Difficult Endoscopic Submucosal Dissection Research Articles

Usefulness of an ultrathin endoscope in esophageal endoscopic submucosal dissection.

Background and study aims Endoscopic submucosal dissection (ESD) is sometimes challenging because of stenosis and scarring. We examined the use of an ultrathin endoscope for esophageal ESD, which is difficult using conventional endoscopes. Patients and methods A designated transparent hood and ESD knife for ultrathin endoscopes have been developed and clinically introduced. Esophageal ESD was performed on 303 lesions in 220 patients in our hospital from February 2021 to February 2023. Of them, an ultrathin endoscope was used on 26 lesions in 23 cases. The safety and utility of an ultrathin endoscope in esophageal ESD were retrospectively verified. Results All 26 lesions were resected en bloc, and serious complications such as perforation, massive bleeding, or pneumonia, were not observed. Lesions were found on the anal side of the stenosis and over the scarring in 38.6% (10/26) and 50% (13/26) of participants, respectively. Moreover, 46.2% of participants (12/26) had lesions on the cervical esophagus. The total procedure time was 64.1 ± 37.7 minutes, but the average time from oral incision to pocket creation was 121.2 ± 109.9 seconds. Conclusions Ultrathin endoscopes may be useful for difficult esophageal ESD.

The Derivation and External Validation of a Fibrosis Risk Model for Colorectal Tumours Undergoing Endoscopic Submucosal Dissection.

Background: Endoscopic submucosal dissection (ESD) is an advanced technique that can become more challenging in the presence of submucosal fibrosis. Predicting the grade of fibrosis is important in order to identify technically difficult ESD. Aims and Methods: Our study aimed to derive and validate a prediction model to determine the preoperative degree of submucosal fibrosis in colorectal tumours undergoing ESD. A predictive model was developed to derive the probability of an increasing submucosal fibrosis in the derivation cohort and then externally validated. Results: 309 patients (age: 68 ± 10.9 years) underwent colorectal ESD between January 2016 and June 2020. F0, F1, and F2 fibroses were reported in 196 (63.4%), 70 (22.6%), and 43 (13.9%) cases, respectively. R0 resection was found in 266 (87%) lesions. At multivariable analysis in the derivation cohort, lesion morphology (OR = 0.37 and CI = 0.14-0.97 for LST-NG vs. 0-Is; OR = 0.29 and CI = 0.1-0.87 for the LST mixed type vs. 0-Is; and OR = 0.32 and CI = 0.1-1.03 for LST-G vs. 0-Is) and increasing size (OR = 1.02 and CI = 1.01-1.04 for a 1 mm increase) were significantly associated with an increasing degree of fibrosis. The model had fair discriminating ability in the derivation group (AUROC = 0.61 and CI = 0.52-0.69 for F1-F2 vs. F0 fibroses; AUROC = 0.61 and CI = 0.45-0.77 for F2 vs. F0-F1 fibroses) and in the validation group (AUROC = 0.71 and CI = 0.59-0.83 for F1-F2 vs. F0 fibroses; AUROC = 0.65 and CI = 0.52-0.77 for F2 vs. F0-F1 fibroses). Conclusions: Our findings introduce a new tool for the stratification of ESD technical difficulty based on lesion size and morphological characteristics which could become crucial during the procedure's planning process.

Predictive factors associated with technical difficulty in colorectal endoscopic submucosal dissection: A Honam Association for the Study of Intestinal Disease (HASID) multicenter study.

Colorectal endoscopic submucosal dissection (ESD) is a promising but challenging procedure. It is not widely performed due to its technical difficulty. We aimed to find the predictive factors associated with technical difficulty in colorectal ESD before the procedure. Clinical data from patients who underwent ESD for colorectal tumors in 5 hospitals in Honam province of South Korea between 2015 and 2020 were reviewed retrospectively. Technically difficult colorectal ESD procedure was defined in 3 points. Long procedure time (longer than 60 minutes), occurrence of perforation, and failure of en bloc resection. Factors associated with technically difficult ESD were included as main outcome measure. 1446 patients were identified and their data were analyzed. Median procedure time was 30.0 minutes and median long axis of the tumor was 20.1 mm. Technically difficult procedures including long procedure time were 231 cases (16.0%), perforation occurred in 34 cases (2.3%), and en bloc resection was done in 1292 cases (89.3%). Tumor size larger than 35 mm (odd ratio [OR]: 1.474, P = .047), central depression or ulceration in the lesion (OR: 1.474, P = .013), previous endoscopic mucosal resection (EMR) or polypectomy procedure (OR: 2.428, P = .020) were associated with technically difficult ESD. Descending colon-located tumor (OR: 5.355, P < .001), and use of IT knife (OR: 4.157, P = .003) were associated with perforation. Recognizing factors associated with technically difficult ESD can help in planning the ESD procedure beforehand.

