Colorectal ESD Research Articles

Implementation of mentor-assisted colorectal endoscopic submucosal dissection in Sweden; learning curve and clinical outcomes

Objective: It’s still challenging to introduce colorectal (CR) ESD in Western countries. We assessed the feasibility of introducing and implementing CR-ESD in Sweden with hiring Japanese expert as a supervisor.Methods: We analyzed 71 consecutive CR-ESD cases performed by two endoscopists who had no (endoscopist A (E-A)) or 20 cases (endoscopist B (E-B)) of experience in ESD. E-A performed rectal lesions while E-B performed lesions in any locations. Factors associated with failure in en bloc resection and in self-accomplishment were analyzed.Results: Overall en bloc and R0 resection rates were 80.3% and 70.4%. Adverse event occurred in 7.0% including two perforations, two post-operative hemorrhage and one delayed perforation. Only case with delayed perforation underwent surgical treatment. Total self-accomplishment rate was 50% (10/20) for E-A, and 37.3% (19/51) for E-B. Dividing each performer’s cases into three learning phases, self-accomplishment rates increased from 42.9% to 83.3% for E-A, and from 29.4% to 70.6% for E-B, as well as en bloc resection rates from 71.4% to 100% for E-A, and from 52.9% to 94.1% for E-B. Multivariate analysis revealed that location upper than rectum, lesions with formerly taken biopsy and lesions larger than 30mm were significantly associated with en bloc resection failure.Conclusions: Implementation of CR-ESD with hiring Japanese supervisor for certain period was safe for patients and effective for good learning curve.

Line-assisted complete closure for a large mucosal defect after colorectal endoscopic submucosal dissection decreased post-electrocoagulation syndrome.

The incidence of post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) can be decreased by closing mucosal defects. However, large mucosal defects after colorectal ESD cannot be closed endoscopically. We established line-assisted complete clip closure (LACC), a novel technique for large mucosal defects after colorectal ESD. We evaluated the prophylactic efficacy of LACC for preventing PECS. Sixty-one consecutive patients on whom LACC after colorectal ESD was attempted from January 2016 to August 2016 were analyzed. After exclusion of patients with incomplete LACC and adverse events during ESD, 57 patients comprised the LACC group. In contrast, 495 patients who did not undergo closure of a mucosal defect comprised the control group. Propensity score matching was used to adjust for patients' backgrounds. Treatment outcomes were evaluated between the groups. Median resected specimen size in the LACC-attempted group was 35 mm (range, 20-72 mm), and LACC success rate was 95% (58/61). Median procedure time of LACC was 14 min. In the LACC group, incidence of PECS was only 2%, and no delayed bleeding or perforation occurred. Propensity score matching created 51 matched pairs. Adjusted comparisons between the LACC and control groups showed a lower incidence of PECS (0% vs 12%, respectively; P = 0.03) and shorter hospitalization (5 vs 6 days, respectively; P < 0.001) in the LACC group. This study suggests that LACC can effectively reduce the incidence of PECS, although further large-scale studies are warranted.

Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection

ObjectiveEndoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is...

A novel lens cleaner to prevent water drop adhesions during colonoscopy and esophagogastroduodenoscopy.

Background and study aims Water drop adhesions (WDA) impair endoscopic view during gastrointestinal endoscopy. We developed a novel lens cleaner designed using two types of harmLess surfactants and it is reported to be useful for preventing lens cloudiness during colorectal ESD. In the current study, we examined the ability of it for preventing and removing WDA. Patients and methods During laboratory experiments, the cleaner (Cleash; Fujifilm Co., Tokyo, Japan and Nagase Medicals Co., Hyogo, Japan) was applied to the endoscopic lens and an air/water device (AWD) (water 200 mL, dimethicone 1 mL, Cleash 1 mL). The endoscope was submerged in water 100 times for 5 cycles. Rates of WDA were calculated for various groups (lens and AWD with or without Cleash) and compared to a normal cleaner (SL cleaner). During clinical research, 30 colonoscopies and 30 esophagogastroduodenoscopies were analyzed. For the Cleash group, the cleaner was applied to both lens and AWD. The numbers of WDA and WDA with non-rapid removal were calculated, compared to those of the SL cleaner group. Results The mean WDA rate for the Cleash setting (lens: Cleash; AWD: Cleash) was 11.0 %, which was significantly lower than other settings (lens: SL cleaner; AWD: water, 31.0 %; P < 0.001) (lens: Cleash; AWD: water, 19.0 %; P < 0.001). Clinical research of colonoscopies indicated that the numbers of WDA (number/15 sec) and WDA with non-rapid removal were 0.38 and 0.17 for the Cleash group and 0.91 and 0.46 for the SL cleaner groups ( P < 0.001, P < 0.001). For esophagogastroduodenoscopies, the results were 0.47 and 0.24 for the Cleash group and 0.54 and 0.42 for the SL cleaner group ( P = 0.72, P = 0.018). Conclusion A clear and beautiful image without WDA is useful not only for routine endoscopy but also, more importantly, for magnifying endoscopy and other endoscopic treatments. The use of Cleash to lens and AWD showed positive results for preventing and removing WDA during laboratory experiments and clinical research involving CS. Additionally, it also showed positive results for the removal of WDA during EGD.

