
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Ahmad Madkour
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
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Alric H, Barret M, Becar A, Perez Cuadrado Robles E, Belle A, Perrod G, Corre F, Chaussade S, Cellier C, Rahmi G. Endoscopic submucosal dissection versus endoscopic mucosal resection for laterally spreading rectal tumours. Colorectal Dis 2024; 27. [PMID: 39694879 DOI: 10.1111/codi.17268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 10/29/2024] [Accepted: 11/08/2024] [Indexed: 12/20/2024]
Abstract
AIM Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the two main techniques used for endoscopic resection of superficial rectal tumours. The aim of this study was to compare the outcomes of ESD and EMR in treating superficial rectal tumours. METHOD A retrospective observational study was conducted at two French centres including all patients treated with ESD or EMR for superficial rectal tumours. The primary outcome was the rate of local recurrence at the first follow-up endoscopy after endoscopic resection. Secondary outcomes included the curative resection rate, procedure duration, length of hospital stay, complication rates and the need for additional surgery. RESULTS A total of 254 patients were included, 159 treated with ESD and 95 treated with EMR. The local recurrence rate at the first follow-up endoscopy was 8.6% and was significantly lower in the ESD group than in the EMR group (4.3% vs. 16.9%; p = 0.005). The rates of en bloc and histologically complete resections were higher in the ESD group (88.1% vs. 42.7% and 85.5% vs. 38.9%, respectively; p < 0.001), while the curative resection rate was 90.6% in the EMR group and 92.5% in the ESD group (p = 0.59). Mostly due to poor histoprognostical criteria, 6.0% of patients underwent additional surgery (6.3% vs. 5.2% in the ESD vs. EMR group, respectively; p = 0.73). CONCLUSION ESD demonstrated higher rates of en bloc, R0 resection than EMR, translating into significantly lower rates of local recurrence at the first follow-up endoscopy.
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Affiliation(s)
- Hadrien Alric
- Service d'Hépato-gastroentérologie et Endoscopies Digestives, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Université Paris-Cité, Paris, France
| | - Maximilien Barret
- Université Paris-Cité, Paris, France
- Service de Gastroentérologie, Endoscopie et Oncologie Digestive, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alix Becar
- Service d'Hépato-gastroentérologie et Endoscopies Digestives, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Enrique Perez Cuadrado Robles
- Service d'Hépato-gastroentérologie et Endoscopies Digestives, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Université Paris-Cité, Paris, France
| | - Arthur Belle
- Service de Gastroentérologie, Endoscopie et Oncologie Digestive, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Guillaume Perrod
- Service d'Hépato-gastroentérologie et Endoscopies Digestives, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Félix Corre
- Université Paris-Cité, Paris, France
- Service de Gastroentérologie, Endoscopie et Oncologie Digestive, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Stanislas Chaussade
- Université Paris-Cité, Paris, France
- Service de Gastroentérologie, Endoscopie et Oncologie Digestive, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Christophe Cellier
- Service d'Hépato-gastroentérologie et Endoscopies Digestives, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Université Paris-Cité, Paris, France
| | - Gabriel Rahmi
- Service d'Hépato-gastroentérologie et Endoscopies Digestives, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Université Paris-Cité, Paris, France
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Swiridoff N, Ziachehabi A, Wewalka F, Spaun G, Alibegovic V, Schöfl R. Retrospective Analysis of Rectal Endoscopic Submucosal Dissection at Ordensklinikum Linz and Kepler Universitätsklinikum Linz. J Clin Med 2024; 13:3530. [PMID: 38930059 PMCID: PMC11205019 DOI: 10.3390/jcm13123530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Background and study aim: Endoscopic submucosal dissection is a minimally invasive endoscopic procedure for the removal of neoplastic benign and early malignant lesions in the gastrointestinal tract. In this study, we analyse the success and safety of rectal ESD at Linz hospitals, focusing on a specific endoscopist. Additionally, we examine whether there is a learning curve regarding success parameters. Methods: This retrospective study included all 102 patients who underwent endoscopic submucosal dissection of the rectum by a defined endoscopist at Ordensklinikum Hospital and Kepler University Hospital between December 2010 and May 2021. With the collected data, a descriptive statistic was carried out and regression analyses were performed. Results: The en bloc resection rate was 78.4% and the rate of lesions removed in healthy tissue was 55.6%. The average procedure time was 179 min and the complication rate was 7.8%. In total, 26.4% of cases showed carcinoma; in 25.9% of these cases, an oncologically curative resection was achieved with ESD. Follow-up data were available for 61.1% of cases, with recurrence being diagnosed in 3.6% of cases. A learning curve was observed regarding the rate of lesions removed in healthy tissue and the procedure time, but not regarding the en bloc resection rate. Conclusions: Endoscopic submucosal dissection is a safe method for the removal of large rectal adenomas and early carcinomas. The en bloc resection rate of the analysed procedures is within the range of comparable European studies. The rate of lesions removed in healthy tissue is below the R0 resection rate of the comparative literature; however, a learning curve could be observed in this parameter.
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Affiliation(s)
- Nikolaj Swiridoff
- Interne IV (Gastroenterology), Ordensklinikum Linz Barmherzige Schwestern, 4010 Linz, Austria (R.S.)
| | - Alexander Ziachehabi
- Clinic for Internal Medicine 2—Gastroenterology and Hepatology, Endocrinology and Metabolism, Nephrology, Rheumatology, Kepler University Hospital, 4020 Linz, Austria
| | - Friedrich Wewalka
- Interne IV (Gastroenterology), Ordensklinikum Linz Barmherzige Schwestern, 4010 Linz, Austria (R.S.)
| | - Georg Spaun
- General and Visceral Surgery, Ordensklinikum Linz Barmherzige Schwestern, 4010 Linz, Austria
| | - Vedat Alibegovic
- Pathology, Ordensklinikum Linz Barmherzige Schwestern, 4010 Linz, Austria
| | - Rainer Schöfl
- Interne IV (Gastroenterology), Ordensklinikum Linz Barmherzige Schwestern, 4010 Linz, Austria (R.S.)
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Pecha RL, Ayoub F, Patel A, Muftah A, Wright MW, Khalaf MA, Othman MO. Outcomes of endoscopic submucosal dissection in cirrhotic patients: First American cohort. World J Hepatol 2024; 16:784-790. [PMID: 38818291 PMCID: PMC11135272 DOI: 10.4254/wjh.v16.i5.784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/29/2024] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Among patients with cirrhosis and pre-malignant or early malignant mucosal lesions, surgical intervention carries a much higher bleeding risk. When such lesions are discovered, endoscopic submucosal dissection (ESD) may offer curative therapy with lower risks than surgery and improved outcomes compared to traditional endoscopic resection. AIM To evaluate the outcomes of ESD in patients with cirrhosis. METHODS Patients with cirrhosis undergoing ESD between July 2015 and August 2022 were retrospectively matched in 1:2 fashion to controls based on lesion location, size, and anticoagulation use. Procedural outcomes were compared between groups. RESULTS A total of 64 Lesions from 59 patients were included (16 cirrhosis, 43 control). There were no differences in patient or lesion characteristics between groups. En bloc and curative resection was achieved in 84.21%, 78.94% of the cirrhosis group and 88.89%, 68.89% of controls, respectively, with no significant differences. Cirrhotic patients had significantly higher rates of intra-procedural coagulation grasper use for control of bleeding (47.37% vs 20%; P = 0.02). There were otherwise no significant differences in adverse event rates. In the 29 patients with follow up, we found higher rates of recurrence in the cirrhosis group compared to controls (40% vs 5.26%; P = 0.019), however this effect did not persist on multivariable analysis controlling for known confounders. CONCLUSION ESD may be safe and effective in patients with cirrhosis. Most procedure related outcomes were not significantly different between groups. Intra-procedural bleeding requiring use of the coagulation grasper use was expectedly higher in the cirrhosis group given the known effects of liver disease on hemostasis.
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Affiliation(s)
- Robert Luke Pecha
- Department of Gastroenterology and Hepatology, UC Davis, Sacramento, CA 95817, United States.
| | - Fares Ayoub
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Ankur Patel
- Internal Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Abdullah Muftah
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch at Galveston, Galveston, TX 77550, United States
| | - Michael W Wright
- Medical School, Baylor College of Medicine, Houston, TX 77030, United States
| | - Mai A Khalaf
- Department of Tropical Medicine, Tanta University, Tanta 31527, Egypt
| | - Mohamed O Othman
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
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Onda T, Goto O, Otsuka T, Hayasaka Y, Nakagome S, Habu T, Ishikawa Y, Kirita K, Koizumi E, Noda H, Higuchi K, Omori J, Akimoto N, Iwakiri K. Tumor size discrepancy between endoscopic and pathological evaluations in colorectal endoscopic submucosal dissection. World J Gastrointest Endosc 2024; 16:136-147. [PMID: 38577641 PMCID: PMC10989246 DOI: 10.4253/wjge.v16.i3.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/22/2023] [Accepted: 01/29/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Tumor size impacts the technical difficulty and histological curability of colorectal endoscopic submucosal dissection (ESD); however, the preoperative evaluation of tumor size is often different from histological assessment. Analyzing influential factors on failure to obtain an accurate tumor size evaluation could help prepare optimal conditions for safer and more reliable ESD.
AIM To investigate the tumor size discrepancy between endoscopic and pathological evaluations and the influencing factors.
METHODS This was a retrospective study conducted at a single institution. A total of 377 lesions removed by colorectal ESD at our hospital between April 2018 and March 2022 were collected. We first assessed the difference in size with an absolute percentage of the scaling discrepancy. Subsequently, we compared the clinicopathological characteristics of the correct scaling group (> -33% and < 33%) with that of the incorrect scaling group (< -33% or > 33%), which was further subdivided into the underscaling group (-33% or less of the discrepancy) and overscaling group (33% or more of the discrepancy), respectively. As secondary outcome measures, parameters on size estimation were compared between the underscaling and correct scaling groups, as well as between the overscaling and correct scaling groups. Finally, multivariate analysis was performed in terms of the following relevant parameters on size estimation: Pathological size, location, and possible influential factors (P < 0.1) in the univariate analysis.
