Complications Of Endoscopic Submucosal Dissection Research Articles

Risk factors for intraoperative and delayed perforation related with gastric endoscopic submucosal dissection.

Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients. This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012. Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100min; tumor size >35mm; body mass index (BMI)<18.5kg/m2; and ≥72years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60min; BMI<18.5kg/m2; ≥75years; ulceration; and tumor size >20mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%). This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.

Injury to the Muscle Layer and Risk of Non-cardiac Chest Pain after Endoscopic Submucosal Dissection for Esophageal Cancer.

Non-cardiac chest pain (NCCP) is a frequent complication of endoscopic submucosal dissection (ESD) for early-stage esophageal cancer. However, little is known about relationships between ESD findings and NCCP. This study aims to evaluate the risk factors for NCCP, including ESD findings related to injury to the muscle layer. We enrolled a total of 296 lesions from 270 patients with esophageal squamous cell carcinoma (ESCC), who underwent ESD in our center. The grade of injury to the muscle layer caused by ESD was categorized as follows: grade 0: no exposure of muscularis propria; grade 1: muscularis propria exposure and/or whitish color change by the electrocoagulation; grade 2: torn muscularis propria with whitish color change by the electrocoagulation; and grade 3, esophageal perforation. The risk factors for NCCP, including ESD findings, were analyzed by univariate and multivariate analyses. NCCP occurred in 89 patients (33.0%) after esophageal ESD. Multivariate analysis demonstrated that younger age [odds ratio (OR) 0.95, 95% confidence interval (95%CI) 0.92-0.98, p=0.003), postoperative fever (>= 38°C) (OR=25.9, 95%CI: 2.89-232.10, p=0.004), ESD findings (grade 1: OR=3.99, 95%CI: 1.63-9.75, p=0.003 and grade 2: OR=3.18, 95%CI: 1.54-6.57, p=0.002) were independently associated with the incidence of post ESD NCCP. ESD findings relate to slight Injury to the muscle layer, such as muscularis propria exposure and whitish color change by the electrocoagulation were identified as risk factor for post ESD NCCP. We should therefore perform esophageal ESD carefully to avoid injuring the muscle layers.

[Efficacy and safety of endoscopic submucosal dissection with additional radiotherapy for T1a-MM/T1b-SM esophageal squamous cell carcinoma].

Objective: To clarify the efficacy and safety of endoscopic submucosal dissection (ESD) with additional radiotherapy in T1a-MM/T1b-SM esophageal squamous cell carcinoma (ESCC). Methods: A retrospective analysis was conducted on 71 patients with T1a-MM/T1b-SM ESCC admitted to Southeast University Affiliated Zhongda Hospital from January 2015 to December 2019. The patients were divided into two groups based on the treatment method: the ESD group (ESD therapy alone) and the ESD-radiotherapy group (ESD combined radiotherapy). The follow-up duration after ESD was (44±17) months. The difference of disease-free survival (DFS) rate and overall survival (OS) rate between the two groups was compared by survival analysis, and the occurrence of complications was compared. Baseline variables of the two groups were compared and the influencing factors of DFS rate were analyzed by Cox proportional risk regression model. Results: There were 44 patients in the ESD-radiotherapy group [28 males, 16 females, aged (65±7) years] and 27 patients in the ESD group [18 males, 9 females, aged (67±9) years]. The results of survival analysis show that the 1, 3 and 5-year DFS rates of ESD-radiotherapy group were 95.5%, 92.9% and 77.4%, respectively, which were higher than those of ESD group 85.2%, 73.2% and 62.7% (all P<0.05). The 1, 3 and 5-year OS rates of the ESD-radiotherapy group were 100%, 94.7% and 94.7%, while those of the ESD group were 96.3%, 96.3% and 79.4%, respectively. The difference was not statistically significant (all P>0.05). Cox proportional hazard regression model analysis showed that ESD combined with radiotherapy (HR=0.19, 95%CI: 0.04-0.90, P=0.037), complete tumor resection (HR=0.25, 95%CI: 0.07-0.86, P=0.027), and vascular invasion (HR=12.06, 95%CI: 1.61-90.26, P=0.015) were the influencing factors of DFS rates. The most common complication of ESD was esophageal stenosis, and no grade 3 or higher radiation adverse reactions occurred after combined radiotherapy. Conclusion: ESD combined radiotherapy is an effective and safe therapeutic strategy for patients with T1a-MM/T1b-SM ESCC.

