Colorectal Endoscopic Submucosal Dissection Cases Research Articles

Prophylactic clip closure in preventing delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulants: a multicenter retrospective cohort study in Japan.

The effectiveness of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) is uncertain among patients on anticoagulants. We therefore aimed to assess this effectiveness using data from a large multicenter study. We used the ABCD-J study database to analyze delayed bleeding among 34 455 colorectal ESD cases from 47 Japanese institutions. Delayed bleeding rates among the no/partial and complete closure groups were compared in patients on direct oral anticoagulants (DOACs) or warfarin. Propensity score matching was used for baseline characteristics to reduce the effects of selection bias. Overall, data from 1478 patients on anticoagulants who underwent colorectal ESD were examined. After propensity score matching, the complete and no/partial closure groups were compared in 212 patients on DOACs and 82 on warfarin. The complete closure group showed a significantly lower delayed bleeding rate in patients receiving DOACs (10.8 % vs. 5.2 %, absolute risk reduction [ARR] 5.7 %, P = 0.048) and warfarin (17.1 % vs. 6.1 %, ARR 11.0 %, P = 0.049). Additionally, complete closure significantly reduced the risk of delayed bleeding among patients taking DOACs for right-sided lesions (ARR 6.7 %, P = 0.04), whereas no risk reduction was observed for left-sided (P > 0.99) or rectal (P = 0.50) lesions. A similar trend was observed among patients on warfarin. Prophylactic complete clip closure after colorectal ESD significantly reduced the delayed bleeding rate in patients receiving DOACs or warfarin. It should be performed after ESD, particularly for right-sided lesions.

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

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

Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases.

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.

Tips for difficult colorectal endoscopic submucosal dissection

Colorectal endoscopic submucosal dissection (ESD) is now widely performed and firmly established in the treatment of early-stage colorectal cancer. In particular, there have been many studies on difficult cases of colorectal ESD. Difficult cases can be divided into two groups: difficult dissection of the lesions and difficult approach to the lesion. In most cases, a combination of strategies can solve the problem. Challenging lesions such as those in the anal canal and ileum can also be treated from an anatomical perspective. In the rectum, there are no limits to size or circumference. In addition, the indications for ESD in patients without risk of metastasis other than deep invasion are being considered. Therefore, when ESD is performed on difficult lesions, it is necessary to ensure the quality of dissection.

Efficacy of early clip-with-line method for colorectal endoscopic submucosal dissection.

Colorectal endoscopic submucosal dissection (ESD) remains demanding due to technical difficulties and high risk of perforation. Most of the reported traction methods are initiated after creating a mucosal flap, which is time consuming. To obtain a good visualization at the mucosal incision stage, we developed the early clip-with-line (ECL) method. This method was started immediately after injection of sodium hyaluronate solution into the submucosal layer. In this study, we evaluated the efficacy and the safety of the ECL method for colorectal ESD. We retrospectively analyzed all cases of colorectal ESDs (41 cases in total) performed from January 2017 to February 2019 in our institution. From January 2017 to August 2018, 27 of these cases were performed using conventional (non-ECL) ESDs, while from September 2018 onwards, the remaining 14 cases were performed using the ECL method. Retrospective comparison between the ECL group and the non-ECL group was conducted in terms of clinical characteristics, treatment outcomes, and adverse events. There were no significant differences in clinical characteristics between two groups. Procedure time (median [range]) was significantly shorter in the ECL group than in the non-ECL group (66 [29-131] min vs 90 [30-410] min; P = 0.03). As for adverse events, no case of perforation occurred in the ECL group, whereas perforation was observed in 7.4% (2/27) cases in the non-ECL group (no significant difference). Early clip-with-line method for colorectal endoscopic submucosal dissection reduced procedure time.

Mo1720 FACTORS ASSOCIATED WITH FIBROSIS DURING COLORECTAL SUBMUCOSAL DISSECTION (ESD): DOES PRETREATMENT BIOPSY POTENTIALLY ELICT SUBMUCOSAL FIBROSIA AND AFFECT ESD OUTCOMES?