RESULTS The mean of absolute percentage in the scaling discordance was 21%, and 91 lesions were considered to be incorrectly estimated in size. The incorrect scaling was significantly remarkable in larger lesions (40 mm vs 28 mm; P < 0.001) and less experience (P < 0.001), and these two factors were influential on the underscaling (75 lesions; P < 0.001). Conversely, compared with the correct scaling group, 16 lesions in the overscaling group were significantly small (20 mm vs 28 mm; P < 0.001), and the small lesion size was influential on the overscaling (P = 0.002).
CONCLUSION Lesions indicated for colorectal ESD tended to be underestimated in large tumors, but overestimated in small ones. This discrepancy appears worth understanding for optimal procedural preparation.
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Affiliation(s)
- Takeshi Onda
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
- Endoscopy Center, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Yoshiaki Hayasaka
- Center for Medical Education, Nippon Medical School, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Shun Nakagome
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Tsugumi Habu
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Yumiko Ishikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Kumiko Kirita
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Eriko Koizumi
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Hiroto Noda
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Kazutoshi Higuchi
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Naohiko Akimoto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Bunkyo-ku 113-8603, Tokyo, Japan
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Barbaro F, Papparella LG, Chiappetta MF, Ciuffini C, Fukuchi T, Hamanaka J, Quero G, Pecere S, Gibiino G, Petruzziello L, Maeda S, Hirasawa K, Costamagna G. Endoscopic full-thickness resection vs. endoscopic submucosal dissection of residual/recurrent colonic lesions on scars: a retrospective Italian and Japanese comparative study. Eur J Gastroenterol Hepatol 2024; 36:162-167. [PMID: 38131424 DOI: 10.1097/meg.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIMS Endoscopic treatment of recurrent/residual colonic lesions on scars is a challenging procedure. In this setting, endoscopic submucosal dissection (ESD) is considered the first choice, despite a significant rate of complications. Endoscopic full-thickness resection (eFTR) has been shown to be well-tolerated and effective for these lesions. The aim of this study is to conduct a comparison of outcomes for resection of such lesions between ESD and eFTR in an Italian and a Japanese referral center. METHODS From January 2018 to July 2020, we retrospectively enrolled patients with residual/recurrent colonic lesions, 20 treated by eFTR in Italy and 43 treated by ESD in Japan. The primary outcome was to compare the two techniques in terms of en-bloc and R0-resection rates, whereas complications, time of procedure, and outcomes at 3-month follow-up were evaluated as secondary outcomes. RESULTS R0 resection rate was not significantly different between the two groups [18/20 (90%) and 41/43 (95%); P= 0.66]. En-bloc resection was 100% in both groups. No significant difference was found in the procedure time (54 min vs. 61 min; P= 0.9). There was a higher perforation rate in the ESD group [11/43 (26%) vs. 0/20 (0%); P= 0.01]. At the 3-month follow-up, two lesions relapsed in the eFTR cohort and none in the ESD cohort (P= 0.1). CONCLUSION eFTR is a safer, as effective and equally time-consuming technique compared with ESD for the treatment of residual/recurrent colonic lesions on scars and could become an alternative therapeutic option for such lesions.
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Affiliation(s)
- Federico Barbaro
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Luigi Giovanni Papparella
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Michele Francesco Chiappetta
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Section of Gastroenterology and Hepatology, Promise, Policlinico Universitario Paolo Giaccone, Palermo, Italy
| | - Cristina Ciuffini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Takehide Fukuchi
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Jun Hamanaka
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Università Cattolica del Sacro Cuore, Roma
| | - Silvia Pecere
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Morgagni-Pierantoni, AUSL Romagna, Forlì, Italy
| | - Lucio Petruzziello
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, Roma
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8
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Oyama T, Yahagi N, Ponchon T, Kiesslich T, Wagner A, Toyonaga T, Uraoka T, Takahashi A, Ziachehabi A, Neureiter D, Fuschlberger M, Schachinger F, Seifert H, Kaehler G, Mitrakov A, Kantsevoy SV, Messmann H, Hochberger J, Berr F, Halm U, Schulz H, Chabrun E, Cholet F, Thorlacius H, Dumoulin FL, Herreros de Tejada A, Łozinski C, Caillol F, Spychalski M, Santos-Antunes JC, Lutz M, Bermoser K, Schäfer A, Krankenhaus AK, LeBaleur Y, Jacob H, Allgaier HP, Kleber G, Steinbrück I, Tringali A, Flatz T, Österreicher C, Glas A, Schroder R, Lutterer A, Wedi E, Anzinger M, Boger P, Suchánek S, Laquière A, Rajkumar S, Rupinski M, Jue T, Barawi M, Schlag C, Möschler O, Sferrazza S, Pekarek B, Poyrazoglu OK, Baran B, Mayer A, Tribl B, Goetz M, Plamenig D, Pickartz T, Hayward C, Grünhage F, Qutob T, Seerden T, Schmitz V, Wiest R, Hoffman A, Flatz T, Horvath H, Viale E, LaRoche M, Peveling-Oberhag J, Aerts M, Gal E, Doykov D, Allerstorfer D, Bodlaj G, Maskelis R, Vassiljeva V, Kapetanakis N, Appenrodt B, Moura M, Bastiaansen BA, Barsic N, Zimmer V. Implementation of endoscopic submucosal dissection in Europe: survey after 10 ESD Expert Training Workshops, 2009 to 2018. IGIE 2023; 2:472-480.e5. [DOI: 10.1016/j.igie.2023.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2025]
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9
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Gonzalez JM, Meunier E, Debourdeau A, Basile P, Le-Mouel JP, Caillo L, Vitton V, Barthet M. Training in esophageal peroral endoscopic myotomy (POEM) on an ex vivo porcine model: learning curve study and training strategy. Surg Endosc 2023; 37:2062-2069. [PMID: 36289086 DOI: 10.1007/s00464-022-09736-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/11/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a very effective treatment for achalasia. However, training remains non-standardized. We evaluated a training curriculum, including ex vivo cases, followed by patients' cases under expert supervision. The objective was to establish a learning curve of POEM. MATERIALS AND METHODS Four operators having completed advanced endoscopy fellowship were involved. They had already observed > 30 cases performed by experts. They performed 30 POEMs standardized (tunnel and myotomy lengths) procedures on ex vivo porcine model. Procedural times, number/volume of injections, mucosal and serous perforations, and myotomy length were collected. The learning curve was assessed using dissection speed (DS) and a dedicated performance score (PS), including learning rate (LR) and learning plateau (LP). RESULTS The operators completed all cases within 4 months (median of 3.5 cases/week). The mean procedural time was 43.3 min ± 14.4. Mean myotomy length was 70.0 mm ± 15.6 mm. Dissection speed averaged 1.78 mm/min ± 0.78. Using DS and PS as parameter, the LR was reached after 12.2 cases (DS = 2.0 mm/min) and 10.4 cases, respectively. When comparing the LP and the plateau phase, the DS was slower (1.3 ± 0.5 mm/min versus 2.1 ± 0.54 mm/min, p < 0.005) and perforations were decreased: 0.35 ± 0.82 in LP vs. 0.16 ± 0.44 in PP. Following this training, all operators performed 10 supervised cases and are competent in POEM. CONCLUSION The association of observed cases and supervised ex vivo model training is effective for starting POEM on patients. The learning curve is 12 cases to reach a plateau.
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Affiliation(s)
- Jean-Michel Gonzalez
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France.
| | - Elise Meunier
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France
| | | | | | | | | | - Véronique Vitton
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France
| | - Marc Barthet
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France
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10
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Mueller J, Kuellmer A, Schiemer M, Thimme R, Schmidt A. Current status of endoscopic full-thickness resection with the full-thickness resection device. Dig Endosc 2023; 35:232-242. [PMID: 35997598 DOI: 10.1111/den.14425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/21/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD) is an integral part of diagnostic and therapeutic endoscopy. Since its market launch in Europe in 2014, its safety and effectiveness have been proven in numerous studies. Adaptations in design as well as new techniques, such as hybrid EFTR, expand the spectrum of the FTRD system. The following review is intended to provide an overview of the clinical application and current evidence of EFTR with the FTRD system.
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Affiliation(s)
- Julius Mueller
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Schiemer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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11
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Stéphane S, Timothée W, Jérémie A, Raphael O, Martin D, Emmanuelle P, Elodie L, Quentin D, Nikki C, Sonia B, Hugo L, Guillaume G, Romain L, Mathieu P, Sophie G, Jeremie J. Endoscopic submucosal dissection or piecemeal endoscopic mucosal resection for large superficial colorectal lesions: A cost effectiveness study. Clin Res Hepatol Gastroenterol 2022; 46:101969. [PMID: 35659602 DOI: 10.1016/j.clinre.2022.101969] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Endoscopic management is preferred to surgical management for large superficial colorectal lesions. However, the optimal endoscopic resection strategy (piecemeal endoscopic mucosal resection [pEMR] or endoscopic submucosal dissection [ESD]) is still debated from an economical point of view. To date, in France, there is no Health Insurance reimbursement rate for the hospital stays related to ESD. We searched to estimate the global cost of colorectal ESD and to define the most cost-effectiveness endoscopic strategy. METHODS A model was created to compare the cost-effectiveness of ESD and pEMR according to optical diagnosis (Japan NBI Expert Team [JNET], laterally spreading tumour [LST], CONECCT). We distinguished three groups from the same multicentre ESD cohort and compared the medical and economic outcomes: real-life ESD data (Universal-ESD or U-ESD) compared to modelled selective ESD (S-ESD JNET; S-ESD LST; S-ESD CONECCT) and exclusive pEMR strategies (Universal-EMR or U-EMR). RESULTS The en-bloc, R0, and curative resection rates were 97.5%, 86.5%, and 82.6%, respectively in the real life French ESD cohort of 833 colorectal lesions. U-ESD was the least-expensive strategy, with a global cost of 2,858,048.17 €, i.e. 3,431.03 €/patient and was also the most effective strategy because it avoided 774 surgeries, which was more than any other strategy. It outperformed S-ESD CONNECT (global cost = 2,951,411.44 €, and 3,543.11 €/patient, 765 surgeries avoided, S-ESD LST (global cost = 3,055,951.53 €, and 3,668.61 €/patient, 749 surgeries avoided), and S-ESD JNET (global cost = 3,547,426.97 € and 4,258.62 €/patient, 704 surgeries avoided) and U-EMR (global cost = 4,060,547.62 € and 4,874.61 €/patient, 620 surgeries avoided). Even though a model which optimized pEMR results (0% technical failure, 0% primary surgery), U-EMR strategy remained the most expansive strategy and the one that avoided the least surgeries. CONCLUSION ESD for all LSTs upper than 20 mm is more cost-effective than pEMR, and S-ESD.
