The multi-loop traction device (MLTD) facilitates optimal visualization of the submucosa throughout endoscopic submucosal dissection (ESD). This trial aimed to assess the efficacy of MLTD for colorectal ESD.

We conducted a multicenter, open-label, randomized controlled trial involving patients with colorectal lesions ≥ 20 mm suspicious for noninvasive carcinoma. Participants were randomly assigned in a 1:1 ratio to undergo ESD with MLTD (MLTD-ESD group) or ESD without any traction device (control group). Endoscopists were allowed to convert treatments if dissection became challenging for 10 minutes. The primary endpoint was dissection speed; secondary endpoints included technical success rate and adverse events (AEs).

A total of 108 participants were randomized to the MLTD-ESD group (n = 53) and the control group (n = 55). There was no statistically significant difference in median dissection speed between the MLTD-ESD group and the control group (14.8 mm 2 /min; interquartile range [IQR] 8.9-23.9 mm 2 /min vs. 13.3 mm 2 /min; IQR 8.9-18.8 mm 2 /min) ( P = 0.33). The technical success rate was significantly higher in the MLTD-ESD group (96.2%) compared with the control group (71.0%) ( P < 0.0001). All technical failures were due to treatment conversions. No significant difference was observed in AEs. Subgroup analysis revealed that experts in the MLTD-ESD group had faster dissection speed than controls (21.6 mm2/min; IQR 15.5-28.8 mm 2 /min vs. 14.4 mm 2 /min; IQR 9.9-21.2 mm 2 /min) ( P = 0.009).

This multicenter randomized trial demonstrated that use of MLTD did not significantly increase dissection speed for colorectal ESD. Treatment conversions may have influenced the primary endpoint, and further investigation is warranted.

We aimed to identify independent factors for intraoperative endoscopic lens cloudiness during gastric and colorectal endoscopic submucosal dissections, investigate the effectiveness of Cleastay, an endoscope anti-fog solution, and examine factors associated with severe submucosal fat deposition.

A total of 220 patients who underwent gastric or colorectal endoscopic submucosal dissections in two institutions between January 2022 and October 2023 were included. Significant factors related to cloudiness were determined using univariate and multivariate analyses. Patient background and tumor characteristics related to severe submucosal fat deposition were investigated, and the degree of intraoperative endoscopic lens cloudiness and outcomes were compared between the Cleash and Cleastay groups.

In the multivariate analysis, factors increasing lens cloudiness included long procedure time (odds ratio [OR], 17.51; 95% confidence interval [CI], 1.52-202.08), stomach (vs. colon; OR, 5.08; 95% CI, 1.99-12.96), and severe submucosal fat deposition (OR, 12.19; 95% CI, 5.02-29.60). Conversely, the use of Cleastay (vs. Cleash; OR, 0.066; 95% CI, 0.021-0.21) was identified as a factor reducing cloudiness. Location analysis revealed that severe submucosal fat deposition was more common in the upper stomach and right colon.

It was suggested that Cleastay is more useful for endoscopic submucosal dissection of the upper stomach and right colon, where severe submucosal fat deposition is expected.

Colorectal endoscopic submucosal dissection (ESD) has become a standard treatment for superficial colorectal neoplasms worldwide. However, challenges remain in achieving dissection at the precise layer. In this study, we evaluated the effectiveness of a novel ESD technique involving natural traction, referred to as the bridge formation method (BFM).

The two main features of the BFM are creating a large mucosal flap and leaving normal mucosa on both sides of the lesion until the bridge is made at the end of the procedure. This retrospective study included consecutive patients with 2647 colorectal lesions resected by ESD from September 2003 to December 2023. We divided them into the BFM group and the non-BFM group and conducted propensity score matching.After propensity score matching, 1648 cases were enrolled (824 cases in each group). The en bloc resection rate was significantly higher in the BFM than non-BFM group (99.6% vs. 96.7%, p < 0.01). The R0 resection rate and the average dissection speed (㎟/min) were significantly higher in the BFM than non-BFM group (98.8% vs. 96.4%, p < 0.01, and 18.9 vs. 18.0, p = 0.03). The occurrence rates of perforation and delayed bleeding showed no significant difference between the non-BFM and BFM groups (2.8% vs. 3.6%, p = 0.40, and 1.1% vs. 1.0%, p = 1.00).

The BFM is a suitable method for colorectal ESD as it enables rapid dissection and improves both en bloc resection and R0 resection rates.

A relationship between endoscopic submucosal dissection (ESD) and deep vein thrombosis has been recognized. We previously reported that a high corrected midazolam dose (total midazolam dose/initial dose of midazolam used to induce sedation) is related to elevated D-dimer levels after ESD. In this study, the effect of compression stockings (CSs) in preventing thrombosis following ESD under sedation was evaluated by measuring D-dimer levels before and after ESD.

The participants were patients who underwent ESD for upper gastrointestinal tumors during the period between April 2018 and October 2022. Patients with pre-ESD D-dimer levels ≥1.6 µg/m and patients with corrected midazolam doses ≤3.0 were excluded. A retrospective investigation of the relationship between CS use and high post-ESD D-dimer levels (difference in D-dimer levels ≥1.0 µg/mL between before and after ESD) was conducted.