Submucosal fibrosis observed during colorectal endoscopic submucosal dissection (ESD) is an important factor related to incomplete resection. Biopsy is generally accepted as having the potential to elicit submucosal fibrosis, but few reports have presented definitive proof. This study investigated the relation between submucosal fibrosis and colorectal ESD outcomes and assessed factors related to fibrosis, including pretreatment biopsy. In the current study, we retrospectively included and reviewed 369 colorectal ESD cases. We assessed the relation between fibrosis and ESD outcomes. Multiple logistic regression analysis revealed fibrosis risk factors. Severe fibrosis was related significantly to ESD outcomes such as the mean procedure time (p<0.001), en bloc resection rate (p<0.001), and R0 resection rate (p=0.011). Multivariate analyses indicated residual lesions (ORs 175.4, p<0.001), pretreatment biopsy (ORs 8.30, p=0.002), non-granular-type laterally spreading tumors (LST-NG; ORs 5.86, p=0.025) and invasive carcinoma (ORs 5.83, p=0.03) as independent risk factors of severe fibrosis. In each macroscopic type, LST-NG was more strongly related to fibrosis induced by pretreatment than granular-type laterally spreading tumors with adjust ORs of 50.8 and 4.69. Results of this study demonstrate that pretreatment biopsy causes submucosal fibrosis, thereby resulting in longer procedure times, lower en bloc resection rates, and lower R0 resection rate. Those findings were particularly noticeable in flat type tumors such as LST-NG. The evidence presented above suggests important benefits of avoiding biopsy before ESD.

Mo1779 CLINICAL ANALYSIS OF COLORECTAL ESD CARRIED OUT BY ENDOSCOPISTS LACKING EXPERIENCE IN GASTRIC ESD

Objective: Colorectal endoscopic submucosal dissection (ESD) is now carried out mainly by endoscopists with sufficient experience in gastric ESD. However, the detection rate of early gastric carcinoma is still low in China and endoscopic maneuverability differs between the stomach and colorectum. The aim of this study was to assess the feasibility of colorectal ESD carried out by endoscopists with no or little experience in gastric ESD. A total of 120 colorectal ESD cases, composed of each endoscopist’s who had no or <5 cases of experience in gastric ESD first 60 consecutive cases, were retrospectively reviewed. The endoscopists who participated in the present study had completed over 3000 colonoscopy and 500 colorectal EMR. They had inspected and learned from other endoscopists’ ESD procedures for more than 50 cases and undergone training using resected pig stomachs to get experience of basic ESD skills. We analyzed demographic data of patients, characteristics of lesions, procedure time, complete resection rate, en bloc resection rate and complication rate, et al. All cases were divided into three groups: the first 20 cases of each endoscopist were in early phase group, 21-40 cases were in middle phase group and 41-60 cases were in late phase group. All data were compared among three groups. There were 65 (54.2%) male and 55 (45.8%) female in these 120 cases. The average age was 63.5±12.4 years old. The rate of LST (82/120,68.3%) and lesion in rectum (52/60, 43.3%) were the highest. The size of non-SMT group was 2.28±1.01 cm, while SMT lesions was 0.70±0.16 cm. The average procedural time was 60.5+61.7 min. The en bloc resection and complete resection rates were 74.2% and 71.7%, respectively. 1 case suffered from hemorrhage after ESD and 8 cases of perforation occurred during ESD. However, no patients needed endoscopy again or surgery. According to learning curve, procedural time was significant longer in early phase compared with middle and late phases(P=0.000). Other data did not have significant difference among early, middle and late phases (P>0.05). Endoscopists who lack experience in gastric ESD can carry out colorectal ESD safely based on rigorous training, including enough colonscopy cases, inspecting colorectal ESD and excercising using resected pig stomachs. The procedural time could be shorten after 20 cases.

Su1070 ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL LATERALLY SPREADING TUMORS: CLINICAL OUTCOMES AND PREDICTORS OF TECHNICAL DIFFICULTY