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Affiliation(s)
- Scheer Stéphane
- Gastroenterology Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Wallenhorst Timothée
- Gastroenterology Department, University Hospital of Rennes, 35000 Rennes, France
| | - Albouys Jérémie
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Olivier Raphael
- Gastroenterology Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Dahan Martin
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | | | - Leclerc Elodie
- Gastroenterology Department, University Hospital of Rennes, 35000 Rennes, France
| | - Denost Quentin
- Colorectal and Pelvic Surgery, Bordeaux University Hospital, 33604 Bordeaux, France
| | - Christou Nikki
- Digestive Surgery, Limoges University Hospital, 87042 Limoges, France
| | | | - Lepetit Hugo
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Gschwind Guillaume
- Public Health Care Department, University Hospital of Limoges, 87042 Limoges, France
| | - Legros Romain
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Pioche Mathieu
- Gastroenterology Department, Hospital Edouard Heriot, Hospices civils de Lyon, 69003 Lyon, France
| | - Geyl Sophie
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Jacques Jeremie
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France.
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12
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Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022; 54:591-622. [PMID: 35523224 DOI: 10.1055/a-1811-7025] [Citation(s) in RCA: 346] [Impact Index Per Article: 115.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.
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Affiliation(s)
- Pedro Pimentel-Nunes
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- Department of Surgery and Physiology, Porto Faculty of Medicine, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, The Netherlands
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia and Western Clinical School, University of Sydney, Sydney, Australia
| | - Gianluca Esposito
- Department of Medical-Surgical Sciences and Translational Medicine, Sant' Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
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13
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Pérez-Cuadrado-Robles E, Chupin A, Perrod G, Severyns T, Cellier C, Rahmi G. Endoscopic submucosal dissection in tumors extending to the dentate line compared to proximal rectal tumors: a systematic review with meta-analysis. Eur J Gastroenterol Hepatol 2022; 34:121-127. [PMID: 34967816 DOI: 10.1097/meg.0000000000001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Endoscopic submucosal dissection (ESD) is a validated treatment for early rectal tumors, but whether this therapy is efficient or not for rectal tumors extending to the dentate line (RTDL) remains unclear. We performed a systematic review and meta-analysis to assess the effectiveness and safety of ESD in RTDL compared to non-RTDL. A search in PubMed, Scopus and the Cochrane library up to April 2020 was conducted to identify studies that compared ESD in both localizations (RTDL and non-RTDL), reporting at least one main outcome (en bloc, complete resection, recurrence). Secondary outcomes were adverse event occurrence. Five observational studies including 739 patients with a total of 201 RTDL and 538 non-RTDL were considered. The proportion of female sex (66% vs. 36.9%, P < 0.001) and tumor size [mean difference = 7.75, 95% confidence interval (CI): 3.01-12.49, P = 0.001] were higher in the RTDL group. There were no differences in en bloc resection rates between RTDL and non-RTDL groups [odds ratio (OR): 0.95, 95% CI: 0.50-1.79, P = 0.087]. The complete resection rate was significantly higher in the non-RTDL group (OR: 1.72, 95% CI: 1.18-2.53, P = 0.005, I2 = 0%). However, recurrence rates were comparable (RD: -0.04, 95% CI: -0.07 to 0.00, P = 0.06, I2 = 0%). Concerning adverse events, there were no differences in terms of perforation (OR: 0.9, 95% CI: 0.26-3.08, P = 0.86, I2 = 0%) or delayed bleeding (OR: 0.64, 95% CI: 0.17-2.42, P = 0.51, I2 = 35%). Anal pain rate was 28% (95% CI: 21.4-35.8%). ESD is an effective and safe therapeutic approach for RTDL with comparable recurrence rate to non-RTDL. The lower complete resection rate in RTDL needs to be clarified in studies.
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Affiliation(s)
| | - Antoine Chupin
- Department of Gastroenterology, Georges-Pompidou European Hospital, Paris University
| | - Guillaume Perrod
- Department of Gastroenterology, Georges-Pompidou European Hospital, Paris University
| | - Thomas Severyns
- Department of Gastroenterology, Georges-Pompidou European Hospital, Paris University
| | - Christophe Cellier
- Department of Gastroenterology, Georges-Pompidou European Hospital, Paris University
| | - Gabriel Rahmi
- Department of Gastroenterology, Georges-Pompidou European Hospital, Paris University
- INSERM U970, PARCC, Paris, France
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14
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Initial clinical experience with a novel flexible endoscopic robot for transanal surgery. Tech Coloproctol 2022; 26:301-308. [PMID: 35091792 PMCID: PMC8917022 DOI: 10.1007/s10151-022-02577-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/17/2022] [Indexed: 12/04/2022]
Abstract
Background The Flex® Robotic System (Medrobotics, Raynham, MA, USA) is the first miniaturised flexible endoscopic robot that aims to allow surgical manoeuvres beyond the area currently reached by transanal endoscopic microsurgery. The aim of this study is to evaluate our initial clinical experience with this novel tool. Methods We prospectively collected all consecutive cases of local excisions of rectal lesions performed with the Flex® Robotic System performed at the Department of Surgical Sciences of the University of Turin between October 2018 and December 2019. Indications were benign, or early rectal lesions judged unsuitable for endoscopic removal, within 20 cm of the anal verge. Debriefing meetings after each procedure allowed technology assessment leading to the modification, development, and implementation of tools according to the clinical experience. We analysed the data in terms of the safety and efficacy of treatment. Results Between October 2018 and February 2020, 26 patients were treated. We performed a full-thickness excision in 14 patients and a submucosal dissection in 12. The median operating time was 115 min (range 45–360 min). In six patients (23.1%), we converted to standard transanal endoscopic operation (TEO®) (Karl Storz, Tuttlingen, Germany) to complete the procedure. The 30-day morbidity rate was 11.5% (3/26). Positive resection margins were detected in 4 (15.4%) patients. At a minimum follow-up of 12 months, 2 (7.7%) local recurrences were observed. Conclusions This first clinical series demonstrates that the Flex® Robotic System is a fascinating technology that deserves further development to increase surgical dexterity, thereby overcoming current technical limitations and improving clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02577-1.
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15
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Shahini E, Libânio D, Lo Secco G, Pisani A, Arezzo A. Indications and outcomes of endoscopic resection for non-pedunculated colorectal lesions: A narrative review. World J Gastrointest Endosc 2021; 13:275-295. [PMID: 34512876 PMCID: PMC8394186 DOI: 10.4253/wjge.v13.i8.275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/14/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Endrit Shahini
- Department of Gastroenterology and Digestive Endoscopy Unit, National Institute of Research “Saverio De Bellis,” Castellana Grotte (Bari) 70013, Italy
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute, Porto 4200-072, Portugal
| | - Giacomo Lo Secco
- Department of Surgical Sciences, University of Torino, Turin 10126, Italy
| | - Antonio Pisani
- Department of Gastroenterology and Digestive Endoscopy Unit, National Institute of Research “Saverio De Bellis,” Castellana Grotte (Bari) 70013, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin 10126, Italy
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16
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Keihanian T, Othman MO. Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice. Clin Exp Gastroenterol 2021; 14:317-330. [PMID: 34377006 PMCID: PMC8349195 DOI: 10.2147/ceg.s249869] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/17/2021] [Indexed: 12/13/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a method of en-bloc resection of neoplastic colorectal lesions which is less invasive compared to surgical resection. Lesion stratification, architecture recognition and estimation of depth of invasion are crucial for patient selection. Expert endoscopists have integrated a variety of classification systems including Paris, lateral spreading tumor (LST), narrow band imaging (NBI), international colorectal endoscopic (NICE) and Japanese NBI expert team (JNET) in their day-to-day practice to enhance lesion detection accuracy. Major societies recommend ESD for LST-non granular (NG), Kudo-VI type, large depressed and protruded colonic lesions with shallow submucosal invasion. Chance of submucosal invasion enhances with increased depth as well as tumor location and size. In comparison to endoscopic mucosal resection (EMR), ESD has a lowerl recurrence rate and higher curative resection rate, making it superior for larger colonic lesions management. Major complications such as bleeding and perforation could be seen in up to 11% and 16% of patients, respectively. In major Western countries, performing ESD is challenging due to limited number of expert providers, lack of insurance coverage, and unique patient characteristics such as higher BMI and higher percentage of previously manipulated lesions.
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Affiliation(s)
- Tara Keihanian
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, TX, USA
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17
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Kang DU, Park JC, Hwang SW, Park SH, Yang DH, Kim KJ, Ye BD, Myung SJ, Yang SK, Byeon JS. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasia with or without the hybrid technique. Colorectal Dis 2020; 22:2008-2017. [PMID: 32866340 DOI: 10.1111/codi.15339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/04/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
AIM The main aim of this study was to compare the long-term outcome of a conventional colorectal endoscopic submucosal dissection (ESD) in which submucosal dissection was continued throughout until the completion of resection (ESD-T) to hybrid endoscopic submucosal dissection (ESD-H) in the colorectum. METHOD Medical records of 836 colorectal neoplasia patients treated by ESD-T or ESD-H were reviewed. ESD-H was defined as colorectal ESD with additional snaring in the final stage of the procedure. Primary outcomes were the overall and metastatic recurrence rates. Secondary outcomes were short-term outcomes such as the en bloc resection rate, procedure time and adverse events. RESULTS The overall recurrence rate was higher in the ESD-H than in the ESD-T group (5.7% vs 0.7%, P = 0.001). The metastatic recurrence rate showed no significant difference between these groups (1.4% vs 1.4%, P = 1.000). Multivariate analysis revealed that a failed en bloc resection (hazard ratio 24.097; 95% CI 5.446-106.237; P < 0.001) and larger tumour size (hazard ratio 1.042; 95% CI 1.014-1.070; P = 0.003) were independently associated with overall recurrence. The ESD-H group showed a lower en bloc resection rate (56.8% vs 96.5%, P < 0.001), shorter procedure time (45.6 vs 54.3 min, P < 0.001) and higher perforation rate (10.3% vs 6.0%, P = 0.029). CONCLUSION Although long-term outcomes in terms of overall recurrence are inferior following ESD-H, a failed en bloc resection and large tumour size are the only independent risk factors for recurrence. Further investigations are warranted to improve the long-term outcomes of ESD-H.