There were 27 patients in the non-CS group (NCS) and 33 patients in the CS group. The number of patients with high post-ESD D-dimer levels was 13 (48.2%) in the non-CS group and six (18.2%) in the CS group; the number in the CS group was significantly lower (p = 0.024). On logistic regression analysis, a relationship was seen between the wearing of CSs and a lower number of patients with high post-ESD D-dimer levels (odds ratio 0.24, 95% confidence interval 0.08-0.79, p = 0.019).

Wearing CSs was related to a lower risk of high post-ESD D-dimer levels. This result suggests that thrombus formation is a cause of elevated D-dimer levels after ESD.

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.

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.

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).

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.

Thermal damage may lead to inflammation of the peeled mucosal surface during endoscopic submucosal dissection (ESD).

To determine the effect of Joule heat on the onset of post-ESD electrocoagulation syndrome (PECS).

In this prospective study, PECS was characterized by in-hospital fever (white blood cell count: ≥ 10000 μ/L or body temperature ≥ 37.5 °C) and abdominal pain (visual analog scale score ≥ 30 mm during hospitalization or increased by ≥ 20 mm from baseline at admission). High Joule heat was defined as 15390 J. Between April 2020 and April 2024, 209 patients underwent colorectal ESD; those with intraoperative perforation or penetration were excluded. The remaining 202 patients were divided into the PECS and non-PECS groups.

PECS occurred in 30 (14.9%) patients. Multivariate analysis revealed high Joule heat as an independent factor associated with PECS (odds ratio = 7.96; 95% confidence interval: 2.91-21.8, P < 0.01). The procedure time and presence of lesions in the right colon were not associated with PECS.

Accumulated thermal damage on the peeled mucosal surface should be considered during PECS onset. This thermal damage is likely a major component of the mechanism underlying PECS.

The aim of this study is to establish a nomogram that can predict the risk factors for delayed bleeding after endoscopic submucosal dissection (ESD). This model can be used to assess the probability of delayed bleeding before ESD surgery, thereby avoiding wasting medical resources and improving patient satisfaction.

This was a retrospective study in which all patients underwent ESD surgery for colorectal tumors between August 2021 and February 2024. Patient demographics and surgical characteristics were collected. All patients were randomly divided into a training set and a testing set. Univariate and multivariate regression analyses of the training set revealed the independent risk factors for delayed bleeding after ESD. These independent risk factors were used to construct a nomogram model. This model was validated using internal validation methods such as the C-index, calibration curve, and decision curve analysis.

This study included 587 patients. The occurrence rate of delayed bleeding after ESD in the training set was 8.98%. Multivariate regression analysis revealed that the location of the lesion in the rectum, a large lesion, and a prolonged surgery time were independent risk factors for delayed bleeding after ESD. The C-index for this model was 0.89, and validation of this nomogram model demonstrated good consistency between the predicted and actual values.

Multivariate regression analysis revealed the independent risk factors for delayed bleeding after ESD, and a nomogram with a relatively consistent accuracy was established. The clinical application of this model can reduce the incidence of delayed bleeding and therefore improve patient healing.

Hybrid endoscopic submucosal dissection (H-ESD), which utilizes ESD knife along with snare-based resection, has been developed to overcome the technical complexity of conventional ESD (C-ESD). The aim of this study was to compare the therapeutic outcomes of H-ESD vs C-ESD for nonpedunculated colorectal lesions ≥20 mm in size.

We conducted a multicenter randomized controlled trial to compare H-ESD and C-ESD (Short-ESD trial). Patients with colorectal lesions between 20 and 50 mm in size were randomly assigned (1:1) to H-ESD or C-ESD. Primary outcome was procedure time/speed. Secondary outcomes were en bloc and complete (R0) resection rates and adverse event rates.

A total of 89 patients (median age 63 years; 49.3% women) with the median polyp size of 30 mm underwent H-ESD (n = 40) and C-ESD (n = 49). The mean procedure time of H-ESD was significantly shorter than that of C-ESD (41.1 ± 16.3 vs 54.3 ± 28.2 minutes; P = 0.007). The en bloc and R0 resection rates trended lower in the H-ESD vs C-ESD groups (77.5% vs 87.8%; P = 0.26% and 72.5% vs 79.6%; P = 0.46) without reaching statistical significance. Adverse event rate was similar between H-ESD and C-ESD (10% vs 8.2%; P = 1.00).

Both H-ESD and C-ESD were safe and effective for resection of large colorectal lesions. H-ESD was associated with a shorter procedure time. H-ESD may represent a viable alternative to C-ESD, with the main advantage being easy applicability of a snare-based technique for colorectal lesions. Future studies are needed to further define the most suitable lesions for H-ESD, as to optimize efficiency and safety without compromising resection outcomes. ClinicaTrials.gov NCT NCT05347446.