Endoscopic submucosal dissection (ESD) has been used for colorectal laterally spreading tumors (LSTs), yet is technically challenging. We aimed to investigate the clinical outcomes of ESD for colorectal LSTs and predictors of technical difficulty. Consecutive patients who underwent ESD for colorectal LSTs in Beijing Friendship Hospital between June 2013 and March 2019 were retrospectively involved. We evaluated the en bloc resection rate, R0 resection rate, curative resection rate and adverse events with per lesion analysis. Dissection with a slow speed (<8mm2/min), conversion to piecemeal resection or abandonment of endoscopic procedure was considered as technically difficult. Factors associated with difficult ESD procedure, including LST subtype, size, non-lifting sign, procedure duration and operator experience (scaled by prior ESD case numbers) were determined using logistic regression. Significant factors with p<0.05 were adjusted in multivariate logistic regression. A total of 322 patients (56.5% men, mean age 64.7 years old) with 335 colorectal LSTs (median size 20.0mm, range 10.0-100.0mm) were enrolled. The proportions of granular (G) subtype and the non-granular (NG) subtype LSTs were 61.9% and 38.1%, respectively (Table 1). The en bloc, R0 and curative resection rate were 90.7%, 76.1% and 73.4%, respectively. The median dissection speed was 8.2mm2/min. Endoscopic procedure was abandoned in 4 lesions (1.2%), and 27 (8.1%) converted to piecemeal resection because of technical difficulty. Four cases (1.2%) had delayed bleeding and treated under endoscopy successfully. Perforation occurred in 10 LSTs (3.0%), of which only 1 (0.3%) needed surgery. Table 2 listed the risk factors for technically difficult ESD. NG subtype (odds ratio [OR] 1.9, p=0.012), positive non-lifting sign (OR 3.2, p=0.012), and less experienced operators (≤60 colorectal ESD cases) (OR 1.8, p=0.019) associated with a slow dissection speed. After adjusted in multivariate analysis, NG subtype (OR 2.2, p=0.004), positive non-lifting sign (OR 3.4, p=0.009), and less experienced operators (OR 2.1, p=0.009) remained to be independent predictors of low speed procedure. Lesions with size ≥20mm (OR 3.6, p=0.004) and positive non-lifting sign (OR 7.5, p<0.001) had higher risk for ESD abandonment or conversion to piecemeal resection due to difficult procedure. After adjustment in multivariate analysis, larger size (OR 8.3, p<0.001) and positive non-lifting sign (OR 13.3, p<0.001) were still significant factors. Procedure with prolonged duration of ≥60min associated with perforation (OR 5.8, p=0.014). ESD is feasible and safe for treating colorectal LSTs. NG subtype, larger size and positive non-lifting sign indicate difficult ESD procedure. The dissection speed can be improved with operator experience increased.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clinical usefulness of the S-O clip during colorectal endoscopic submucosal dissection in difficult-to-access submucosal layer.

Background and study aims In colorectal endoscopic submucosal dissection (ESD), the S-O clip improves the accessibility to the submucosal layer of the colon. However, its safety and usefulness in difficult colorectal ESDs are unclear. Thus, in this study, we aimed to assess the effectiveness of the S-O clip in colorectal ESD in the difficult-to-access submucosal layer. Patients and methods From January 2016 to December 2016, 189 consecutive cases of colorectal ESD were performed at Hiroshima University Hospital before the S-O clip was introduced. Between January 2017 and June 2018, among 271 consecutive colorectal ESD cases, 41 cases were performed colorectal ESD using the S-O clip. We compared outcomes between the two groups (41 cases with S-O clip [use group] and 189 cases without S-O clip [non-use group]) using propensity score matching. Results Prior to propensity score matching, 41 cases with the S-O clip (use group) and 189 cases without the S-O clip (non-use group) were extracted. The degree of submucosal fibrosis was more severe and the procedure time was longer in the use group than in the non-use group. In the use and non-use groups, en bloc resection (100 % vs. 94.7 %) and complete en bloc resection (100 % vs. 92.6 %) rates were satisfactory. After propensity score matching, 33 cases in each group were extracted. As a result, complete en bloc resection rate was significantly higher in the use group than in the non-use group (100 % vs. 84.9 %). Conclusion The S-O clip is effective and can be used safely in colorectal ESD in the difficult-to-access submucosal layer.

Efficacy and suitable indication of colorectal endoscopic submucosal dissection using a balloon-assisted endoscope.