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Affiliation(s)
- D U Kang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J C Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S W Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S H Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D H Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - K J Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - B D Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S J Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S K Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J S Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Rajendran A, Pannick S, Thomas-Gibson S, Oke S, Anele C, Sevdalis N, Haycock A. Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy. Colorectal Dis 2020; 22:1085-1100. [PMID: 31925890 DOI: 10.1111/codi.14960] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/26/2019] [Indexed: 02/08/2023]
Abstract
AIM The performance of therapeutic procedures in lower gastrointestinal endoscopy (LGI) can be challenging and carries an increased risk of adverse events. There is increasing demand for the training of endoscopists in these procedures, but limited guidelines exist concerning procedural competency. The aim of this study was to assess the learning curves for LGI polypectomy, colorectal endoscopic mucosal resection (EMR) and colorectal endoscopic submucosal dissection (ESD). METHOD A systematic review of electronic databases between 1946 and September 2019 was performed. Citations were included if they reported learning curve data. Outcome measures that defined the success of procedural competency were also recorded. RESULTS A total of 34 out of 598 studies met the inclusion criteria of which 28 were related to ESD, three to polypectomy and three to EMR. Outcome measures for polypectomy competency (en bloc resection, delayed bleeding and independent polypectomy rate) were achieved after completion of between 250 and 400 polypectomies and after 300 colonoscopies. EMR outcome measures, including complete resection and recurrence, were achieved variably between 50 and 300 procedures. Outcome measures for ESD included efficiency (resection rates and procedural speed) and safety (adverse events). En bloc resection rates of over 80% and R0 resection rates of over 70% were achieved at 20-40 cases and procedural speed increased after 30 ESD cases. Competency in safety metrics was variably achieved at 20-200 cases. CONCLUSION There is a paucity of data on learning curves in LGI polypectomy, EMR and ESD. Despite limited evidence, we have identified relevant outcome measures and threshold numbers for the most common LGI polyp resection techniques for potential inclusion in training programmes/credentialing guidelines.
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Affiliation(s)
- A Rajendran
- The Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
- Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - S Pannick
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Thomas-Gibson
- The Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Oke
- Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Anele
- Department of Surgery and Cancer, Imperial College, London, UK
| | - N Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - A Haycock
- The Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
- Department of Surgery and Cancer, Imperial College, London, UK
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19
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Feasibility and learning curve of unsupervised colorectal endoscopic submucosal hydrodissection at a Western Center. Eur J Gastroenterol Hepatol 2020; 32:804-812. [PMID: 32175984 DOI: 10.1097/meg.0000000000001703] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Colorectal endoscopic submucosal dissection (CR-ESD) is an evolving technique in Western countries. We aimed to determine the results of the untutored implementation of endoscopic submucosal hydrodissection for the treatment of complex colorectal polyps and establish the learning curve for this technique. METHODS This study included data from 80 consecutive CR-ESDs performed by a single unsupervised western therapeutic endoscopist. To assess the learning curve, procedures were divided into four groups of 20 each. RESULTS En bloc resection was achieved in 55, 75, 75 and 95% cases in the consecutive time periods (period 1 vs. 4, P = 0.003). Curative resection was achieved in 55, 75, 70 and 95%, respectively (P = 0.037). Overall, series results demonstrated R0 resection in 75% of cases, with 23.7% requiring conversion to endoscopic piecemeal mucosal resection, and 1.25% incomplete resections. Complications included perforations (7.5%) and bleeding (3.7%). Multivariate analysis revealed factors more likely to result in association with non en bloc vs. En bloc resection, where polyp size ≥35 mm [70 vs. 23.4%; odds ratio (OR) 13.2 (1.7-100.9); P = 0. 013], severe fibrosis [40 vs. 11.7%; OR 10.2 (1.2-86.3); P = 0.033] and where carbon dioxide for insufflation was not used [65 vs. 30%; OR 0.09 (0.01-0.53); P = 0.008]. CONCLUSION CR-ESD by hydrodissection has good safety and efficacy profile and offers well tolerated and effective treatment for complex polyps. As such, this technique may be useful in the West, in centers, where previous gastric ESD is not frequent or Japanese mentoring is not possible.
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20
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Roland D, Rahmi G, Pérez-Cuadrado-Robles E, Perrod G, Jacques J, Barret M, Leblanc S, Berger A, Albouys J, Chaussade S, Cellier C. Endoscopic submucosal dissection in rectal tumors extending or not to the dentate line: A comparative analysis. Dig Liver Dis 2020; 52:296-300. [PMID: 31744774 DOI: 10.1016/j.dld.2019.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 09/13/2019] [Accepted: 10/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The feasibility of endoscopic submucosal dissection (ESD) in rectal tumors extending to the dentate line (RTDL) is unclear. AIMS To analyze the outcomes of ESD in RTDL compared to non-RTDL, with a special focus on the lower rectum location. METHODS Observational multicenter retrospective study. All patients with a rectal tumor who underwent ESD in 2013-2017 were included. A comparative analysis between RTDL and non-RTDL groups was done. RESULTS Two-hundred and twenty-eight patients (median age: 69 years, range: 33-89, 51.3% male) with RTDL (n = 65, 28.5%) and non-RTDL lesions (n = 163, 71.5%) were included. There were no significant differences between the en-bloc (89.2% vs. 90.8%, p = 0.718), complete (60% vs. 71.8%, p = 0.084) and curative resection rates (58.5% vs. 68.7%, p = 0.141). The overall complication rate (4.6% vs. 8%, p = 0.370) was not different, independently of the rectal location. Local recurrence was higher in RTDL (7.3% vs. 1.5%, p = 0.065). The indication for surgery due to non-curative resections in the lower rectum was lower in RTDL (9.2% vs. 14.6%, p = 0.378). CONCLUSION The safety, effectiveness and long-term impact of ESD in RTDL and non-RTDLs is comparable. Local recurrence in the lower rectum may be higher in RTDL.
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Affiliation(s)
- Déborah Roland
- Department of Gastroenterology and Endoscopy, Georges-Pompidou European Hospital, Paris, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Endoscopy, Georges-Pompidou European Hospital, Paris, France.
| | | | - Guillaume Perrod
- Department of Gastroenterology and Endoscopy, Georges-Pompidou European Hospital, Paris, France
| | - Jérémie Jacques
- Department of Gastroenterology, Dupuytren University Hospital, Limoges, France
| | | | - Sarah Leblanc
- Department of Gastroenterology, Cochin Hospital, Paris, France
| | - Arthur Berger
- Department of Gastroenterology and Endoscopy, Georges-Pompidou European Hospital, Paris, France
| | - Jérémie Albouys
- Department of Gastroenterology, Dupuytren University Hospital, Limoges, France
| | | | - Christophe Cellier
- Department of Gastroenterology and Endoscopy, Georges-Pompidou European Hospital, Paris, France
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21
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Efficacy and safety of endoscopic full-thickness resection in the colon and rectum using an over-the-scope device: a meta-analysis. Surg Endosc 2020; 35:249-259. [PMID: 31953724 DOI: 10.1007/s00464-020-07387-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 01/10/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Relevant publications were identified by searching PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science before December 1, 2019. Studies in which ≥ 10 cases of colorectal lesions were resected with endoscopic full-thickness resection (EFTR) were included. Rates of efficacy (technical success (en bloc), full-thickness resection and R0 resection), rates of safety (bleeding, perforation and postpolypectomy syndrome) and rates of follow-up (residual/recurrent adenoma, fate of over-the-scope clip and surgery for any reason) were pooled and analyzed. Forest plots were graphed based on random effects models. Subgroup analyses and sensitivity analyses were also performed if significant heterogeneity existed. RESULTS A total of 469 patients across 9 studies were eligible for analysis. The pooled rates of technical success, full-thickness resection and R0 resection were 94.0% (95% CI 89.8-97.3%), 89.5% (83.9-94.2%) and 84.9% (75.1-92.8%), respectively. The pooled estimates of bleeding, perforation and postpolypectomy syndrome were 2.2% (95% CI 0.4-4.9%), 0.19% (95% CI 0.00-1.25%) and 2.3% (95% CI 0.1-6.3%), respectively. Finally, the pooled rates of residual/recurrent adenoma, fate of OTSC and surgery for any reason were 8.5% (95% CI 4.1-14.0%), 80.3% (95% CI 67.5-90.8%) and 6.3% (2.4-11.7%), respectively. CONCLUSIONS EFTR for nonlifting, invasive lesions in the colon and rectum appears to be effective and safe. However, future studies are necessary to explore the role of EFTR in large colorectal lesions and specify its indications.