The efficacy and safety of multi-loop traction device for gastric endoscopic submucosal dissection: a single center prospective pilot study

Although gastric endoscopic submucosal dissection (ESD) is widely used, the degree of difficulty varies greatly depending on the lesion. Since the multi-loop traction device (MLTD) has been suggested to shorten the procedure time in colorectal ESD, we examined the efficacy and safety of using the MLTD in gastric ESD. Thirty patients with gastric neoplasms were prospectively enrolled from February 2022 to December 2022, and the outcomes of ESD with the MLTD were evaluated. The primary outcomes were procedure time and dissection speed. The secondary outcomes were en bloc and R0 resection rates, MLTD attachment time, and complications of ESD with the MLTD. After excluding 1 patient, 29 patients (29 lesions) were treated by ESD with the MLTD. The median procedure time was 26 min (range, 9–210 min), and the median submucosal dissection speed was 39.9 mm2/min (12.4–102.7 mm2/min). The rate of en bloc resection was 100%, the median MLTD attachment time was 3 min (1–7 min), and none of the patients showed intraoperative or postoperative perforations. Thus, gastric ESD with the MLTD showed a favorable procedure time and dissection speed and an acceptable complication rate. Hence, the MLTD may be effective for gastric ESD.

328. ENDOSCOPIC SUBMUCOSAL DISSECTION FOR SUPERFICIAL ESOPHAGEAL CARCINOMA INVOLVING THE ENTIRE ESOPHAGUS: SHORT-TERM RESULTS

Abstract Background The treatment of superficial esophageal carcinoma involving the entire esophagus remains challenging due to the difficulty in accurate preoperative diagnosis and the complexity of the Endoscopic Submucosal Dissection (ESD) technique. The management of esophageal stricture following ESD also remains controversial. In this study, we analyzed the advantages and disadvantages of ESD for superficial whole circumferential esophageal carcinoma in our hospital, based on short-term results. Methods We retrospectively analyzed 10 patients diagnosed with superficial esophageal carcinoma involving the entire circumference and treated with ESD from January 2021 to the present. We evaluated the accuracy of preoperative diagnosis, treatment-related complications of ESD, post-ESD stenosis, and adverse events associated with stenosis prophylaxis. Treatment Course: The primary treatment consisted of circumferential resection under general anesthesia followed by local injection of 120–320 mg of steroids into the ulcer after resection. Patients were started on a diet 2–3 days after surgery and initiated oral steroid therapy starting with 30 mg with PPI and Sulfamethoxazole Trimethoprim. The dose of steroids was gradually reduced by 5 mg every 3 weeks for a total of 18 weeks. Results The study included 7 males and 3 females with a mean age of 72.9 years. The lesions were located in Upper 1, Middle 5, and Lower 4. The average dissection time was 89.1 minutes, the mean length of endoscopic longitudinal mucosal defects was 70 mm, and the en bloc resection rate was 100%. The histological depth was EP/LPM 5, MM/SM 13, and SM2 or deeper 2. The accuracy of preoperative diagnosis was 80%, but all SM2 lesions were underdiagnosed as SM1. No ESD-related adverse events were observed in any case. Two patients with SM2 after ESD underwent additional surgery. Stenosis occurred in 25% of cases. Steroid-related events included drug-induced liver dysfunction in 4 cases, esophageal candida in 2 cases, pulmonary tuberculosis in 1 case, and delayed perforation in 1 case. Conclusion ESD for superficial esophageal carcinoma involving the entire esophagus can be safely and effectively performed. Steroid administration may be useful for preventing post-ESD stenosis, but its management requires attention as it may cause adverse events.

Complications after endoscopic submucosal dissection for early colorectal cancer (Review).