Design of Virtual Endoluminal Surgery Simulator (VESS): Colorectal Endoscopic Submucosal Dissection Training Module

Introduction: ESD is an endoscopic technique for the en bloc resection of gastrointestinal lesions. ESD is a widely-used technique in Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula has restricted its wide acceptance in the US. Thus, we aim to develop the VESS for ESD procedures. The VESS platform will aim to provide a training and assessment platform by highly realistic visualization and high fidelity of simulating the colorectal ESD procedure. The goal of the ESD simulation is to deliver realistic haptic (touch) feedback to provide a more immersive virtual experience. This abstract describes the design and task analysis study performed to date. Methods: Based on the ESD videos, we performed a detailed colorectal ESD task analysis to determine the critical procedural steps for the design of the VESS. Through the task analysis, the critical ESD steps including lesion identification, lesion marking, injection, circumferential cutting, dissection, intraprocedural complication management and post-procedure examination were detailed. Furthermore, endoscopic devices were allocated to each step of the task analysis. Results: Using our task analysis, we constructed a hierarchical task tree that elaborates the order of tasks in these steps (Figure 1). Furthermore, we developed quantitative ESD performance metrics for each phase in the task tree. For the VESS design, we generated three dimensional (3D) virtual models for various colorectal mucosal lesions (Figure 2), using the Paris and Japanese tumor classifications. 3D models of ESD devices were created. We developed realistic ESD instrument-lesion interactions with our custom-designed haptic device. We designed the electromechanical interface with 2-degrees of freedom to manipulate a dummy endoscope to provide the users with haptic feedback (Figure 3).Figure: Hierarchical task tree.Figure: (a) Paris type 0 + Is tumor and (b) Japanese type 0 + ls tumor.Figure. 3D: Design of the simulator.Conclusion: We describe the initial phases of the design of the VESS for colorectal ESD. Through a task analysis, simulation software and Hardware-software interface developments will allow for the manipulation of virtual colorectal lesions using 3D endoscopic accessories with haptic feedback. Our quantitative ESD metrics will be used in future validation studies of the VESS simulator for performance score computation of trainees.

Su1607 The Influence of Colorectal Esd on Abdominal Symptoms

Su1607 The Influence of Colorectal Esd on Abdominal Symptoms

Current status of colorectal ESD and challenge to the limit.

Current status of colorectal ESD and challenge to the limit.

Su1718 Metachronous Neoplasia and Local Recurrence After Colorectal ESD

Su1718 Metachronous Neoplasia and Local Recurrence After Colorectal ESD

Sa1030 The Analysis of Risk Factors of Post Colorectal ESD Localized Pain Syndrome

Sa1030 The Analysis of Risk Factors of Post Colorectal ESD Localized Pain Syndrome

当院におけるESDトレーニングの現状−traineeの立場から−

Formerly our colorectal ESD training required preceding mastery of gastric ESD, but we have changed the system so that it can be started irrespective of gastric ESD experiences since 2014. Here, we present the course of a trainee who was trained in the new training system. The trainee had an experience of 40 gastric and 5 colorectal ESD at another institution. At the first step of the new training system, the teaching expert taught the following points to the trainee ; how to operate endoscope at will to meet the pre-determined objective criteria, and how to perform colorectal ESD in a pig colon model. After that, the trainee was allowed to perform colorectal ESD practice, starting with rectal lesions, under full back-up by the expert. 20 colorectal lesions were treated by the trainee within six months. The en bloc and self-completion resection rates were both 100%. The mean procedure time was 106 minutes with a mean tumor size of 36.6 mm. Thus, the trainee who had a limited experience of ESD at another hospital could perform colorectal ESD safety under our training system. We believe intensive coaching before ESD practice and full-back up by an expert in the initial step of ESD practice are necessary.

Su1665 Incidence and Predictive Factors of Electrocoagulation Syndrome After Colorectal Endoscopic Submucosal Dissection

major immediate and delayed bleeding per tumor were 1% and 2.2%. Need for emergency surgery was reported in 17 cases mainly due to perforation and severe bleeding. Procedure-related mortality rate was 0%. After an average follow up of 22.9 11.5 months, overall recurrence rate was 1.1%, and 0.1% after en bloc resection.. Conclusion: Given the safety and efficacy of colorectal ESD in this meta-analysis, development of systematic training programs to promote safe adoption is warranted.