Endoscopic submucosal dissection (ESD) is considered the best modality for achieving en bloc resection of larger neoplastic mucosal lesions in the upper and lower gastrointestinal (GI) tract. Multiple devices are available for ESD, and refinements continue to be made to develop devices that improve the safety and efficiency of performing ESD. Submucosal injection with viscous fluids like glycerol, which prolong submucosal expansion, could facilitate the procedure. We aimed to evaluate the safety and performance of the new Erbe HYBRIDknife® flex, which combines electrosurgical dissection with waterjet-assisted injection in a slim and flexible form factor.

In a prospective animal study with six pigs, four endoscopists, each with 10-20 years of experience in ESD, performed 28 esophageal ESDs. One half was performed with physiological saline injectate, the other half with fructose-added glycerol. Various performance aspects were evaluated on a five-point scale [5 = best], including dissection properties, handling, and usability.

No perforations or major bleeding occurred. All resections were performed en bloc, with one technical failure (3.6%, 1 of 28). Performance scores were similar for saline and glycerol (4.5 ± 0.31 vs. 4.5 ± 0.32, P = 0.36), as was dissection speed (13 ± 6.2 mm2/min vs. 15 ± 6.1 mm2/min, P = 0.22).

We demonstrated that esophageal ESD can be performed safely and rapidly using HYBRIDknife flex, with excellent performance evaluation by the endoscopists. Combining this device with glycerol or saline is precise and effective for ESD, although experience could compensate for the theoretical disadvantage of using normal saline.

The goal of surveillance after the endoscopic resection of colorectal tumors is to reduce colorectal cancer (CRC) incidence and mortality. Considering the effective use of the limited endoscopic capacity and the cost of surveillance, it is desirable to develop a surveillance program that is as minimal as possible. In Europe (European Society of Gastrointestinal Endoscopy [ESGE]) and the USA (Multi-Society Task Force [MSTF]), after the results of the National Polyp Study (NPS) were established, guidelines were developed that stratified risk based on initial endoscopy, and surveillance programs for each risk group were proposed. More than 10 years later, the "colonoscopy screening and surveillance guidelines" were developed with the basic principle of "aiming for zero CRC deaths during surveillance, bowel preservation, and emphasis on patient quality of life" as the guideline principles in Japan.

Randomized controlled trials to evaluate the appropriate surveillance intervals after endoscopic resection of colorectal tumors, the NPS, the Nottingham Study, and the Japan Polyp Study (JPS), are summarized. The ESGE, USMSTF, and Japanese guidelines compared low-risk adenoma, high-risk adenoma, advanced neoplasia, piecemeal resection, and serrated lesions by category.

Surveillance guidelines based on risk stratification were developed in Japan. Guidelines are meaningful only when they are effectively utilized in clinical practice. They must also be revised based on new evidence. It is hoped that new knowledge will be accumulated, especially in Japan, on topics that are currently lacking.

The goal of surveillance after the endoscopic resection of colorectal tumors is to reduce colorectal cancer (CRC) incidence and mortality. Considering the effective use of the limited endoscopic capacity and the cost of surveillance, it is desirable to develop a surveillance program that is as minimal as possible. In Europe (European Society of Gastrointestinal Endoscopy [ESGE]) and the USA (Multi-Society Task Force [MSTF]), after the results of the National Polyp Study (NPS) were established, guidelines were developed that stratified risk based on initial endoscopy, and surveillance programs for each risk group were proposed. More than 10 years later, the "colonoscopy screening and surveillance guidelines" were developed with the basic principle of "aiming for zero CRC deaths during surveillance, bowel preservation, and emphasis on patient quality of life" as the guideline principles in Japan.

Randomized controlled trials to evaluate the appropriate surveillance intervals after endoscopic resection of colorectal tumors, the NPS, the Nottingham Study, and the Japan Polyp Study (JPS), are summarized. The ESGE, USMSTF, and Japanese guidelines compared low-risk adenoma, high-risk adenoma, advanced neoplasia, piecemeal resection, and serrated lesions by category.

Surveillance guidelines based on risk stratification were developed in Japan. Guidelines are meaningful only when they are effectively utilized in clinical practice. They must also be revised based on new evidence. It is hoped that new knowledge will be accumulated, especially in Japan, on topics that are currently lacking.

Endoscopic resection techniques for colorectal tumors are constantly evolving with improvements.

Over the past decade, there has been a paradigm shift toward cold polypectomy for the removal of small lesions (<10 mm), known as the "cold revolution". In recent years, underwater endoscopic mucosal resection (EMR) has emerged as an alternative to conventional EMR and has been gaining popularity for resection of intermediate and large-sized lesions (≥10 mm). Although colorectal endoscopic submucosal dissection (ESD) requires a high level of advanced skills, improvements in dissection techniques and devices have facilitated the procedure. In Japan, the safety and efficacy of ESD for resecting large lesions (≥20 mm) have been demonstrated in a large-scale, multicenter, prospective cohort study (CREATE-J). ESD is also being increasingly adopted in Western countries. As endoscopic resection continues to advance and include large and more complex defects, a variety of closure techniques and new devices are being developed. Meanwhile, the number of endoscopic resections for T1-colorectal cancer (T1-CRC), including those intended for total excisional biopsy, has been increasing owing to the aging population and improvements in endoscopic technique.