Background and AimCases of colorectal endoscopic submucosal dissection (ESD) with poor maneuverability are often encountered. We aimed to evaluate the efficacy of balloon‐assisted endoscopy (BAE) for such cases.MethodsWe confirmed maneuverability preoperatively in 400 consecutive cases of colorectal ESD performed at a single center from April 2011 to April 2018. A total of 83 deep colon cases judged as having poor maneuverability were retrospectively reviewed; 54 cases underwent BAE with a single balloon endoscope (group B), and 29 cases underwent conventional procedures without BAE (group C). Tumor size, procedure duration, dissection speed, en bloc resection rate, histology, and associated complications were compared between groups.ResultsThe mean tumor size, tumor invasiveness, fibrosis, and complications did not differ between groups. Although the en bloc resection rate did not differ (both 98%), the groups significantly differed with regard to the R0 resection rate (B: 96%; C: 83%; P = 0.048). Overall, the procedure duration (B: 51 min; C: 70 min; P = 0.17) and dissection speed (B: 19.4 mm2/min; C: 17.4 mm2/min; P = 0.13) were not significantly different between groups. However, the dissection speed for lesions in the cecum/ascending colon was significantly faster in group B than in group C (B: 22.3 mm2/min; C: 11.3 mm2/min; P = 0.037).ConclusionsIn cases of colorectal ESD with poor maneuverability, the use of BAE contributed to an improvement in the R0 resection rate. In addition, BAE contributed to a quicker dissection speed for lesions located in the cecum/ascending colon.

Implementation of endoscopic submucosal dissection for early upper gastrointestinal tract cancer after primary experience in colorectal endoscopic submucosal dissection.

Background Current guidelines recommend endoscopic submucosal dissection (ESD) as a treatment option for early cancers of the upper gastrointestinal tract with absent or minimal risk of lymph node metastasis. However, due to the low prevalence of these entities, it is difficult to achieve a competence level for ESD of upper gastrointestinal tract cancers in the Western World. Here, we present single-center data on the implementation of upper gastrointestinal ESD after previous experience with 89 colorectal ESD cases. Methods Retrospective case series of 39 consecutive patients with early cancers of the esophagus (n = 13) or cardia and stomach (n = 26) treated with ESD over a 4-year period. Results ESD was technically feasible in all cases with en bloc, R0, and curative resection rates of 100 %, 76.9 %, and 71.8 %, respectively, and a mean procedure time of 100 minutes (30 – 360 minutes). After an initial 20 procedures, the R0 and curative resection rates increased from 65.0 % to 89.5 %, and from 60.0 % to 84.2 %, respectively. Complications were observed in four patients (10.3 %): three perforations, one case of delayed bleeding, and one esophageal stricture. No case required emergency surgery; the 30-day mortality rate was 0 %. Conclusion In this modest case series from Europe, we observed an effectiveness and complication rate for ESD for early esophageal and gastric cancer that are comparable to other series from Europe but also to more abundant data from Asia. The results indicate that even small numbers of upper gastrointestinal cancers can be managed adequately in centers with expertise in colorectal ESD.

Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience.

Endoscopic submucosal dissection (ESD) allows for en bloc resection of superficial gastrointestinal neoplasms; however, US experience has been limited. We aimed to evaluate our clinical outcomes in colorectal ESD. This prospective study included consecutive patients undergoing colorectal ESD at a major US center. Demographics, lesion and technical characteristics, outcomes, adverse events, and pathological diagnoses were recorded. Factors affecting resection outcomes and procedure time were evaluated. 77 patients who underwent colorectal ESD were analyzed. Mean colorectal lesion diameter was 49.4mm. Mean procedure time was 104.7min, and 97.4% of patients were discharged home on the same day. En bloc, complete, and curative resection was achieved in 97.4%, 97.4%, and 93.5% of colorectal ESD cases. Microperforation and delayed bleeding rates were 1.3% and 3.9%. On univariable analysis, the presence of tattoo adversely affected en bloc resection (p = 0.002), complete resection (p = 0.002), and curative resection (p = 0.008). Prior EMR attempts adversely affected en bloc resection (p = 0.028), complete resection (p = 0.028), and procedure time (p = 0.008). On multivariable analysis, the presence of tattoo predicted failure to achieve curative resection (OR 0.13; 95% CI 0.02-0.98; p = 0.048). Lesion size > 50mm (OR 3.89; 95% CI 1.13-13.41; p = 0.031), presence of tattoo (OR 9.38; 95% CI 1.05-83.83; p = 0.045), and prior EMR attempts (OR 7.13; 95% CI 1.76-28.90; p = 0.006) predicted procedure time ≥ 90min. A scoring system was created to predict prolonged ESD procedure time and was externally validated, with AUC 0.78 (95% CI 0.73-0.83). This study demonstrates the effects of multiple risk factors on resection outcomes and procedure time in colorectal ESD. Tattoo placement and attempted EMR should be avoided for lesions being considered for ESD.

Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe.

Background and study aims Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results Median size was 4 cm (range 1 – 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 – 588) and median proficiency was 7.2 cm 2 /h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 – 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm 2 /h) and the last study period (10.8 cm 2 /h). Conclusions This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.