Colorectal cancer (CRC) is a gastrointestinal malignancy that seriously threatens human life and health, resulting in a heavy disease burden. Endoscopic submucosal dissection (ESD) is widely used in clinical practice and is an effective treatment for early CRC (ECC). Colorectal ESD is a challenging operation, and the incidence of postoperative complications is relatively high because of the thin intestinal wall and limited space for endoscopic operations. Systematic reports on the postoperative complications of colorectal ESD, such as fever, bleeding and perforation, from both China and elsewhere are lacking. In the present review, progress in research on postoperative complications after ESD for ECC is summarized.

A135 ENDOSCOPIC SUBMUCOSAL DISSECTION OF GASTRIC ADENOMAS AND EARLY CARCINOMAS

Abstract Background Management of gastric adenoma and early gastric cancer requires endoscopic resection. This can often be achieved with endoscopic mucosal resection (EMR), which has been shown to be effective with a good safety profile. One disadvantage of EMR is that it is often completed piecemeal, leading to indeterminant margins and higher rates of recurrences that require additional intervention. Endoscopic submucosal dissection (ESD) is a more advanced endoscopic resection technique that has been shown to be more effective than EMR at en-bloc resection. ESD requires high technical proficiency but it is becoming more widely available in western countries. Purpose The purpose of this study is to report on the outcomes and rates of complications of gastric ESD completed in a tertiary centre in British Columbia. Method All gastric ESD was completed by a senior therapeutic endoscopist who has previously received training in Japan. Retrospective data were collected on all gastric ESD procedures done in St. Paul’s Hospital from May 7th, 2015, when the procedure first became available, to Aug 30th, 2022. Inclusion criteria were all adults who have undergone ESD for resection of a gastric lesion. Exclusion criteria were patients younger than 18. Data collected included demographic variables, polyp characteristics, procedural outcomes, and complications. Result(s) A total of 49 ESD procedures were completed. The mean size of the resected lesions was 25.3 mm (range: 5 – 100 mm). Technical success, defined as successful resection of all polypoid tissue, was achieved in 48/49 procedures (98.0%). En bloc resection was achieved in 42/48 (87.5%) completed ESD. The rate of R0 resection was also 42/48 (87.5%). Curative resection, defined as technically successful ESD with an R0 margin and no lymphovascular invasion, was achieved in 41/49 (83.7%) of the cases. In our cohort, 8 patients had adenocarcinoma, 5 of which had a curative resection with no evidence of recurrence. None of the ESD resulted in any intra-procedural or delayed perforation. 5/49 (10.2%) patients had clinically significant post-endoscopic resection bleeding. Out of 37 patients that completed follow-up, 3 (8.1%) had recurrence, and all of them were managed endoscopically. 4/49 (8.2%) of patients required surgery post-ESD. Conclusion(s) In our cohort, ESD is an effective endoscopic resection modality for gastric lesions with a high rate of technical success and curative resection. Despite a deeper plane of resection versus other endoscopic resection modalities, its complication rate remains low. Although ESD requires high technical proficiency, its favorable outcomes along with low rates of complication make ESD highly feasible for the resection of gastric lesions. Further research will be needed to study the implementation and outcomes of ESD in a western setting. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Oral higher dose prednisolone to prevent stenosis after endoscopic submucosal dissection for early esophageal cancer.

Esophageal stenosis is one of the main complications of endoscopic submucosal dissection (ESD) for the treatment of large-area superficial esophageal squamous cell carcinoma and precancerous lesions (≥ 3/4 of the lumen). Oral prednisone is useful to prevent esophageal stenosis, but the curative effect remains controversial. To share our experience of the precautions against esophageal stenosis after ESD to remove large superficial esophageal lesions. Between June 2019 and March 2022, we enrolled patients with large superficial esophageal squamous cell carcinoma and high-grade intraepithelial neoplasia experienced who underwent ESD. Prednisone (50 mg/d) was administered orally on the second morning after ESD for 1 mo, and tapered gradually (5 mg/wk) for 13 wk. In total, 14 patients met the inclusion criteria. All patients received ESD without operation-related bleeding or perforation. There were 11 patients with ≥ 3/4 and < 7/8 of lumen mucosal defects and 1 patient with ≥ 7/8 of lumen mucosal defect and 2 patients with the entire circumferential mucosal defects due to ESD. The longitudinal extension of the esophageal mucosal defect was < 50 mm in 3 patients and ≥ 50 mm in 11 patients. The esophageal stenosis rate after ESD was 0% (0/14). One patient developed esophageal candida infection on the 30th d after ESD, and completely recovered after 7 d of administration of oral fluconazole 100 mg/d. No other adverse events of oral steroids were found. Oral prednisone (50 mg/d) and prolonged prednisone usage time may effectively prevent esophageal stricture after ESD without increasing the incidence of glucocorticoid-related adverse events. However, further investigation of larger samples is required to warrant feasibility and safety.