This review provides a broad summary of endoscopic resection for colorectal tumors including advancements in closure techniques and devices for mucosal defects, as well as the potential role of endoscopic resection for patients with T1-CRC.

Endoscopic submucosal dissection (ESD) is a minimally invasive surgical procedure used for en bloc removal of colorectal tumors. Although colorectal ESD is ideally conducted under conscious sedation, it is often performed under general anesthesia because of its complexity and lengthy duration. Currently, there is limited research on colorectal ESD performed under conscious sedation. The purpose of this study was to evaluate the effectiveness, safety, and economic cost of colorectal ESD under conscious sedation compared to general anesthesia.

Retrospective analysis of 301 patients who underwent ESD treatment for colorectal tumors at the Endoscopy Center of Peking University Cancer Hospital from January 2018 to November 2020. Patients were divided into the sedation group (group S, n=88) and the general anesthesia group (group A, n=213) based on the anesthetic method. To balance the confounding factors between the 2 groups, 75 matched pairs were obtained after using propensity score matching (PSM). Intraoperative and postoperative parameters were then compared between the matched groups.

After PSM, there was no statistically significant difference between group S and group A in terms of the surgical time, en bloc resection rate, and complete resection rate. There was also no statistically significant difference in the occurrence rates of bleeding, perforation, and post-ESD electrocoagulation syndrome (PEECS) between the 2 groups. However, the length of hospital stay was significantly shorter in group S (1.23±0.89d) than in group A (5.92±3.05d) ( P <0.05). The hospitalization costs were also significantly lower in group S (16482.34±13154.32 yuan) compared with group A (34743.74±13779.40 yuan) (P < 0.05 ).

Compared to general anesthesia, performing ESD for colorectal tumors under conscious sedation has equivalent effectiveness and safety while shortening the hospital stay and reducing the economic costs.

Background: To compare tumor margins and surgical outcomes between transanal minimally invasive surgery (TAMIS) and endoscopic submucosal dissection (ESD) for large or malignant rectal adenomatous polyps. Methods: Single institution retrospective analysis of patients who underwent TAMIS or ESD surgery. Results: In total, 30 consecutive patients with similar demographics who underwent either TAMIS (n = 19) or ESD (n = 11) were included. The median (interquartile range, IQR) tumor distances from the anal verge for TAMIS and ESD were 5 cm (3.5-8) and 3 cm (2-4.25) (P = 0.016). Four in TAMIS and two in ESD occupied more than half of the circumference of the bowel lumen. Five (four in situ and one stage 1) in TAMIS and two (one in situ and one stage 1) in ESD were malignant. The median specimen length, width, and height were 3.2 cm, 2.6 cm, and 1.0 cm and 3.5 cm, 2.0 cm, and 0.3 cm for TAMIS and ESD, respectively. There were no statistically significant differences in tumor circumference, malignant ratios, or specimen sizes. Resection margins were involved in two of the ESD, while none of the TAMIS were involved (P = 0.041). The median (IQR) operative time was 72 (62-89) minutes and 120 (90-180) minutes for TAMIS and ESD (P = 0.005). The median (IQR) follow-up time was 3.3 (0.3-11.7) and 0.9 (0.3-15.4) months for TAMIS and ESD. There were no morbidities, no mortalities, or local recurrences among the two groups. Conclusions: Both TAMIS and ESD were found to be feasible and safe in community hospital practice. Operative time was shorter, and there were no involved margins in TAMIS (versus ESD).

Closure of mucosal defects following colorectal endoscopic submucosal dissection (C-ESD) is often performed to prevent post-C-ESD adverse events. However, large mucosal defect closure using conventional clips remains technically challenging. Here, we evaluated the feasibility of the novel endoclip with anchor prongs, called the MANTIS Clip (Boston Scientific, Tokyo, Japan), for mucosal defect closure after C-ESD. This high-volume retrospective study was conducted at a single center. From March until December 2023, consecutive patients who underwent post-C-ESD mucosal defect closure using MANTIS Clip to achieve complete closure were enrolled. Patient clinical characteristics and outcomes were evaluated. Closure of the mucosal defect using the MANTIS Clip was attempted following C-ESD in 32 lesions. The median sizes of the resection specimens and the tumors were 32 mm (range, 17-100 mm) and 23.5 mm (range, 5-96 mm), respectively. The lesions were distributed between the cecum, ascending, transverse, descending, sigmoid, and rectum. Complete closure was achieved in 96.9% of cases (31/32). All lesions up to 61 mm in defect size were completely closed. The median closure time was 7.9 (range, 3.3-18.0) min. The median numbers of MANTIS Clip and additional conventional clips were 3 (range, 1-4) and 5 (range, 1-11), respectively. No adverse events associated with closure, post-ESD bleeding, and delayed perforation occurred. MANTIS Clip closure for large post-C-ESD mucosal defects was found to be feasible and reliable with a high complete closure rate and a short procedure time.

Approximately 10% of patients with submucosal invasive (T1) colorectal cancer (CRC) have lymph node metastasis (LNM). The risk of LNM can be stratified according to various histopathological factors, such as invasion depth, lymphovascular invasion, histological grade, and tumor budding.