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22
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Rex DK, Shaukat A, Wallace MB. Optimal Management of Malignant Polyps, From Endoscopic Assessment and Resection to Decisions About Surgery. Clin Gastroenterol Hepatol 2019; 17:1428-1437. [PMID: 30268567 DOI: 10.1016/j.cgh.2018.09.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/28/2018] [Accepted: 09/16/2018] [Indexed: 02/06/2023]
Abstract
Colorectal cancer is defined clinically as invasion of dysplastic cells into the submucosa. Lesions with submucosal invasion but without invasion into the muscularis propria are generally called malignant polyps. A stepwise approach produces optimal management of malignant polyps (including polypoid and flat/depressed lesions). The first step is to avoid endoscopic resection of non-pedunculated lesions with endoscopic features that predict deep submucosal invasion. Lesions without such features are candidates for endoscopic resection. The second step is to assess candidates for endoscopic resection for features that predict an increased risk of superficial submucosal invasion. Such lesions should be considered for en bloc endoscopic excision if feasible. The third step is giving patients with endoscopically resected malignant polyps good advice regarding whether to undergo adjuvant therapy, usually surgery. We review the endoscopic and histologic criteria that guide clinicians through these steps.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Jacksonville, Florida
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23
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Role of Magnification Chromoendoscopy in the Management of Colorectal Neoplastic Lesions Suspicious for Submucosal Invasion. Dis Colon Rectum 2019; 62:422-428. [PMID: 30730457 DOI: 10.1097/dcr.0000000000001343] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Correctly predicting the depth of tumor invasion in the colorectal wall is crucial for successful endoscopic resection of superficial colorectal neoplasms. OBJECTIVE The aim of this study was to assess the accuracy of magnifying chromoendoscopy in a Western medical center to predict the depth of invasion by the pit pattern classification in patients with colorectal neoplasms with a high risk of submucosal invasion. DESIGN This single-center retrospective study, from a prospectively collected database, was conducted between April 2009 and June 2015. SETTINGS The study was conducted at a single academic center. PATIENTS Consecutive patients with colorectal neoplasms with high risk of submucosal invasion were included. These tumors were defined by large (≥20 mm) sessile polyps (nonpedunculated), laterally spreading tumors, or depressed lesions of any size. INTERVENTIONS Patients underwent magnifying chromoendoscopy and were classified according to the Kudo pit pattern. The therapeutic decision, endoscopic or surgery, was defined by the magnification assessment. MAIN OUTCOME MEASURES Sensitivity, specificity, and positive and negative predictive values of magnifying chromoendoscopy for assessment of these lesions were determined. RESULTS A total of 123 lesions were included, with a mean size of 54.0 ± 37.1 mm. Preoperative magnifying chromoendoscopy with pit pattern classification had 73.3% sensitivity, 100% specificity, 100% positive predictive value, 96.4% negative predictive value, and 96.7% accuracy to predict depth of invasion and consequently to guide the appropriate treatment. Thirty-three rectal lesions were also examined by MRI, and 31 were diagnosed as T2 lesions. Twenty two (70.1%) of these lesions were diagnosed as noninvasive by magnifying colonoscopy, were treated by endoscopic resection, and met the curative criteria. LIMITATIONS This was a single-center retrospective study with a single expert endoscopist experience. CONCLUSIONS Magnifying chromoendoscopy is highly accurate for assessing colorectal neoplasms suspicious for submucosal invasion and can help to select the most appropriate treatment. See Video Abstract at http://links.lww.com/DCR/A920.
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Wedi E, Ho CN, Conrad G, Weiland T, Freidinger S, Wehrmann M, Meining A, Ellenrieder V, Gottwald T, Schurr MO, Hochberger J. Preclinical evaluation of a novel thermally sensitive co-polymer (LiftUp) for endoscopic resection. MINIM INVASIV THER 2019; 28:277-284. [PMID: 30663522 DOI: 10.1080/13645706.2018.1535440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Endoscopic resection techniques can successfully resect large lesions either in "en bloc" fashion or in "piece-meal" technique by using a submucosal injection solution. The aim of this study was to evaluate the safety of a novel injectable, containing thermally sensitive co-polymer from ethylenoxide and propylenoxide (LiftUp) used as submucosal injection solution.Material and methods: We conducted an in vivo animal trial in the porcine model to evaluate the LiftUp gel in a preclinical setting and to study the effectiveness of mucosal lifting and the safety of the new injectable. In seven animals a total of 63 injections and endoscopic resections were carried out in different anatomical locations (esophagus, stomach and rectum). The resection sites were controlled endoscopically one and four weeks after resection and a histopathological evaluation of the resection sites was performed after four weeks.Results: The application of LiftUp was safe and there were no negative effects on wound healing after injection and resection. A major procedural complication rate (defined as perforation and major haemorrhage) of 3.2% was registered, which undercuts the anticipated mean complication rate of 4-8%. Furthermore, there was no necessity of reinjection after the initial submucosal injection in 90.5% and no procedural complications in 98.8%. The histopathological examination of the tissue samples indicated normal wound healing with granulation tissue and epithelialisation.Conclusion: The use of LiftUp as submucosal injection solution was feasible for different endoscopic resection techniques, with high and long-lasting elevation and fewer procedural adverse events than expected at trial planning. The new injectable is a practical advancement over the current state-of-the-art of submucosal injection and could fasten up the resection procedure and make endoscopic 'en bloc' resection safer.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre, Goettingen, Germany
| | | | | | - Timo Weiland
- Novineon CRO & Consulting Ltd, Tuebingen, Germany
| | | | | | - Alexander Meining
- Interventional and Experimental Endoscopy (InExEn), Medizinische Klinik I, University Medical Centre Ulm, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre, Goettingen, Germany
| | | | | | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University, Berlin, Germany
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25
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Bahin FF, Heitman SJ, Rasouli KN, Mahajan H, McLeod D, Lee EYT, Williams SJ, Bourke MJ. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67:1965-1973. [PMID: 28988198 DOI: 10.1136/gutjnl-2017-313823] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/29/2017] [Accepted: 09/10/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of endoscopic submucosal dissection (ESD) and wide-field endoscopic mucosal resection (WF-EMR) for removing large sessile and laterally spreading colorectal lesions (LSLs) >20 mm. DESIGN An incremental cost-effectiveness analysis using a decision tree model was performed over an 18-month time horizon. The following strategies were compared: WF-EMR, universal ESD (U-ESD) and selective ESD (S-ESD) for lesions highly suspicious for containing submucosal invasive cancer (SMIC), with WF-EMR used for the remainder. Data from a large Western cohort and the literature were used to inform the model. Effectiveness was defined as the number of surgeries avoided per 1000 cases. Incremental costs per surgery avoided are presented. Sensitivity and scenario analyses were performed. RESULTS 1723 lesions among 1765 patients were analysed. The prevalence of SMIC and low-risk-SMIC was 8.2% and 3.1%, respectively. Endoscopic lesion assessment for SMIC had a sensitivity and specificity of 34.9% and 98.4%, respectively. S-ESD was the least expensive strategy and was also more effective than WF-EMR by preventing 19 additional surgeries per 1000 cases. 43 ESD procedures would be required in an S-ESD strategy. U-ESD would prevent another 13 surgeries compared with S-ESD, at an incremental cost per surgery avoided of US$210 112. U-ESD was only cost-effective among higher risk rectal lesions. CONCLUSION S-ESD is the preferred treatment strategy. However, only 43 ESDs are required per 1000 LSLs. U-ESD cannot be justified beyond high-risk rectal lesions. WF-EMR remains an effective and safe treatment option for most LSLs. TRIAL REGISTRATION NUMBER NCT02000141.
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Affiliation(s)
- Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Steven J Heitman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Khalid N Rasouli
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Hema Mahajan
- Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Duncan McLeod
- Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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26
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Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, Neuhaus H, Albers D, Birk M, Thimme R, Probst A, Faehndrich M, Frieling T, Goetz M, Riecken B, Caca K. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67:1280-1289. [PMID: 28798042 DOI: 10.1136/gutjnl-2016-313677] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 06/14/2017] [Accepted: 07/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device. DESIGN 181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection. RESULTS EFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%. CONCLUSION EFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions. TRIAL REGISTRATION NUMBER NCT02362126; Results.
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Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany.,Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torsten Beyna
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | | | - Hans-Juergen Richter-Schrag
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Horst Neuhaus
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | - Michael Birk
- Department of Gastroenterology, University Hospital, Ulm, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Faehndrich
- Department of Gastroenterology, Klinikum Dortmund, Dortmund, Germany
| | - Thomas Frieling
- Department of Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany
| | - Martin Goetz
- Department of Gastroenterology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Bettina Riecken
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
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27
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Using Endoscopic Submucosal Dissection as a Routine Component of the Standard Treatment Strategy for Large and Complex Colorectal Lesions in a Western Tertiary Referral Unit. Dis Colon Rectum 2018; 61:743-750. [PMID: 29722731 DOI: 10.1097/dcr.0000000000001081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal endoscopic submucosal dissection results in high rates of en bloc resection, few recurrences, and accurate diagnosis, and it is useful in lesions with significant fibrosis. However, endoscopic submucosal dissection has not been widely adopted by Western endoscopists and the published experience from Western centers is very limited. OBJECTIVES This study aims to report the outcomes from a UK tertiary center using colorectal endoscopic submucosal dissection as part of a standard lesion specific treatment approach. DESIGN This was a retrospective study. SETTING The study was conducted in a tertiary referral unit for interventional endoscopy in the United Kingdom. PATIENTS A total of 116 colorectal lesions were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection in 107 patients. MAIN OUTCOME MEASURES Outcomes included complications, recurrence, requirement for surgery, en bloc and R0 resection. RESULTS One hundred sixteen lesions (mean size 58.8mm) were resected using endoscopic submucosal dissection (n = 58) and hybrid endoscopic submucosal dissection (n = 58). Eighty-two (70.7%) had failed attempts at resection (n = 58) or extensive sampling before referral. Twelve contained invasive adenocarcinoma; endoscopic resection was curative in 6. Only 2 of 6 patients with noncurative endoscopic resection agreed to surgery, and none had lymph node metastases. Six of 7 perforations were successfully treated with endoscopic clips. Where endoscopic submucosal dissection was used alone, en bloc resection was achieved in 93% and R0 resection was achieved in 91%. Two patients experienced recurrence; both were managed with endoscopic resection. LIMITATIONS This was a retrospective study. Procedures were planned as endoscopic submucosal dissection, but some may have been converted to hybrid endoscopic submucosal dissection and not recorded. CONCLUSION Colorectal endoscopic submucosal dissection can be used in a Western center as part of a standard lesion-specific approach to deliver effective organ-conserving treatment to patients with large challenging lesions. Lesion assessment in Western practice should be improved to reduce the incidence of prior heavy manipulation and to guide appropriate referral. See Video Abstract at http://links.lww.com/DCR/A601.