Prevention and management of esophageal stricture after esophageal ESD: 10 years of experience in a single medical center

Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic procedure to deal with local early esophageal neoplasm, although post-ESD esophageal stricture is a major delayed complication of esophageal ESD greatly influencing the patient's quality of life. This retrospective study was conducted to analyze the esophageal stricture after esophageal ESD while determining further treatment and outcome of stricture management. From 2009 to 2021, we reviewed all patients who underwent ESD for esophageal squamous cell neoplasia in Kaohsiung Medical University Hospital. Totally, 133 patients with esophageal squamous cell neoplasm were enrolled. Among these 133 patients, 108 patients had lesions less than three-fourths in circumferential and 25 patients had lesions in excess of three-fourths circumferentially. Totally, 18 patients (13.5%) had symptomatic esophageal stricture and 17 patients (94.4%) had stricture existing over the upper or middle esophagus. The most important risk factor of esophageal stricture was the extent of resection of esophageal circumference, especially whole circumferential resection. Although oral steroid prevention medication was prescribed for high-risk patients with lesions more than three-fourth circumferential ESD, the stricture rate was still up to 40% (10/25). Endoscopic/luminal management with balloon dilation, radial incision and self-bougination achieved 83% (15/18) symptom remission. Three patients received surgical intervention with esophagectomy or jejunostomy. Esophageal stricture is frequently encountered in esophageal ESD. Aggressive preventative strategy is warranted for the high-risk group. Endoscopy/luminal management has high efficacy for post-ESD esophageal stricture.

Efficacy and Safety of Small Bowel Submucosal Tumors Treated by Endoscopic Submucosal Dissection or Endoscopic Full-thickness Resection During Single-balloon Enteroscopy: Prospective Data From a Single-center Study.

Single-balloon enteroscopy (SBE) is a safe and effective modality for the diagnosis and therapeutic treatment of small bowel disorders. However, the efficacy and safety of treating small bowel submucosal tumors (SMTs) with endoscopic submucosal dissection (ESD) or endoscopic full-thickness resection (EFTR) during SBE have not been determined. Hence, the primary aim of this study was to prospectively evaluate the therapeutic yield of SBE in patients with SMTs. Twenty-one patients with SMTs were enrolled in this study. Regarding the sex distribution, there were 12 men (57.1%) and 9 women (42.9%). Regarding the age distribution, 42.9% of the patients were 60 years old or older and 57.1% of the patients were under 60 years old. The preoperative characteristics of SMTs were summarized and analyzed, the complete resection incidence of SMTs was determined, and the incidence of postoperative complications was collected. ESD-related and EFTR-related complications and the duration of follow-up after leaving hospital were also summarized and analyzed. The efficacy and safety of SMTs treated by ESD or EFTR during SBE were calculated as percentages. Among the 21 patients, 10 (47.6%) underwent EFTR and 11 (52.4%) underwent ESD. The mean diameter of SMTs was 113.50mm (range: 80 to 160mm). Anterograde and retrograde SBE were conducted in 11 and 10 patients, respectively. The mean follow-up time was 49.3 days (range: 6.0 to 129d). The complete resection rate of SMTs was 100%. The complete suture rate of SMTs wound was 100%. The SMTs pathology of all patients showed that the margin-negative (R0) resection was 100%. The incidence of physical discomfort complications (ie, infection/fever, abdominal pain, and abdominal distension) of ESD and EFTR was 5 (23.8%) on day 1, 1 (4.8%) on day 2, and 1 (4.8%) on day 3 after operation. Only 1 (4.8%) patient with EFTR had abdominal pain on the sixth day after leaving hospital, and the visual analog scale/score was 1 point, meaning the pain was easily tolerated by the patient. Twenty (95.2%) patients had no abdominal discomfort after leaving hospital. No patients needed additional surgery because of complications after ESD or EFTR during SBE. This preliminary study showed that SMTs can be safely and effectively treated by ESD or EFTR during SBE, particularly SMTs <160mm in diameter.