T1 CRC with a low risk of LNM can be cured by local excision via endoscopic resection (ER), whereas surgical resection (SR) with lymph node dissection is required for high-risk T1 CRC. Current guidelines raise concern that many patients receive unnecessary SR, even though most patients achieve a radical cure. Novel diagnostic techniques for LNM, such as nomograms, artificial intelligence systems, and genomic analysis, have been recently developed to identify more low-risk T1 CRC cases. Assessing the curability and the necessity of additional treatment, including SR with lymph node dissection and chemoradiotherapy, according to histopathological findings of the specimens resected using ER, is becoming an acceptable strategy for T1 CRC, particularly for rectal cancer. Therefore, complete resection with negative vertical and horizontal margins is necessary for this strategy. Advanced ER methods for resecting the muscle layer or full thickness, which may guarantee complete resection with negative vertical margins, have been developed.

Although a necessary SR should not be delayed for T1 CRC given its unfavorable prognosis when SR with lymph node dissection is performed, the optimal treatment method should be chosen based on the risk of LNM and the patient's life expectancy, physical condition, social characteristics, and wishes.

Endoscopic submucosal dissection (ESD) is a curative treatment for laterally spreading tumors (LSTs). However, the outcomes of ESD for LSTs with hemorrhoids remain largely unknown. Our study aimed to evaluate the usefulness of ESD in managing LSTs with hemorrhoids.

We retrospectively collected 418 consecutive LST patients treated with ESD between 2011 and 2023. A retrospective comparative analysis was conducted.

There were 85 patients included in the hemorrhoids group and 333 patients included in the other group. The en-bloc resection rate, R0 resection rate, and curative resection rate were comparable in these two groups (p > 0.05). The LSTs with hemorrhoids have a significantly higher intraoperative bleeding rate during ESD when compared to the other group (12.9% vs. 5.4%, p = 0.028). Rates of intraoperative perforation and anal pain in the hemorrhoid group were significantly higher than those in the no-hemorrhoid group (2.4% vs. 0%, p = 0.041; 9.4% vs.0.6%, p < 0.001; respectively). Moreover, most of the related manifestations caused by hemorrhoids were relieved to various degrees after ESD.

ESD is a safe and effective treatment strategy for LSTs with hemorrhoids. A multi-center and prospective study should be conducted in the future to validate our results.

The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line.

We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed.

We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions.

ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

As global life expectancy rises and gastrointestinal tumor incidence increases, more elderly patients are undergoing endoscopic submucosal dissection (ESD) for tumor treatment. The current situation highlights the importance of sarcopenia assessment before ESD. This systematic review and meta-analysis aim to assess sarcopenia's role in predicting post-ESD adverse outcomes in the elderly.

We conducted a systematic review and meta-analysis to investigate the impact of sarcopenia on the prognosis of elderly patients undergoing ESD treatment. A comprehensive search was conducted across three databases (PubMed, Embase, Web of Science). We were using NEWCASTLE-OTTAWA ASSESSMENT SCALE for risk of bias assessment. The data were synthesized using Review Manager 5.3.

A total of 9 reports were identified, analyzing 7 indicators, with a combined sample size of 6044. Through a series of analyses, we have derived several highly credible research findings: the overall OR and 95% CI for gastric and colorectal post-ESD perforation between sarcopenia and nonsarcopenia groups were 1.34 [0.92, 1.97], for CTCAE grade > 2 was 2.65 [1.45, 4.82], for upper gastrointestinal post-ESD pneumonia were 1.97 [1.30, 2.99], and for gastric post-ESD mortality within 5 years were 2.96 [1.33, 6.58].

Sarcopenia is a risk factor for increased incidence of complications (CTCAE > 2) after undergoing gastric and colorectal ESD, increased pneumonia rates, and higher mortality rates within five years following gastric ESD treatment in elderly patients. However, sarcopenia does not lead to an increased perforation rate in elderly patients undergoing gastric and colorectal ESD treatments. Registration and protocol: The protocol for this study was registered on the Open Science Framework in 2024 https://doi.org/10.17605/OSF.IO/7B2CZ . We also conducted pre-registration on PROSPERO (CRD42024532547).

Background and study aims Endoscopic full-thickness resection (eFTR) allows treatment of "difficult to resect" lesions not amenable to conventional endoscopic methods. Efficacy and safety of the system have already been proven in numerous studies. Follow-up data on outcome of colorectal eFTR and management of recurrences are still rare. Patients and methods All patients undergoing colorectal eFTR at our institution with at least one endoscopic follow-up examination were retrospectively analyzed. The primary endpoint was the rate of recurrent or residual lesions (RRLs) and the secondary endpoint was the rate of late adverse events (AEs). We further aimed to identify risk factors for RRLs and to describe their management. Results Between November 2014 and 2021, 141 patients underwent eFTR at University Medical Center Freiburg. Ninety-one patients fulfilled the inclusion criteria. Indications for eFTR were non-lifting adenoma (n = 65), subepithelial tumors (n = 18) and early carcinoma (n = 8). The median follow-up period was 17 months (range, 2-86). The overall RRL rate was 9.9% (9/91). A significant proportion of RRLs (6/9, 66%) were detected late. All RRLs occurred in the group of non-lifting adenoma, corresponding to a RRL rate of 13.8% in this subgroup. Thirty-three percent (3/9) were initially treated by hybrid eFTR. Of the RRLs, 66.6% could were successfully treated endoscopically. On χ2 analysis, the hybrid eFTR technique ( P = 0.006) was associated with a higher rate of RRL. No late AEs occurred. Conclusions The rate of RRL after colorectal eFTR is low and the majority could be treated endoscopically. For non-lifting adenomas and early carcinomas, close follow-up is mandatory to detect late recurrence. Long-term outcomes after hybrid eFTR need further investigation.