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Fujihara S, Mori H, Kobara H, Nishiyama N, Yoshitake A, Masaki T. Endoscopic Full-Thickness Resection for Colorectal Neoplasm: Current Status and Future Directions. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0399-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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29
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Transanal Minimally Invasive Anal Canal Polyp Resection. Surg Laparosc Endosc Percutan Tech 2018; 28:e59-e61. [PMID: 29334527 DOI: 10.1097/sle.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are operative endoscopies that have been performed since a long time. Recently, an evolution of laparoscopy called transanal minimally invasive surgery began to be popularized, and it can be adopted in the face of difficult cases for EMR/ESD. In this video, a 36-year-old woman was submitted to transanal minimally invasive surgery resection, after unsuccessful ESD, for a 2-cm polyp located anteriorly in the anal canal, just beyond the pectineal line. Preoperative workup showed a uT1m versus T1sm N0 M0 lesion. The procedure was performed with a new reusable transanal platform and a monocurved coagulating hook and grasping forceps. The operative time was 90 minutes. No perioperative complications were registered, and the patient was discharged on postoperative day 1. The pathologic report showed a villotubular adenoma with high-grade dysplasia and distant-free margins. After 1 year, the patient was going well, without any recurrent disease. Transanal minimally invasive surgery resection is a good alternative to conventional endoscopic therapies, allowing a meticulous dissection under the magnified operative field's exposure, and a mucosal-submucosal flap closure under satisfactory surgeon's ergonomics.
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30
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Rex DK, Hassan C, Bourke MJ. The colonoscopist's guide to the vocabulary of colorectal neoplasia: histology, morphology, and management. Gastrointest Endosc 2017; 86:253-263. [PMID: 28396276 DOI: 10.1016/j.gie.2017.03.1546] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/29/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
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31
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Emmanuel A, Gulati S, Burt M, Hayee B, Haji A. Colorectal endoscopic submucosal dissection: patient selection and special considerations. Clin Exp Gastroenterol 2017; 10:121-131. [PMID: 28761366 PMCID: PMC5516776 DOI: 10.2147/ceg.s120395] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered.
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Affiliation(s)
- Andrew Emmanuel
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Shraddha Gulati
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Margaret Burt
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Bu'Hussain Hayee
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Amyn Haji
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
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Training and competency in endoscopic mucosal resection. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Fuccio L, Hassan C, Ponchon T, Mandolesi D, Farioli A, Cucchetti A, Frazzoni L, Bhandari P, Bellisario C, Bazzoli F, Repici A. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86:74-86.e17. [PMID: 28254526 DOI: 10.1016/j.gie.2017.02.024] [Citation(s) in RCA: 201] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 02/16/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is an endoscopic resection technique for lesions suspicious of superficial malignancy. It is performed using an ESD knife on its own (standard technique) or by the sequential use of a knife and a snare (hybrid technique). The experience with these techniques is different in Asian and non-Asian countries. We performed a systematic review and meta-analysis of available evidence on colorectal ESD. METHODS Electronic databases were searched up to August 2016 for studies evaluating R0, en bloc resection, and adverse event rates of both techniques for the treatment of colorectal lesions. Proportions were pooled by a random effects model. RESULTS Ninety-seven studies (71 performed in Asia) evaluated the standard technique and 12 studies (7 in Asia) the hybrid technique. The R0 resection rate of the standard technique was 82.9%, and it was significantly lower in non-Asian versus Asian countries: 71.3% versus 85.6%. The en bloc resection rate was 91% and was significantly lower in non-Asian versus Asian countries (81.2% vs 93%, respectively). Surgery was needed in 1.1% of the ESD-related adverse events, with a significant difference between non-Asian and Asian countries (3.1% vs 0.8%). The R0 and en bloc resection rates with the hybrid technique were significantly lower than those achieved with the standard technique: 60.6% and 68.4%, respectively, with similar adverse event rates. CONCLUSIONS In non-Asian countries the standard ESD technique is still failing to achieve acceptable levels of performance. The hybrid technique showed low R0 resection rates and should not be considered as an adequate alternative to the standard technique.
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Affiliation(s)
- Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Thierry Ponchon
- Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Daniele Mandolesi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology (CPO), University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research and University Hospital, Rozzano (MI), Italy
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Shiga H, Ohba R, Matsuhashi T, Jin M, Kuroha M, Endo K, Moroi R, Kayaba S, Iijima K. Feasibility of colorectal endoscopic submucosal dissection (ESD) carried out by endoscopists with no or little experience in gastric ESD. Dig Endosc 2017; 29 Suppl 2:58-65. [PMID: 28425662 DOI: 10.1111/den.12814] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 01/16/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Colorectal endoscopic submucosal dissection (ESD) is recommended to be carried out only by endoscopists with sufficient experience in gastric ESD. However, early gastric carcinoma is less common in Western countries than in Japan, and endoscopic maneuverability differs between the stomach and colorectum. We assessed the feasibility of colorectal ESD carried out by endoscopists with no or little experience in gastric ESD. METHODS We analyzed en bloc resection, R0 resection and perforation rates in 180 consecutive colorectal ESD carried out by three endoscopists who had no or <5 cases of experience in gastric ESD. We also identified factors associated with R0 resection failure. RESULTS Overall en bloc and R0 resection rates were 93.3% (168/180) and 82.2% (148/180), respectively. All 11 cases with perforation were treated endoscopically. Dividing 180 cases into three learning phases (early, middle, or late phases), the en bloc and R0 resection rates increased from 88.3% and 75.0% in the early phase to 98.3% and 88.3% in the late phase, respectively. Perforation rate also improved from 10.0% to 3.3%. Factors associated with R0 resection failure were location at junctions (odds ratio: 6.8, 95% CI: 1.9-27.5), preoperative factors reflecting fibrosis (5.8, 1.9-19.0), and late phase (0.2, 0.1-0.7). CONCLUSION Endoscopists without experience in gastric ESD carried out colorectal ESD safely. In the early and middle phases (≤40 cases), they should treat mainly rectal lesions but may also resect lesions in the colon avoiding flexures. Lesions located at junctions and those with preoperative factors reflecting fibrosis should be resected after completing 40 procedures.
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Affiliation(s)
- Hisashi Shiga
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Reina Ohba
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Mario Jin
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Masatake Kuroha
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Katsuya Endo
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rintaro Moroi
- Department of Gastroenterology, Iwate Prefectural Isawa Hospital, Oshu, Japan
| | - Shoichi Kayaba
- Department of Gastroenterology, Iwate Prefectural Isawa Hospital, Oshu, Japan
| | - Katsunori Iijima
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
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Imai K, Hotta K, Yamaguchi Y, Ito S, Ono H. Endoscopic submucosal dissection for large colorectal neoplasms. Dig Endosc 2017; 29 Suppl 2:53-57. [PMID: 28425660 DOI: 10.1111/den.12850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD) for colorectal neoplasms (CRN) of >50 mm is considered technically difficult. The ITknife nano™ was developed specifically for ESD of CRN and esophageal superficial neoplasms; however, only limited data are available regarding its use in this procedure. Here we assessed the safety and efficacy of ESD using the ITknife nano™ for large CRN (>50 mm). METHODS We carried out a retrospective study, including consecutive patients with CRN larger than 50 mm that were treated by ESD between September 2002 and August 2016 at our institution. To clarify features of the ITknife nano™ and to assess its safety and efficacy, we compared en bloc/curative resection rates, complications, and resection speed between ESD done using the Dual knife™ with and without the ITknife nano™. RESULTS We analyzed a total of 177 ESD-treated large CRN (median tumor size, 61 mm). Among the 133 CRN treated by ESD using the ITknife nano™, en bloc and curative resection rates were 96.2% and 80.5%, respectively. Perforation occurred in eight cases (6.0%) and delayed bleeding in four cases (3.0%). All complications were endoscopically managed. Resection speed was significantly faster for ESD using the ITknife nano™ (25.3 mm2 /min) compared to using the Dual knife™ only (19.9 mm2 /min; P = 0.02). CONCLUSIONS Use of the ITknife nano™ for ESD treatment of large CRN (>50 mm) is feasible and may contribute to reduced procedure times. Further controlled studies are needed to confirm these findings.
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Rex DK, Hassan C, Dewitt JM. Colorectal endoscopic submucosal dissection in the United States: Why do we hear so much about it and do so little of it? Gastrointest Endosc 2017; 85:554-558. [PMID: 28215767 DOI: 10.1016/j.gie.2016.09.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - John M Dewitt
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
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Abstract
OPINION STATEMENT Polypectomy reduces the incidence and mortality of colorectal cancer (CRC). The widespread adoption of CRC screening, more rigorous colonoscopy techniques, and advancements in endoscopic imaging have led to a greater awareness of complex polyps. Whereas surgery was once considered necessary for many large sessile or laterally spreading lesions (LSLs) in the colorectum, the majority can now be removed endoscopically. Endoscopic mucosal resection (EMR) is an established technique for treatment of colorectal LSLs. When performed by experts, EMR is highly effective and safe and can be completed in an outpatient or day-stay setting. Advancements in EMR effectiveness encompass a better understanding of the factors leading to post-EMR recurrence, protocols to recognize and treat it, and interventions that prevent recurrent or residual adenoma. New techniques for treating intra-procedural bleeding and a novel classification system to identify and inform proactive management of deep mural injury enhance the safety profile of EMR. However, each of these incremental advancements necessitates a meticulous and systematic approach that only committed and properly trained endoscopists can master. While alternative interventions such as endoscopic submucosal dissection (ESD) offer potential advantages over EMR, the added procedural complexity, risks, and costs limit the relevance of ESD to a minority of lesions in the colorectum. This article reviews the expanding body of evidence supporting EMR as the first-line treatment of colorectal LSLs ≥20 mm.
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Affiliation(s)
- Steven J Heitman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, c/-Suite 106a, 151-155 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, c/-Suite 106a, 151-155 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia.
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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Plumé Gimeno G, Bustamante-Balén M, Satorres Paniagua C, Díaz Jaime FC, Cejalvo Andújar MJ. Endoscopic resection of colorectal polyps in patients on antiplatelet therapy: an evidence-based guidance for clinicians. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:49-59. [PMID: 27809553 DOI: 10.17235/reed.2016.4114/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Due to the rising prevalence of coronary heart disease, endoscopists are more frequently performing a polypectomy in patients on antiplatelet therapy (APT) and dual antiplatelet therapy (DATP). Despite the availability of several guidelines with regard to the management of antiplatelet drugs during the periprocedure period, there is still variability in the current clinical practice. This may be influenced by the low quality of the evidence supporting recommendations, because most of the studies dealing with APT and polypectomy are observational and retrospective, and include mainly small (< 10 mm) polyps. However, some recommendations can still be made. An estimation of the bleeding and thrombotic risk of the patient should be made in advance. In the case of DAPT the procedure should be postponed, at least until clopidogrel can be safely withheld. If possible, non-aspirin antiplatelet drugs should be withheld 5-7 days before the procedure. Polyp size is the main factor related with post-polypectomy bleeding and it is the factor that should drive clinical decisions regarding the resection method and the use of endoscopic prophylactic measures. Non-aspirin antiplatelet agents can be reintroduced 24-48 hours after the procedure. In conclusion, there is little data with regard to the management of DAPT in patients with a scheduled polypectomy. Large randomized controlled trials are needed to support clinical recommendations.