Sa1592 Long-Term Outcomes of Colorectal ESD in a Western Tertiary Referral Centre.

Sa1592 Long-Term Outcomes of Colorectal ESD in a Western Tertiary Referral Centre.

New isolated bovine colon model dedicated to colonic ESD hands-on training: development and first evaluation.

ESD is the reference method to achieve en bloc resections for large digestive lesions. Nevertheless, it is a difficult and risky technique. Animal models exist to teach the initial skills, particularly in Japan, where pigs' stomachs are dedicated models to gastric ESD. In Europe, we have to develop different strategies of teaching with dedicated colon models. A pig colon is a good model but thinner and narrower than a human's. In this present work, we evaluated a bovine colon model to perform rectal ESD in retroflexion. First, we prepared six bowels to precise the preparation protocol. Then, two endoscopists unexperienced in ESD performed 64 procedures on eight models. Learning curves and factors of variation were studied. A precise protocol to prepare the colon was defined. The two students achieved en bloc resection in 89.1% of cases with a rate of 6.2% of perforations. A large heterogeneity appeared between the speed and the success rate depending mainly on the age of the animal bowel. Using calf colons, the failure rates were higher (p=0.002) and the speed was lower (p<0.001) than for adult bovine ones. A learning curve appeared with, respectively, 0.49 and 0.59cm(2)/min throughout the study. No significant difference appeared between measured and calculated specimen areas. Bovine colon is a new model to teach ESD in colorectal conditions. The bovine age is important to homogenize the model. A learning curve existed with a time procedure decreasing throughout the study. Further studies are needed to evaluate the precise learning curve with more students. A bovine colon model is a suitable model to teach colorectal ESD. Nevertheless, an adult bovine colon model is more homogeneous than a calf one.

Su1538 A Novel Ex Vibo Training Model for Colorectal Endoscopic Submucosal Dissection Using a Bovine Rectum

The colorectal ESD (CR-ESD) procedure is highly technically demanding due to the inherent histological and anatomical features of the human colorectum, and has a steep learning curve. Endoscopists clinically should start to perform CR-ESD on rectum because of the lower risk of perforation and less difficulty. Training using animal model is generally recommended before starting CR-ESD in human. However, we often experienced discrepancy of technical difficulty between an animal model and a human colorectum due to the different thickness of submucosal layer and the excessive fat tissue in submucosal layer.

Mo1382 A Biopsy Before the Colorectal ESD - Is it Useful?

Because of the anatomic characteristics of the colorectum, it is more difficult to perform ESD successfully and safely on colorectal lesions than on gastric lesions. However a few reports have indicated an effect of a biopsy before the colorectal ESD on procedure. We aimed to clarify a usefulness of a previous endoscopic biopsy.

Sa1595 Muscle Retracting Sign in Colorectal ESD and Its Significance

Sa1595 Muscle Retracting Sign in Colorectal ESD and Its Significance

W1446: Colorectal ESD; Treatment Results and Management of Complications

W1446: Colorectal ESD; Treatment Results and Management of Complications

W1441: The Application of Dexmedetomidine Sedation to Colorectal ESD

W1441: The Application of Dexmedetomidine Sedation to Colorectal ESD

Treatment strategy for laterally spreading tumors in Japan: Before and after the introduction of endoscopic submucosal dissection

Laterally spreading tumors (LST) in the colorectum are considered good candidates for endoscopic resection (ER). Because LST-non-granular (NG) tumors show multifocal invasion into the submucosal layer, en bloc resection is necessary for adequate histopathological evaluation. Therefore, surgical resection has been recommended when a lesion is suspected to be an invasive cancer and too large to resect en bloc. The aim of the present study was to evaluate whether the introduction of colorectal ESD, which was developed for en bloc resection of early gastric cancers, could improve the en bloc resection rate of large LST-NG-type tumors and reduce the surgical resection rate. Between January 1999 and December 2005, a total of 166 LST-NG-type tumors measuring > or = 20 mm in 161 patients were included in this study. The en bloc resection rate and the surgical resection rate were historically compared between two periods, before and after the introduction of ESD. The en bloc resection rate for ER lesions was significantly higher in the latter period (35.0% [14/40]vs 76.5% [75/98]; P < 0.001), and the rate of surgery for adenomas and intramucosal or sm minute cancers was significantly lower in the latter period (20.0% [10/50]vs 1.1% [1/89]; P < 0.001). The introduction of colonic ESD was able to change our treatment strategy for LST, improving the en bloc resection rate and reducing the surgical resection rate.