Endoscopic submucosal dissection (ESD) has revolutionized the treatment of early stage gastrointestinal cancers. However, ESD can be associated with increased postprocedural pain and higher complication rates. This systematic review and meta-analysis evaluated the efficacy and safety of local anesthesia.

A comprehensive search was conducted to identify relevant randomized controlled trials investigating the effect of local anesthesia in ESD procedures. The Cochrane risk of bias tool for randomized trials was used to assess study quality. A meta-analysis was performed using Review Manager 5.4, with summary measures expressed as pooled odds ratios (OR) or mean differences with corresponding 95% confidence intervals (CI).

Four randomized controlled trials with 296 patients undergoing ESD procedures were included. The use of local anesthesia did not significantly impact procedural time (mean difference = -2.05, 95% CI = -9.29, 5.18, I2 = 30%, P = 0.58). Lastly, the use of local anesthesia did not increase the risk of bleeding or other adverse events (P > 0.05) and decreased the incidence of bradycardia (OR = 0.16, 95% CI = 0.03, 0.95; I2 = 0%; P = 0.04).

Our study found that the use of local anesthesia did not significantly affect the procedural time of ESD. However, it effectively reduced postoperative pain in some trials with no risk of increased incidence of adverse events.

Endoscopic submucosal dissection (ESD) is an effective procedure for the en bloc resection of colorectal neoplasms. However, risk factors for local recurrence after ESD have not been identified. This study aimed to evaluate such risk factors after ESD for colorectal neoplasms.

This retrospective study included 1344 patients with 1539 consecutive colorectal lesions who underwent ESD between September 2003 and December 2019. We investigated various factors associated with local recurrence in these patients. The main outcomes were the incidence of local recurrence and its relationship with clinicopathological factors during long-term surveillance.

The en bloc resection rate was 98.6%, the R0 resection rate was 97.2%, and the histologically complete resection rate was 92.7%. Local recurrence was observed in 7/1344 (0.5%) patients and the median follow-up period was 72 months (range 4-195 months). The incidence of local recurrence was significantly higher in lesions ≥40 mm in diameter (hazard ratio [HR] 15.68 [1.88-130.5]; p = 0.011), piecemeal resection (HR 48.42 [10.7-218.7]; p < 0.001), non-R0 resection (HR 41.05 [9.025-186.7]; p < 0.001), histologically incomplete resection (HR 16.23 [3.627-72.63]; p<0.001), and severe fibrosis (F2; HR 9.523 [1.14-79.3]; p = 0.037).

Five risk factors for local recurrence after ESD were identified. Patients with such factors should undergo careful surveillance colonoscopy.

Colorectal cancer is a public health concern associated with high incidence rates. Sarcopenia is a known risk factor for postoperative complications, although an association between increased complications after colorectal endoscopic submucosal dissection (ESD) and sarcopenia remains undocumented. Herein, we aimed to explore the feasibility of colorectal ESD in patients with sarcopenia.

This retrospective study included 499 patients (69 with and 430 without sarcopenia). We evaluated the short- and long-term outcomes of colorectal ESD.

There were no significant differences between the two groups regarding en bloc, R0, or curative resection rates. However, poor bowel preparation was significantly more common in the sarcopenia group. Moreover, patients with sarcopenia exhibited a significant increase in complications (37.7% vs. 10.5%). Multivariate analysis revealed that sarcopenia (odds ratio [OR]: 3.78, 95% confidence interval [Cl]: 1.85-7.73, p < 0.001), anticoagulation therapy (OR: 3.59, 95% Cl: 1.86-6.92, p < 0.001), procedure time (OR: 1.28, 95% Cl: 1.11-1.47, p < 0.001), and resection size (OR: 1.25, 95% Cl: 1.03-1.52, p = 0.02) were significantly correlated with the Common Terminology Criteria for Adverse Events (CTCAE) ≥ grade 2. The correlation between sarcopenia and CTCAE ≥ grade 2 was maintained after matching, resulting in more extended hospital stays in patients with sarcopenia. However, we detected no association between sarcopenia and overall survival and ESD-related death.

Sarcopenia is a risk factor for complications in colorectal ESD, suggesting that colorectal ESD could be performed for patients with sarcopenia, although much caution should be taken.