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Jacques J, Legros R, Charissoux A, Mesturoux L, Couquet CY, Carrier P, Tabouret T, Valgueblasse V, Debette-Gratien M, Le-Sidaner A, Loustaud-Ratti V, Sautereau D. A local structured training program with live pigs allows performing ESD along the gastrointestinal tract with results close to those of Japanese experts. Dig Liver Dis 2016; 48:1457-1462. [PMID: 27590842 DOI: 10.1016/j.dld.2016.08.111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 06/12/2016] [Accepted: 08/08/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The high specific skill needed by ESD limit its widespread use in Europe and animal training is recommended in Europe to improve the results of ESD that are far from Japanese at present. We create a local training program using live pigs as models, along with our human cases, to provide continuous exposure to the technique. METHODS Between February 2013 and December 2015, two young operators performed 55 pig gastric ESDs in parallel with 62 human cases for large superficial cancerous lesions. The number and training dates of pig cases were adapted to those of the human cases to achieve continuous exposure to ESD cases. RESULTS The en bloc, R0, and curative resection rates were 100%, 85.5% (53/62), and 77.5% (48/62), respectively with no recurrence observed during the one year follow up. There was no statistically significant difference in terms of the R0 or curative resection rates among ESDs performed during 2013-2015 (R0: 80% vs. 86.6% vs. 86.4%; Curative: 80% vs. 86.6% vs. 73%). CONCLUSION A local structured training program using live pig models was used to train endoscopists for ESD in humans with high safety and efficiency, similar to results published by Japanese experts.
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Affiliation(s)
- Jérémie Jacques
- Hepato-Gastro-Enterology Department, University Hospital, Limoges, France.
| | - Romain Legros
- Hepato-Gastro-Enterology Department, University Hospital, Limoges, France.
| | | | | | | | - Paul Carrier
- Hepato-Gastro-Enterology Department, University Hospital, Limoges, France.
| | - Tessa Tabouret
- Hepato-Gastro-Enterology Department, University Hospital, Limoges, France.
| | | | | | - Anne Le-Sidaner
- Hepato-Gastro-Enterology Department, University Hospital, Limoges, France.
| | | | - Denis Sautereau
- Hepato-Gastro-Enterology Department, University Hospital, Limoges, France.
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Rees CJ, Bevan R, Zimmermann-Fraedrich K, Rutter MD, Rex D, Dekker E, Ponchon T, Bretthauer M, Regula J, Saunders B, Hassan C, Bourke MJ, Rösch T. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut 2016; 65:2045-2060. [PMID: 27802153 PMCID: PMC5136701 DOI: 10.1136/gutjnl-2016-312043] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 09/08/2016] [Accepted: 09/11/2016] [Indexed: 12/12/2022]
Abstract
Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.
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Affiliation(s)
- Colin J Rees
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, UK
| | - Roisin Bevan
- Department of Gastroenterology, North Tees University Hospital, Stockton-on-Tees, UK
| | | | - Matthew D Rutter
- Department of Gastroenterology, North Tees University Hospital, Stockton-on-Tees, UK
| | - Douglas Rex
- Department of Gastroenterology, Indiana University, Indianapolis, USA
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Thierry Ponchon
- Department of Gastroenterology and Hepatology, Edouard Herriot Hospital, Lyon University, Lyon, France
| | - Michael Bretthauer
- Department of Health Management and Health Economics and KG Jebsen Center for Colorectal Cancer Research, University of Oslo, Oslo, Norway
| | - Jaroslaw Regula
- Department of Gastroenterology, Medical Center for Postgraduate Education and the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Brian Saunders
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Akintoye E, Kumar N, Aihara H, Nas H, Thompson CC. Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis. Endosc Int Open 2016; 4:E1030-E1044. [PMID: 27747275 PMCID: PMC5063641 DOI: 10.1055/s-0042-114774] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/29/2016] [Indexed: 02/07/2023] Open
Abstract
Background and study aims: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows en-bloc resection of gastrointestinal tumor. We systematically review the medical literature in order to evaluate the safety and efficacy of colorectal ESD. Patients and methods: We performed a comprehensive literature search of MEDLINE, EMBASE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of colorectal ESD. Results: Included in this study were 13833 tumors in 13603 patients (42 % female) who underwent colorectal ESD between 1998 and 2014. The R0 resection rate was 83 % (95 % CI, 80 - 86 %) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in continent (P = 0.004), study design (P = 0.04), duration of the procedure (P = 0.009), and, marginally, by average tumor size (P = 0.09). Endoscopic en bloc and curative resection rates were 92 % (95 % CI, 90 - 94 %) and 86 % (95 % CI, 80 - 90 %), respectively. The rates of immediate and delayed perforation were 4.2 % (95 % CI, 3.5 - 5.0 %) and 0.22 % (95 % CI, 0.11 - 0.46 %), respectively, while rates of immediate and delayed major bleeding were 0.75 % (95 % CI, 0.31 - 1.8 %) and 2.1 % (95 % CI, 1.6 - 2.6 %). After an average postoperative follow up of 19 months, the rate of tumor recurrence was 0.04 % (95 % CI, 0.01 - 0.31) among those with R0 resection and 3.6 % (95 % CI, 1.4 - 8.8 %) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 1.0 % (95 % CI, 0.42 - 2.1 %). Conclusions: Our meta-analysis, the largest and most comprehensive assessment of colorectal ESD to date, showed that colorectal ESD is safe and effective for colorectal tumors and warrants consideration as first-line therapy when an expert operator is available.
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Affiliation(s)
- Emmanuel Akintoye
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Nitin Kumar
- Developmental Endoscopy Lab, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Hiroyuki Aihara
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Hala Nas
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Christopher C. Thompson
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Massachusetts, United States
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Abstract
Appropriate endoscopic resection for colorectal polyps can present a challenge to endoscopists, as these lesions may harbor malignancy. With recent advances in endoscopy, however, we are now entering an exciting frontier of endoscopic therapy for gastrointestinal lesions. These techniques include endoluminal mucosal resection and endoscopic submucosal dissection, which may be utilized on several colonic lesions. This article will discuss these principle endoscopic techniques, their outcomes, and briefly highlight their influence on endoscopic interventions, including transanal endoscopic microsurgery and natural orifice transluminal endoscopic surgery.
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Affiliation(s)
- Katherine A Kelley
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - V Liana Tsikitis
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
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De Ceglie A, Hassan C, Mangiavillano B, Matsuda T, Saito Y, Ridola L, Bhandari P, Boeri F, Conio M. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review. Crit Rev Oncol Hematol 2016; 104:138-55. [PMID: 27370173 DOI: 10.1016/j.critrevonc.2016.06.008] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/23/2016] [Accepted: 06/14/2016] [Indexed: 12/12/2022] Open
Abstract
AIM To assess the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for the treatment of colorectal lesions. METHODS A literature search was conducted from January 2000 to May 2015. The main outcomes were: recurrence after "en bloc" and "piecemeal" resection; procedure related adverse events; the EMR endoscopic success rate and the completely eradicated resection rate (R0) after ESD. RESULTS A total of 66 studies were included in the analysis. The total number of lesions was 17950 (EMR: 11.873; ESD: 6077). Recurrence rate was higher in the EMR than ESD group (765/7303l vs. 50/3910 OR 8.19, 95% CI 6.2-10.9 p<0.0001). EMR-en bloc resection was achieved in 6793/10803 lesions (62.8%) while ESD-en bloc resection was obtained in 5500/6077 lesions (90.5%) (OR 0.18, p<0.0001, 95% CI 0.16-0.2). Perforation occurred more frequently in ESD than in EMR group (p<0.0001, OR 0.19, 95% CI 0.15-0.24). CONCLUSIONS Endoscopic resection of large colorectal lesions is safe and effective. Compared with EMR, ESD results in higher "en bloc" resection rate and lower local recurrence rate, however ESD has high procedure-related complication rates.
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Affiliation(s)
| | - Cesare Hassan
- Gastroenterology Department, Nuovo Regina Margherita Hospital, Rome, Italy
| | | | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Lorenzo Ridola
- Gastroenterology Unit, "Sapienza" University, Rome, Italy
| | - Pradeep Bhandari
- Gastroenterology Department, Portsmouth Hospital NHS Trust, Portsmouth, Hampshire, UK
| | - Federica Boeri
- Gastroenterology Department, General Hospital, Sanremo, Italy
| | - Massimo Conio
- Gastroenterology Department, General Hospital, Sanremo, Italy.
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Sauer M, Hildenbrand R, Oyama T, Sido B, Yahagi N, Dumoulin FL. Endoscopic submucosal dissection for flat or sessile colorectal neoplasia > 20 mm: A European single-center series of 182 cases. Endosc Int Open 2016; 4:E895-900. [PMID: 27540580 PMCID: PMC4988858 DOI: 10.1055/s-0042-111204] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 06/13/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Colorectal endoscopic submucosal dissection (ESD) is an attractive method for en bloc resection of larger flat neoplastic lesions. Experience with this method is limited in the Western World. PATIENTS AND METHODS A total of 182 consecutive flat or sessile colorectal lesions (cecum n = 43; right-sided colon n = 65; left-sided colon n = 11, rectum: n = 63) with a size > 20 mm (mean 41.0 ± 17.4 mm) were resected in 178 patients. The data were recorded prospectively. RESULTS ESD was technically feasible in 85.2 % of patients with a mean procedure time of 127.5 min (± 99.8) min and a complication rate of 11.5 % (microperforation 9.3 %, delayed bleeding 2.7 %, no case of emergency surgery, 30-day mortality rate 0 %). For 155 successfully completed procedures the en bloc and R0 resection rates were 88.4 and 62.6 %. Efficacy was better for smaller lesions (20 mm to 49 mm; n = 131) than for larger lesions (50 mm to 140 mm; n = 51) with R0 rates of 70.8 vs. 40.5 % (P < 0.001) and procedure times of 92.7 ± 62.4 minutes vs. 217.0 ± 120.9 minutes (P < 0,001). CONCLUSIONS This series confirms the efficacy of ESD for en bloc resection of colorectal lesions > 20 mm. RESULTS are satisfactory for lesions up to 50 mm. ESD for larger lesions was associated with low R0 resection rates and very long procedure times. The clinical consequences of microperforations were minor and do not argue against the spread of ESD in the West. Meeting presentations: The data were presented in part at DDW 2014, Chicago IL, USA (Gastrointest Endosc 2014; 79: AB536).