Analysis of Prognostic Risk Factors of Endoscopic Submucosal Dissection (ESD) and Curative Resection of Gastrointestinal Neuroendocrine Neoplasms.

Objective To explore the prognostic risk factors of ESD curative resection of gastrointestinal-neuroendocrine neoplasms (GI-NENs). Methods A total of 97 patients treated with ESD successfully in our hospital were selected, their surgical site, size, number of resection lesions, operation time, intraoperative complications (such as bleeding and perforation), and treatment status were recorded, and the number of hemostatic clamps used after the postoperative follow-up results and the independent risk factors for ESD complications were obtained through the comparison between the noncomplication group and the ESD complication group using regression analysis. Results A total of 97 patients with gastrointestinal neuroendocrine tumors were treated with ESD. 61 were males, 36 were females, the ratio of male to female was 1.7 : 1, onset age was 20–78 years old, and median onset age was 50 years old. In 81 cases, tumors were located in the stomach, 10 in the duodenum, and 6 in the rectum. A total of 103 lesions were detected by endoscopy, including 1 case with 2 sites in the stomach, 5 cases with 2 sites in the rectum, and the rest were single. The tumor diameter was 0.3 ∼ 2.5 cm, and the median diameter was 0.6 cm; there were 25 sites with a diameter less than 5 cm. There were 57 places with 10 mm, 16 places with 10–15 mm, and 5 places with >15 mm. All ESD operations were performed in one piece, with a total resection rate of 100%; 89.6% (60/67) of postoperative pathology showed negative basal, and 90.3% (56/62) showed negative resection margin, with a complete resection rate of 88.9% (48/54). ESD's operation time is 6 ∼ 66 min, and the median time is 18 min. During the operation, 5 cases had small amount of bleeding, 3 cases were perforated, 2 cases of delayed postoperative bleeding, 1 case of bleeding was caused by the patient's failure to follow the advice of the doctor to eat a large amount of solid food too early, and 1 case of delayed perforation (all recovered and discharged). ESD operation that bled, age, gender, and perforation location, pathological grade, pathological classification, tumor diameter, tumor surface, operation time, number of titanium clips, origin, echo uniformity, and echo level were statistically insignificant (P > 0.05). Postoperative bleeding was related to the operation time (P=0.017), but it was not an independent risk factor for postoperative bleeding (P=0.118; OR, 0.226; 95% CI, 0.035–1.461). 59 cases were followed up by endoscopy after the operation, and recurrence or no new tumors were found. Conclusion ESD is an effective and safe treatment method for gastrointestinal neuroendocrine tumors with a diameter of 1-2 cm without invading the muscularis propria. The intraoperative complications seem to have little relationship with the patient; postoperative delayed bleeding is closely related to the ESD operation time but it is not an independent risk factor.

The effects of oral steroid duration on stricture prevention after extensive endoscopic submucosal dissection for superficial esophageal cancer.

BackgroundEsophageal stricture is a major complication of endoscopic submucosal dissection (ESD) in patients with superficial esophageal cancer (SEC). Oral steroids have been used to prevent esophageal stricture in patients with more than 75% of the esophageal circumference resected. However, there are no established guidelines regarding the optimal duration of steroid use. This retrospective observational study aimed to compare the incidence of esophageal stricture according to the period of prophylactic oral steroid use and to identify the risk factors for esophageal stricture.MethodsEighty-one patients who were prescribed prophylactic steroid after undergoing ESD for SEC with more than 75% of esophageal circumference resected were enrolled. Patients were classified into the four-week steroid group (n=72) or eight-week steroid group (n=9) to compare the incidence of esophageal stricture. In addition, the patients were subdivided into those who developed esophageal stricture (n=24) and those who did not (n=57) to identify the risk factors for esophageal stricture.ResultsTwenty patients (27.8%) in the four-week oral steroid group and four patients (44.4%) in the eight-week oral steroid group developed esophageal stricture (P=0.44). The univariable analysis identified tumor size, longitudinal length of semi-circumferential resection, and proportion of circumferential resection as risk factors of esophageal stricture. The multivariable analysis identified the proportion of circumferential resection as an independent risk factor. After adjusting for the proportion of circumferential resection, the incidence of stricture was marginally higher in the eight-week steroid group [P=0.05; odds ratio (OR): 5.69; 95% confidence interval (CI): 1.01–32.15].ConclusionsEight weeks of oral steroid prophylaxis does not reduce the risk of stricture after extensive ESD more than four weeks of oral steroid prophylaxis. The proportion of circumferential resection is the strongest risk factor for stricture in patients with SEC undergoing ESD.