This study aimed to investigate the lesion and endoscopist factors associated with unintentional endoscopic piecemeal mucosal resection (uniEPMR) of colorectal lesions ≥ 10 mm. uniEPMR was defined from the medical record as anything other than a preoperatively planned EPMR. Factors leading to uniEPMR were identified by retrospective univariate and multivariate analyses of lesions ≥ 10 mm (adenoma including sessile serrated lesion and carcinoma) that were treated with endoscopic mucosal resection (EMR) at three hospitals. Additionally, a questionnaire survey was conducted to determine the number of cases treated by each endoscopist. A learning curve (LC) was created for each lesion size based on the number of experienced cases and the percentage of uniEPMR. Of 2557 lesions, 327 lesions underwent uniEPMR. The recurrence rate of uniEPMR was 2.8%. Multivariate analysis showed that lesion diameter ≥ 30 mm (odds ratio 11.83, 95% confidence interval 6.80-20.60, p < 0.0001) was the most associated risk factor leading to uniEPMR. In the LC analysis, the proportion of uniEPMR decreased for lesion sizes of 10-19 mm until 160 cases. The proportion of uniEPMR decreased with the number of experienced cases in the 20-29 mm range, while there was no correlation between the number of experienced cases and the proportion of uniEPMR ≥ 30 mm. These results suggest that 160 cases seem to be the minimum number of cases needed to be proficient in en bloc EMR. Additionally, while lesion sizes of 10-29 mm are considered suitable for EMR, lesion sizes ≥ 30 mm are not applicable for en bloc EMR from the perspective of both lesion and endoscopist factors.

Endoscopic submucosal dissection (ESD) is a well-established treatment for gastrointestinal tumors and enables en bloc resection. Adequate counter traction with good visualization is important for safe and effective dissection.

Based on magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD), we would like to explore the feasibility of magnetic hydrogel as an internal magnetic anchor that can be injected into the submucosa through an endoscopic needle to assist colonic endoscopic submucosal dissection.

This prospective trial was conducted on 20 porcine colons ex vivo. We injected magnetic hydrogel into submucosa of the porcine colons ex vivo for MAG-ESD to evaluate the traction effect and operation satisfaction.

Magnetic hydrogel assisted ESD was successfully performed on 20 porcine colons ex vivo. Adequate counter traction with good visualization was successfully obtained during the procedure of dissection.

Magnetic hydrogel assisted MAG-ESD is feasible and effective.

Advanced endoscopic therapy techniques have been developed and have created alternative treatment options to surgical therapy for several gastrointestinal diseases. This work will focus on new endoscopic tools for special indications of advanced endoscopic resections (ER), especially endoscopic submucosal dissection (ESD), which were developed in our institution. This paper aims to analyze these specialized instruments and identify their status.

Initially, the technical process of ESD was analyzed, and the following limitations of the different endoscopic steps and the necessary manipulations were determined: the problem of traction-countertraction, the grasping force needed to pull on tissue, the instrument tip maneuverability, the limited angulation/triangulation, and the mobility of the scope and instruments. Five instruments developed by our team were used: the Endo-dissector, additional working channel system, external independent next-to-the-scope grasper, 3D overtube working station, and over-the-scope grasper. The instruments were used and applied according to their special functions in dry lab, experimental in vivo, and clinical conditions by the members of our team.

The Endo-dissector has a two-fold function: (1) grasping submucosal tissue with enough precision and strength to pull it off the surrounding mucosa and muscle, avoiding damage during energy application and (2) effectively dividing tissue using monopolar energy. The AWC system quickly fulfills the lack of a second working channel as needed to complete the endoscopic task on demand. The EINTS grasper can deliver a serious grasping force, which may be necessary for a traction-countertraction situation during endoscopic resection for lifting a larger specimen. The 3D overtube multifunctional platform provides surgical-like work with bimanual-operated instruments at the tip of the scope, which allows for a coordinated approach during lesion treatment. The OTSG is a grasping tool with very special features for cleaning cavities with debris.

The research and development of instruments with special features can solve unmet needs in advanced endoscopic procedures. The latter may help to increase indications for the endoscopic resections of gut lesions in the future.

Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD).

We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes.

Resection time was significantly shorter in the following order: RH-ESD (149 [90-197] minutes) >C-ESD (90 [60-140] minutes) >SH-ESD (52 [29-80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%-30%]) than in the en bloc resection group (40% [20%-60%]).

RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

Endoscopic submucosal dissection (ESD) was developed for the removal of benign and early malignant lesions in the gastrointestinal tract. We aimed to evaluate the performance and safety of a novel high-pressure waterjet-assisted ESD knife in colorectal applications. Six female German Landrace pigs with an average weight of 62 kg (range 60-65 kg) were used in this prospective, randomized, and controlled study. Twenty-four ESDs were performed by three endoscopists: Twelve each with the new Erbe HYBRIDknife® flex T-Type (HK-T) and the Olympus DualKnife® J (DK-J), including six rectal and six colonic ESDs per instrument. The order of performance was randomized regarding anatomic position and instrument. As the primary endpoint, ESD knife performance characteristics were combined and rated on a 5-point Likert scale, with 5 Likert points (LP) representing the best response (5 = very good). The HK-T was rated significantly better than the DK-J (4.7 LP versus 4.4 LP, p = 0.0295), mainly because of HK-T injection ability (5 LP versus 3 LP, p < 0.0001) and hemostasis (5 LP versus 4 LP, p = 0.0452). There was no difference in procedure time (HK-T: 35 min versus DK-J: 34 min, p = 0.8005), resection diameter (3.1 cm versus 2.8 cm, p = 0.3492), injection volume (41 mL versus 46 mL, p = 0.5633), and complication rates. HK-T is as effective as DK-J in colorectal ESD in terms of dissection quality but has better injection and hemostatic properties. The impact of these technical advantages on the ESD treatment of patients with large superficial colorectal lesions remains to be clinically verified.