The efficacy of the pocket-creation method for cases with severe fibrosis in colorectal endoscopic submucosal dissection

Background and study aims Severe fibrosis poses a challenge in colorectal endoscopic submucosal dissection (ESD). Recently, the pocket-creation method (PCM) has been developed for overcoming various difficulties of ESD. A specific tapered hood is used for adequate traction in the PCM, and endoscopic operability becomes stable in the pocket. In this study, we investigated the efficacy of the PCM in ESD for cases with severe fibrosis. Patients and methods We retrospectively reviewed 1000 consecutive colorectal ESD cases (April 2006 to January 2017). Since 2016, the PCM was performed in 58 cases. The indications for ESD included (1) tumors ≥ 20 mm in size diagnosed as intramucosal cancer or high-grade dysplasia and part of T1a cancer using magnifying endoscopic examinations and (2) tumors that appeared impossible to resect with endoscopic mucosal resection because of suspected fibrosis. We identified 120 cases with severe fibrosis and compared them to cases without severe fibrosis. Additionally, the 120 severe fibrosis cases were divided into the PCM and non-PCM groups. En bloc resection, procedure time, discontinuation, and complications were analyzed between these 2 groups. Results Among all 1000 ESDs, severe fibrosis and discontinuation rates were 12.0 % (120 cases) and 1.8 % (18 cases), respectively. Regarding the comparison between cases with severe fibrosis and with no severe fibrosis, there were significant differences about en bloc resection rate (78.3 % vs. 95.7 %, P < 0.001), discontinuance rate (12.5 % vs. 0.3 %, P < 0.001), and perforation rate (8.3 % vs. 2.6 %, P = 0.001). Among the 120 cases with severe fibrosis, 21 and 99 cases were in the PCM and non-PCM groups, respectively. The PCM group had a higher en bloc resection rate (95.2 vs. 74.7, P = 0.03), a shorter mean procedure time (min) (79.6 ± 26.5 vs. 118.8 ± 71.0, P = 0.001), and no cases of discontinuation. An analysis of the interobserver agreement for the diagnosis of severe fibrosis among the 3 endoscopists showed kappa values of > 0.6. Conclusions In cases with severe fibrosis, the PCM with ESD improved en bloc resection rates and shortened the procedure time compared to the conventional non-PCM method. Additionally, the PCM reduced the discontinuation rate.

Clinical outcomes of colorectal endoscopic submucosal dissection and risk factors associated with piecemeal resection.

We aimed to investigate the factors associated with piecemeal resection of colorectal neoplasia (CRN), in spite of endoscopic submucosal dissection (ESD). We analyzed the retrospective data for colorectal ESD cases from January 2005 to April 2014. We also reviewed the piecemeal endoscopic mucosal resection (EMR) for CRNs ≥20 mm, performed over the same period. En bloc resection was possible in 648 (85.7%) of 756 lesions in 740 patients. Multivariate analysis showed that hybrid ESD (odds ratio (OR), 29.07; 95% confidence interval (CI), 15.46-54.65; p<0.01) and mild or severe submucosal fibrosis (OR, 3.62; 95% CI, 1.94-6.76; p<0.01) were independently associated with piecemeal ESD. The en bloc ESD group showed higher histologic complete resection rate than the piecemeal ESD group (80.4% vs. 56.5%; p<0.01), and the piecemeal ESD group showed higher recurrence rate than in the en bloc ESD group (5.6% [4/72] vs. 0.7% [3/450]; p<0.01). Overall recurrence rate was 1.3% (7/522). Hybrid ESD and submucosal fibrosis are independently associated with piecemeal ESD. Piecemeal ESD cases recurred more frequently than en bloc ESD cases.

Evaluation of endoscopic submucosal dissection using a new endosurgical knife DN-D2718B: a first clinical feasibility study.

Background and study aims Endosurgical devices with injection function have been reported to decrease endoscopic submucosal dissection (ESD) operation times for experts, but the efficacy of these devices for inexperienced endoscopists is unclear. The aim of this study was to evaluate the feasibility of ESD using a novel ESD knife (DN-D2718B). Patients and methods This is a single-center prospective pilot clinical feasibility study. Patients diagnosed with superficial gastrointestinal neoplasms were enrolled. A pre-specified group of ESD trainees with ESD experience on a porcine gastric model and fewer than 30 cases of ESD in their selected fields performed ESD under expert supervision, using the DN-D2718B. En bloc resection rates, R0 resection rates, procedure times, and incidence of intra-operational/post-operational adverse events were assessed. Results Between June 2015 and January 2016, 13 esophageal, 27 gastric, and 14 colorectal ESD cases were performed per-protocol with mean resection speeds of 10.2, 12.0, and 15.5 mm 2 /min, respectively. There were no intra-operational complications. Conclusion ESD with this novel knife is feasible even when performed by non-experts.