Outcomes of endoscopic submucosal dissection for colorectal neoplasms: Prospective, multicenter, cohort trial.

Endoscopic mucosal resection (EMR) is the gold standard for the treatment of noninvasive large colorectal lesions, despite challenges associated with nonlifting lesions and a high rate of local recurrence. Endoscopic submucosal dissection (ESD) offers the possibility of overcoming these EMR limitations. However, a higher risk of complications and longer procedure time prevented its dissemination. As ESD now provides more stable results because of standardized techniques compared with those used earlier, this study aimed to quantify the rates of en bloc and curative resections, as well as ESD complications, in the present situation. A multicenter, large-scale, prospective cohort trial of ESD was conducted at 20 institutions in Japan. Consecutive patients scheduled for ESD were enrolled from February 2013 to January 2015. ESD was performed for 1883 patients (1965 lesions). The mean procedure time was 80.6 min; en bloc and curative resections were achieved in 1759 (97.0%) and 1640 (90.4%) lesions, respectively, in epithelial lesions ≥20 mm. Intra- and postprocedural perforations occurred in 51 (2.6%) and 12 (0.6%) lesions, respectively, and emergency surgery for adverse events was performed in nine patients (0.5%). This trial conducted after the standardization of the ESD technique throughout Japan revealed a higher curability, shorter procedure time, and lower risk of complications than those reported previously. Considering that the target lesions of ESD are more advanced than those of EMR, ESD can be a first-line treatment for large colorectal lesions with acceptable risk and procedure time. (Clinical Trial Registration: UMIN000010136).

Endoscopic submucosal dissection for early gastric adenocarcinoma: basic procedures and management of complications

Mastery of endoscopic submucosal dissection (ESD) requires a deep understanding of not only the technique but also the preparation, electrosurgical unit, its peripherals, and probable procedural complications. An endoscope with a water-jet function is suitable for gastric ESD. A transparent attachment on the tip of the endoscope is necessary. The mucosal preparation is important for proper lesion recognition and precise device movement during the procedure and to reduce the risk of complications. A needle-type knife allows accurate tissue dissection and is especially useful for dissecting fibrosis in the submucosa. A partially insulated-type knife prevents current transmission from the tip of the needle to the deep tissues, thus reducing the risk of unintentional perforation or bleeding. When using a scissor-type knife, stable device movement is possible and unintended tissue dissection is minimized. The electrosurgical unit mode must be adjusted according to the different tissue conditions. The basic techniques for ESD incision and dissection should be mastered, and the appropriate knives, accessories, strategy, and traction device should be methodically selected by each operator. The main complications of ESD are bleeding and perforation, which should be treated appropriately when they occur.

Devices, techniques, traction, suturing, and countermeasures for endoscopic submucosal dissection complications

Endoscopic submucosal dissection (ESD) is widely performed to treat superficial colorectal tumors because it enables en bloc resection of various types of lesions. However, ESD sometimes leads to deleterious adverse events, such as perforation and delayed bleeding. Therefore, determining the precise preoperative indication for ESD is vitally important. Furthermore, small lesions with fibrosis and semi-large lesions can be managed using underwater endoscopic mucosal resection, and the “true” indication for ESD is for the treatment of larger lesions, for which ESD carries a higher risk. Here, we reviewed the devices, techniques (i.e., pocket creation method, water pressure method, and clip and flap method), traction (i.e., clip with line, pulley method, and clip with ring), suturing (i.e., line-assisted complete closure, loop clip, clip-on-clip closure method, mucosal incision around the mucosal defect, and hand-suturing), and countermeasures to address complications (i.e., bleeding after ESD, perforation, and post-ESD coagulation syndrome) that facilitate easier and safer ESD.