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms.

All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups.

Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001).

The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort.

Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two.

213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up.

RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases.

NCT01368289 and NCT02000141.

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

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

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

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

Endoscopic submucosal dissection (ESD) is almost always performed with a sedative because of the longer procedure times involved. The risk of post-ESD deep vein thrombosis (DVT) has been reported as relatively high, and D-dimer levels are sometimes elevated after ESD. This retrospective study evaluated factors affecting changes in D-dimer levels from before to after ESD to identify causes of elevated D-dimer levels after ESD. This retrospective analysis included 117 patients with gastrointestinal tumors resected using ESD. After excluding eight patients with pre-ESD levels of D-dimer >1.5 μg/mL, factors correlating with changes in D-dimer from before to after ESD were analyzed using logistic regression analysis in 109 patients. Sedation was accomplished primarily using midazolam, but, because the sedative effect of midazolam shows marked inter-individual variability, a "corrected midazolam dose" was determined by dividing the total midazolam dose by the initial dose to correct for inter-individual differences in the sedative effect of midazolam. This value was used as one potential explanatory variable in the subgroup analysis of the 103 patients who received midazolam. In the subgroup analysis using the corrected midazolam dose as an explanatory variable, only the corrected midazolam dose correlated with a change in D-dimer ≥1.0 μg/mL in multivariate analysis (odds ratio (OR) = 1.5, 95% confidence interval (CI) 0.43-0.95; p = 0.030). The corrected midazolam dose correlated with increases in post-ESD D-dimer levels. This potential relationship indicates that patients undergoing ESD and requiring extended sedation may be at increased risk of DVT.

The serrated neoplasia pathway constitutes an "alternative route" to colorectal cancer (CRC), and sessile serrated lesions with dysplasia (SSLDs) are an intermediate step between sessile serrated lesions (SSLs) and invasive CRC in this pathway. While SSLs show indolent growth before becoming dysplastic (> 10-15 years), SSLDs are considered to rapidly progress to either immunogenic microsatellite instable-high (MSI-H) CRC (presumably 75% of cases) or mesenchymal microsatellite stable (MSS) CRC. Their flat shapes and the relatively short window of this intermediate state make it difficult to detect and diagnose SSLDs; thus, these lesions are potent precursors of post-colonoscopy/interval cancers. Confusing terminology and the lack of longitudinal observation data of serrated polyps have hampered the accumulation of knowledge about SSLDs; however, a growing body of evidence has started to clarify their characteristics and biology. Together with recent efforts to incorporate terminology, histological studies of SSLDs have identified distinct dysplastic patterns and revealed alterations in the tumor microenvironment (TME). Molecular studies at the single-cell level have identified distinct gene alterations in both the epithelium and the TME. Mouse serrated tumor models have demonstrated the importance of TME in disease progression. Advances in colonoscopy provide clues to distinguish pre-malignant from non-malignant-SSLs. Recent progress in all aspects of the field has enhanced our understanding of the biology of SSLDs. The aim of this review article was to assess the current knowledge of SSLDs and highlight their clinical implications.

Diagnostic and therapeutic methods for colorectal cancer (CRC) have advanced; however, they may be inaccessible worldwide, and their widespread use is challenging. This questionnaire survey investigates the current status of diagnosis and treatment of early-stage CRC in Asian countries.

Responses to the questionnaire were obtained from 213 doctors at different institutions in 8 countries and regions. The questionnaire consisted of 39 questions on the following four topics: noninvasive diagnosis other than endoscopy (6 questions), diagnosis by magnification and image-enhanced endoscopy (IEE) including artificial intelligence (AI) (10 questions), endoscopic submucosal dissection (ESD), proper use among other therapeutic methods (11 questions), and pathologic diagnosis and surveillance (12 questions).

Although 101 of 213 respondents were affiliated with academic hospitals, there were disparities among countries and regions in the dissemination of advanced technologies, such as IEE, AI, and ESD. The NICE classification is widely used for the diagnosis of colorectal tumors using IEE, while the JNET classification with magnification was used in countries such as Japan (65/70, 92.9%) and China (16/22, 72.7%). Of the 211 respondents, 208 (98.6%) assumed that en bloc resection should be achieved for carcinomas, and 180 of 212 (84.9%) believed that ESD was the most suitable in cases with a diameter larger than 2 cm. However, colorectal ESD is not widespread in countries such as Thailand, the Philippines, and Indonesia.

The promotion of advanced technologies and education should be continual to enable more people to benefit from them.