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Affiliation(s)
- Malte Sauer
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | | | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Bernd Sido
- Department of General and Abdominal Surgery, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany ,Corresponding author Franz Ludwig Dumoulin, MD, PhD Department of Medicine and GastroenterologyGemeinschaftskrankenhaus BonnBonner Talweg 4-6D-53113 BonnGermany+49-228-508-1561+49-228-508-1562
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Barret M, Lepilliez V, Coumaros D, Chaussade S, Leblanc S, Ponchon T, Fumex F, Chabrun E, Bauret P, Cellier C, Coron E, Bichard P, Bulois P, Charachon A, Rahmi G, Bellon S, Lerhun M, Arpurt JP, Koch S, Napoleon B, Vaillant E, Esch A, Farhat S, Robin F, Kaddour N, Prat F. The expansion of endoscopic submucosal dissection in France: A prospective nationwide survey. United European Gastroenterol J 2016; 5:45-53. [PMID: 28405321 DOI: 10.1177/2050640616644392] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/20/2016] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Early reports of endoscopic submucosal dissection (ESD) in Europe suggested high complication rates and disappointing outcomes compared to publications from Japan. Since 2008, we have been conducting a nationwide survey to monitor the outcomes and complications of ESD over time. MATERIAL AND METHODS All consecutive ESD cases from 14 centers in France were prospectively included in the database. Demographic, procedural, outcome and follow-up data were recorded. The results obtained over three years were compared to previously published data covering the 2008-2010 period. RESULTS Between November 2010 and June 2013, 319 ESD cases performed in 314 patients (62% male, mean (±SD) age 65.4 ± 12) were analyzed and compared to 188 ESD cases in 188 patients (61% male, mean (±SD) age 64.6 ± 13) performed between January 2008 and October 2010. The mean (±SD) lesion size was 39 ± 12 mm in 2010-2013 vs 32.1 ± 21 for 2008-2010 (p = 0.004). En bloc resection improved from 77.1% to 91.7% (p < 0.0001) while R0 en bloc resection remained stable from 72.9% to 71.9% (p = 0.8) over time. Complication rate dropped from 29.2% between 2008 and 2010 to 14.1% between 2010 and 2013 (p < 0.0001), with bleeding decreasing from 11.2% to 4.7% (p = 0.01) and perforations from 18.1% to 8.1% (p = 0.002) over time. No procedure-related mortality was recorded. CONCLUSIONS In this multicenter study, ESD achieved high rates of en bloc resection with a significant trend toward better outcomes over time. Improvements in lesion delineation and characterization are still needed to increase R0 resection rates.
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Affiliation(s)
- Maximilien Barret
- Cochin Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Vincent Lepilliez
- Edouard Herriot Hospital, Lyon, France; Jean Mermoz Hospital, Lyon, France
| | | | | | - Sarah Leblanc
- Cochin Hospital, Paris, France; Paris Descartes University, Paris, France
| | | | | | | | | | | | | | | | | | - Antoine Charachon
- Henri Mondor Hospital, Creteil, France, and Princess Grace Hospital, Monaco
| | | | | | | | | | | | | | | | - Anouk Esch
- Cochin Hospital, Paris, France; Paris Descartes University, Paris, France
| | | | | | | | - Frédéric Prat
- Cochin Hospital, Paris, France; Paris Descartes University, Paris, France
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Rolny P. The need for supplementary surgery after endoscopic treatment of colorectal neoplasms: comparing endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 2016; 83:1299. [PMID: 27206590 DOI: 10.1016/j.gie.2015.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/02/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Peter Rolny
- Division for Gastroenterology/Hepatology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Backes Y, Moons LMG, van Bergeijk JD, Berk L, Ter Borg F, Ter Borg PCJ, Elias SG, Geesing JMJ, Groen JN, Hadithi M, Hardwick JCH, Kerkhof M, Mangen MJJ, Straathof JWA, Schröder R, Schwartz MP, Spanier BWM, de Vos Tot Nederveen Cappel WH, Wolfhagen FHJ, Koch AD. Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial. BMC Gastroenterol 2016; 16:56. [PMID: 27229709 PMCID: PMC4882830 DOI: 10.1186/s12876-016-0468-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/14/2016] [Indexed: 02/08/2023] Open
Abstract
Background Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness of ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the short-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the long-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with less need for repeated procedures. Methods This is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than 20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic assessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints are R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical referral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated taking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying used healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional costs per QALY. Discussion If this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and repeated procedures can be prevented for future patients. Trial registration NCT02657044 (Clinicaltrials.gov), registered January 8, 2016.
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Affiliation(s)
- Y Backes
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3508, GA, Utrecht, Netherlands
| | - L M G Moons
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3508, GA, Utrecht, Netherlands.
| | - J D van Bergeijk
- Department of Gastroenterology & Hepatology, Gelderse Vallei, Ede, Netherlands
| | - L Berk
- Department of Gastroenterology & Hepatology, Sint Franciscus, Rotterdam, Netherlands
| | - F Ter Borg
- Department of Gastroenterology & Hepatology, Deventer Hospital, Deventer, Netherlands
| | - P C J Ter Borg
- Department of Gastroenterology & Hepatology, Ikazia, Rotterdam, Netherlands
| | - S G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - J M J Geesing
- Department of Gastroenterology & Hepatology, Diakonessenhuis, Utrecht, Netherlands
| | - J N Groen
- Department of Gastroenterology & Hepatology, Sint Jansdal, Harderwijk, Netherlands
| | - M Hadithi
- Department of Gastroenterology & Hepatology, Maasstad hospital, Rotterdam, Netherlands
| | - J C H Hardwick
- Department of Gastroenterology & Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - M Kerkhof
- Department of Gastroenterology & Hepatology, Groene Hart Hospital, Gouda, Netherlands
| | - M J J Mangen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - J W A Straathof
- Department of Gastroenterology & Hepatology, Máxima Medical Center, Eindhoven, Netherlands
| | - R Schröder
- Department of Gastroenterology & Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - M P Schwartz
- Department of Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - B W M Spanier
- Department of Gastroenterology & Hepatology, Rijnstate hospital, Arnhem, Netherlands
| | | | - F H J Wolfhagen
- Department of Gastroenterology & Hepatology, Albert Schweitzer, Dordrecht, Netherlands
| | - A D Koch
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
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Abstract
Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques now exist for the resection of polyps, and the endoscopist must decide on the appropriate resection approach for individual patients and lesions. This decision should maximize efficacy, safety and cost-effectiveness and provide optimal oncological outcomes while minimizing unnecessary surgical treatment. Advances in endoscopic imaging technology are improving the accuracy of endoscopic diagnosis and allowing more precise risk assessment of colonic lesions. Resection technique can be tailored to the endoscopic findings. Diminutive (≤5 mm) and small polyps (≤9 mm) are best resected primarily by snare techniques. Cold snare polypectomy has proven safety, but efficacy and technique require further study. There is variation in techniques used for polyps 6-20 mm in size and incomplete resection rates for conventional polypectomy may be considerable. Endoscopic mucosal resection (EMR) is well established, safe and effective for lesions without submucosal invasion (SMI); however, recurrence is a key limitation. Endoscopic submucosal dissection (ESD) is well established in the East; however, it is resource intensive and its role in lesions with a low risk of SMI is questionable. ESD in the West remains incompletely defined and is associated with high adverse event rates, but it is becoming increasingly available and successful as experience grows. Emerging full-thickness resection technologies are still in their infancy and remain experimental as a result of the absence of reliable closure devices and techniques. Patient-focused outcomes should guide technique selection.
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Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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50
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Cao L, Li Q, Zhang C, Wu H, Yao L, Xu M, Yu L, Ding J. Safe and Efficient Colonic Endoscopic Submucosal Dissection Using an Injectable Hydrogel. ACS Biomater Sci Eng 2016; 2:393-402. [PMID: 33429543 DOI: 10.1021/acsbiomaterials.5b00516] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic submucosal dissection (ESD) has not yet been widely adopted in the treatment of early colonic cancers due to the greater technical difficulty involved, longer procedure time, and the increased risk of perforation. Adequate mucosal elevation by submucosal injection is crucial for en bloc resection and prevention of perforation during colonic ESD. This study is aimed to evaluate the efficacy of an injectable thermoreversible hydrogel as the colonic submucosal agent for the first time. Triblock copolymer poly(lactic acid-co-glycolic acid)-poly(ethylene glycol)-poly(lactic acid-co-glycolic acid) (PLGA-PEG-PLGA) was synthesized, and its concentrated aqueous solution was injected into the colonic submucosa of living minipig and spontaneously transformed into an in situ hydrogel with adequate mucosal elevation at body temperature. Such a mucosal lifting lasted for a longer time than that created by the control group, glycerol fructose. Colonic ESD was then performed with the administration of hydrogels at various polymer concentrations or glycerol fructose. All colonic lesions were successfully resected en bloc after one single injection of the hydrogel, and repeated injections were not needed. No evidence of major hemorrhage, perforation and tissue damage were observed. Considering the injection pressure, duration of mucosal elevation and efficacy of "autodissection", the hydrogel containing 15 wt % polymer was the optimized system for colonic ESD. Consequently, the thermoreversible hydrogel is an ideal submucosal fluid that provides a durable mucosal lifting and makes colonic ESD accessible to a large extent. In particular, the efficacy of "autodissection" after one single injection of the hydrogel simplifies significantly the procedures while minimizing the complications.
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Affiliation(s)
- Luping Cao
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
| | - Quanlin Li
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China.,Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chen Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Haocheng Wu
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
| | - Liqing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Meidong Xu
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China.,Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lin Yu
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
| | - Jiandong Ding
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
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