S993 Continued Aspirin Use and Bleeding Risk After Endoscopic Submucosal Dissection of Gastric Neoplasms: A Meta-Analysis

Introduction: With the development of endoscopic technologies, the detection rate of early gastric cancer (EGC) and precancerous lesions is gradually increasing. As an effective minimally invasive therapy, endoscopic submucosal dissection (ESD) has been accepted as a standard treatment for EGC and dysplasia. However, postprocedural bleeding is one of the most common complications of ESD, with a reported incidence of 5.1%. Moreover, the effect of continued low-dose aspirin (LDA) on bleeding during the peri-ESD period is not clear. Methods: We searched the OVID/Medline and Google Scholar databases through June 2021 to find studies relating to continued LDA use in patients undergoing ESD. Studies reporting bleeding rates in patients undergoing ESD with and without continued LDA were included. Postoperative bleeding rates were compared between those who continued LDA during the procedure and those who did not; a random-effects model was used to calculate pooled odds ratio for bleeding risk with continued LDA use. A p-value < 0.05 was considered statistically significant. Results: The initial search identified 2023 studies; after excluding duplicates, review articles, and studies not meeting inclusion criteria, 9 studies (all were retrospective observational studies) were finally included in the analysis. The total number of patients undergoing ESD procedure was 7978, out of which 703 continued LDA during the procedure. Pooled analysis comparing the post-operative bleeding rates between people with and without continued use of LDA revealed that aspirin use during ESD translated into higher postoperative bleeding rates compared to those who did not. (Pooled OR 1.720 , 95%CI: 1.121-2.641, P= 0.01). No interstudy heterogeneity was observed (I2=0). Conclusion: The results of our meta-analysis demonstrated that LDA continuation significantly increased the risk of post-ESD bleeding. Therefore, the physicians should individualize the decision of continuing LDA in patients undergoing ESD based on their thrombotic risk.Figure 1.: Forest plot of gastric neoplasm studies with and without continuation of low-dose aspirin.Table 1.: Baseline Characteristics of Included Studies.

Impact of endoscopic submucosal dissection and epithelial cell sheet engraftment on systemic cytokine dynamics in patients with oesophageal cancer

The tumour microenvironment (TME) plays an important role in cancer development, progression, and metastasis. Various cytokines are present in the TME in oesophageal cancer. Oesophageal stricture is a major complication of endoscopic submucosal dissection (ESD) for oesophageal cancer, and inflammatory cytokines are closely related to its pathogenesis. However, the cytokine crosstalk involved in the oesophageal cancer TME and post-ESD stricture has not been fully elucidated. This study investigated the comprehensive cytokine dynamics following ESD in patients with oesophageal cancer. In addition, the effect of a novel preventive technique for post-ESD stricture, autologous cell sheet engraftment, on cytokine levels was evaluated. Various pro-inflammatory and anti-tumorigenic cytokines were elevated in patients with oesophageal cancer, and ESD transiently influenced cytokine concentrations. IL-1β and TNF-α, two major pro-inflammatory cytokines that induce oesophageal stricture, were significantly suppressed by cell sheet engraftment. In conclusion, this study revealed the distinct cytokine dynamics after ESD in patients with oesophageal cancer, together with the effect of autologous cell sheet engraftment on cytokine fluctuation. These results can accelerate research on the TME and therapeutic strategies for oesophageal cancer.