Efficacy of a Novel Narrow Knife with Water Jet Function for Colorectal Endoscopic Submucosal Dissection.

Backgrounds With respect to the knife's design in colorectal endoscopic submucosal dissection (ESD), diameter, water jet function, and electric power are important because these relate to efficient dissection. In this study, we analyzed a novel, narrow ball tip-typed ESD knife with water jet function (Flush knife BT-S, diameter: 2.2 mm, length: 2000 mm, Fujifilm Co., Tokyo, Japan) compared to a regular diameter knife (Flush knife BT, diameter: 2.6 mm, length: 1800 mm). Methods In laboratory and clinical research, electric power, knife insertion time, vacuum/suction amount with knife in the endoscopic channel, and water jet function were analyzed. We used a knife 2.0 mm long for BT-S and BT knives. Results The BT-S showed faster mean knife insertion time (sec) and better vacuum amount (ml/min) compared to the BT (insertion time: 16.7 versus 21.6, p < 0.001, vacuum amount: 38.0 versus 14.0, p < 0.01). Additionally, the water jet function of the BT-S was not inferior. In 39 colorectal ESD cases in two institutions, there were mean 4.7 times (range: 1–28) of knife insertion. Suction under knife happened 59% (23/39) and suction of fluid could be done in 100%. Conclusions Our study showed that the narrow knife allows significantly faster knife insertion, better vacuum function, and effective clinical results.

Learning curve analysis of colorectal endoscopic submucosal dissection (ESD) for laterally spreading tumors by endoscopists experienced in gastric ESD.

Endoscopic submucosal dissection (ESD) for various colorectal neoplasms is more technically difficult than gastric ESD. We evaluated treatment outcomes and the learning curve for colorectal ESD of laterally spreading tumors (LSTs) based on the experience of a single endoscopist. We included 93 colorectal ESD procedures for colorectal LST that were performed between March 2009 and June 2012 by a single experienced endoscopist who previously performed hundreds of cases of gastric ESD. The cases were grouped chronologically into three periods by multi-dimensional analyses. For procedure time, the learning curve was analyzed using the moving average method, and for complication, the learning curve was analyzed using cumulative sum (cusum) method. The median procedure time for 93 colorectal ESD was 45min, and the rates of en bloc resection and R0 resection were 89.25 and 83.87%. When results were compared among three periods in order to determine the learning curve, the procedure time and en bloc resection rates were not significantly different. However, the procedure proficiency (about 0.16cm(2)/min) was significantly faster during the second period, after about 25 cases of colorectal ESD. In the third period (about 50 cases), the number and rate of en bloc resection (over 90%) reached the same as that of en bloc R0 resection. When comparing outcomes based on LST subtype, the procedure proficiency of LST-granular type (LST-G) was significantly faster than that of LST-non granular type (LST-NG) (LST-NG, 0.072cm(2)/min; LST-G, 0.157cm(2)/min; p=0.01). Endoscopists fully experienced in gastric ESD need a relatively short learning period for colorectal ESD in terms of procedure time and complication. However, approximately 50 cases might be needed to acquire an adequate skill of colorectal ESD for LST in an experienced gastric ESD endoscopist. Colorectal ESD for LST-NG seems to have higher technical difficulty and a longer learning curve than LST-G.

Su1531 Requirements for Mastering Colorectal Endoscopic Submucosal Dissection Indicated by the Learning Curve of Multiple Endoscopists

Colorectal endoscopic submucosal dissection (C-ESD) is an excellent method of treatment for colorectal neoplasms. However, it is technically demanding, so the development of a training system is essential. Aim:1) To clarify pre-training requirements for C-ESD operators. 2) To clarify how many cases of C-ESD are necessary for novice operators to acquire an adequate level of technical skill.

Clinical Practice of Endoscopic Submucosal Dissection for Early Colorectal Neoplasms by a Colonoscopist with Limited Gastric Experience

Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.