Endoscopic submucosal dissection is safe and feasible, allowing for ongoing surveillance and organ preservation in patients with inflammatory bowel disease

Experience of endoscopic submucosal dissection (ESD) for colorectal lesions in the setting of inflammatory bowel disease (IBD) remains limited. The aim of this work was to determine the safety, feasibility and oncological outcomes of ESD in patients with IBD. A retrospective review of all adult patients (≥18years) with a known diagnosis of either ulcerative colitis (UC) or Crohn's disease (CD) who underwent advanced colonoscopy and ESD between 1 January 2014 and 1 October 2020. Data collected included patient demographics, disease characteristics, pathological variables and procedure-related complication rates. A total of 25 patients were included: 19 (76%) were male with a median age of 63years and disease duration of more than 10years. Sixteen had UC and nine had CD; the majority were taking corticosteroids, immunomodulators or monoclonal antibodies at the time of ESD. The median procedure time was 41min and the majority (n=18; 72%) utilized chromoendoscopy. The median lesion size was 30mm: eight had low-grade dysplasia, nine had high-grade dysplasia and three had adenocarcinoma and underwent oncological resection. None had surgical intervention for complication of ESD or perforation. A total of 23 (88%) had a complete R0 resection. Over a median follow-up of 19months, three were found to have dysplasia excised in polyps and none had subsequent adenocarcinoma. ESD in the setting of IBD is safe and effective for complete removal of large neoplastic lesions, allowing for ongoing endoscopic surveillance and organ preservation rather than surgical intervention.

Factors influencing development of non-cardiac chest pain after endoscopic submucosal dissection for esophageal neoplasms: a retrospective case-control study of 309 patients from a single center.

Endoscopic submucosal dissection (ESD) is widely used for early stage esophageal cancer and precancerous lesions. Non-cardiac chest pain (NCCP) is a frequent complication of ESD. However, little is known about its incidence and associated factors. This study investigated the pain incidence and predictive factors for pain development after ESD for esophageal neoplasms. We enrolled a total of 309 patients with esophageal neoplasms, who underwent ESD in our center from January 2018 to June 2019. Sociodemographic and clinicopathological information for all patients was collected, and patients were divided into either a pain-free group (n = 156) or a pain group (n = 153) according to whether there was onset of NCCP 24-48hours after surgery. We made comparisons between groups using Student's t test or the χ2 test. Logistic-regression analysis was used to screen for risk factors. There were statistically significant differences in histories of previous surgery (P = 0.039), lesion size (P = 0.026), operation time (P = 0.009), and postoperative fever (P = 0.001). History of previous surgery (P = 0.043) and postoperative fever (P = 0.007) were independent risk factors for chest pain after esophageal ESD treatment. Chest pain and fever prolonged postoperative hospitalization time (P = 0.005, P = 0.001) and increased hospitalization cost (P = 0.034, P < 0.001). A history of previous surgery and postoperative fever was associated with the occurrence of NCCP after ESD in patients with esophageal neoplasms. NCCP and fever after esophageal ESD increased both hospitalization time and cost.

Endoscopic Submucosal Dissection for Superficial Barrett's Neoplasia in Korea: a Single-Center Experience.

PurposeWhile the incidence of Barrett’s neoplasia has been increasing in Western countries, the disease remains rare in Asian countries. Therefore, very few studies have investigated the endoscopic treatment for Barrett’s neoplasia in Korea. Endoscopic submucosal dissection (ESD) enables en bloc and complete resection of gastrointestinal neoplastic lesions. This study aimed to evaluate the therapeutic outcomes of ESD for Barrett’s neoplasia in a single center in Korea and to examine the predictive factors for incomplete resection.Materials and MethodsWe conducted a retrospective observational study of 18 patients who underwent ESD for superficial Barrett’s neoplasia (dysplasia and early cancer) between January 2010 and December 2019 at Pusan National University Hospital. The therapeutic outcomes of ESD and procedure-related complications were analyzed.ResultsEn bloc resection, complete resection, and curative resection were performed in 94%, 72%, and 61% of patients, respectively. Histopathology (submucosal or deeper invasion of the tumor) was a significant predictive factor for incomplete resection (P=0.047). Procedure-related bleeding and stenosis were not observed, whereas perforation occurred in one case. During the median follow-up period of 12 months (range, 6–74 months), local recurrence occurred in 2 patients with incomplete resection, one patient underwent repeat ESD, and the other patient received concurrent chemoradiotherapy. The 3-year overall and disease-specific survival rates were 73% and 93%, respectively.ConclusionsESD seems to be an effective and safe treatment for superficial Barrett’s neoplasia in Korea. Nevertheless, the suitability of ESD for Barrett’s cancer cases should be determined considering the high risk of deep submucosal invasion.