Lesion size affects the risk of technical difficulty in gastric endoscopic submucosal dissection

Current evidence shows an inter-country inconsistency in the effect of lesion size on the technical difficulty of gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the specific correlation and quantify the ensuing risks. This retrospective study consisted of 405 ESD cases with gastric single lesion from April 2015 to April 2023. The correlation and risk prediction of lesion size with technical difficulty was explored to provide further clinical evidence. An additive generalized model and recursive algorithm were used to describe the non-linear association, and a linear two-piece regression was constructed to analyze the inflection point. Subgroup analysis and interaction were used to explore intergroup characteristics. Overall, difficult cases had larger lesion sizes, and the more significant the increase, the higher the risk of technical difficulty. In the full model, after adjusting for all covariates, each 1 mm, 3 mm, 5 mm, 7 mm, and one standard increase in lesion size increased the risk of technical difficulty by 8%, 26%, 42%, 72%, and 125%, respectively. There is a nonlinear positive correlation between lesion size and risk of technical difficulty, and the premeditated inflection point was 40 (mm) via two-piecewise linear regression and recursive algorithm. Subgroup analysis showed a stronger correlation between lesion size and difficult ESD in the upper site and submucosal fibrosis groups. Available evidence suggests that lesion size as a risk signal nonlinearly increases the technical difficulty of gastric ESD procedure, especially in cases of upper site and submucosal fibrosis, which deserves further investigation.

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.

Factors Related to Difficulty in Endoscopic Submucosal Dissection for Superficial Esophageal Cancer

Background: Endoscopic submucosal dissection (ESD) for superficial esophageal cancer is technically challenging, and research on predictive factors related to the difficulty in the procedure is limited. This study aimed to investigate the factors predicting the difficulty in esophageal ESD. Methods: This retrospective study analyzed 303 lesions treated at our institution between April 2005 and June 2021. The following 13 factors were evaluated: sex, age, tumor location, tumor localization, macroscopic type, tumor size, tumor circumference, preoperative diagnosis of histological type, preoperative diagnosis of invasion depth, previous radiotherapy for esophageal cancer, metachronous lesion located close to post-ESD scar, operator’s skill, and use of a clip-and-thread traction method. Difficult esophageal ESD cases were defined as those requiring long procedure time (>120 min). Results: Fifty-one lesions (16.8%) met the defined criterion for difficult cases of esophageal ESD. Logistic regression analysis identified tumor size larger than 30 mm (odds ratio: 9.17, 95% confidence interval: 4.27–19.69, p < 0.001) and tumor circumference more than half that of the esophagus (odds ratio 2.53, 95% confidence interval: 1.15–5.54, p = 0.021) as independent predictive factors related to difficulty in esophageal ESD. Conclusion: Tumor size larger than 30 mm and tumor circumference more than half that of the esophagus can predict difficulty in performing esophageal ESD. This knowledge can provide useful information for developing ESD strategies and selecting a suitable operator on a case-by-case basis to achieve favorable clinical outcomes.

Effect of robot-assisted gastric ESD in difficult ESD locations.

355 Background: Since its introduction, endoscopic submucosal dissection (ESD) has become a standard treatment for early malignant lesions of stomach. However, ESD is technically demanding and it bears a high risk of complication for beginners. The difficulty of the ESD technique tends to depend on the location of the lesion. We compared and analyzed the efficacy of the ESD assistive robot that we developed in the location where stomach ESD is considered difficult. Methods: We have developed an automated simulator that can implement gastric ESD locations. An EndoGel (Sunarrow, Tokyo, Japan) was attached to the simulator to implement a virtual gastric location where ESD is difficult. "Difficult ESD locations" were selected in consideration of the location where a lot of muscle damage and frequent blind dissections occurred when conventional ESD was performed. An experienced endoscopist performed ten robot-assisted ESDs or conventional ESDs in 3 difficult and 3 easy positions, respectively. Results: While there was no significant difference in dissection speed of robot ESD and conventional ESD in easy positions, the submucosal dissection speed was remarkably faster in robotic ESD than in conventional ESD in difficult positions (P &lt; 0.05). In difficult positions, there was significantly more muscle damage in conventional ESD than in robotic ESD. (P &lt; 0.05). Conclusions: Dissection speed was greatly improved when assistive robots aided gastric ESD procedures in difficult locations. Our robotic device can thus provide simple, effective, and safe multidirectional traction during gastric ESD in difficult location.

Risk Factors Indicating Difficulty During Gastric Endoscopic Submucosal Dissection for Inexperienced Endoscopists: A Retrospective Study.

Factors that may make endoscopic submucosal dissection (ESD) difficult for operators have been evaluated according to results based on the performance of experienced endoscopists. This study aimed to verify the predictors of difficult gastric ESD for ESD beginners. From January 2015 to December 2021, 466 superficial gastric neoplasms were treated with ESD at Showa University Hospital. Excluding 103 lesions that performed ESD by experts who experienced more than 80 ESDs, a total of 363 lesions were included. The lesions were divided into two groups according to the ESD performance experience of the operator:ESD beginner (EB; ESD experience≤30 cases) and ESD intermediate (EI; ESD experience 31-80 cases) groups. Relationships between difficult ESD (having at least one of the following: procedure time>60 min, incomplete resection, change of operator, and occurrence of severe complications) and clinicopathological findings of the lesion were analyzed. The complete resection rates and the difficult ESD rates in the EB and EI groups were 99.3%, 94.8%, and 61.2%, 50.7%, respectively. In the EB group, univariate analysis showed that difficult ESD rate was significantly higher in the non-lower third lesions, the lesser curvature lesions, and cancerous lesions. In the EI group, univariate analysis showed that difficult ESD rate was significantly higher in lesion with ≥20 mm size, lesser curvature lesions, lesions with ulcers, and submucosal cancers. Multivariate analysis showed that the lesser curvature location and cancerous histology in the EB group and ≥20 mm lesion size, the lesser curvature location and submucosal invasion in the EI group were independent predictors of difficult ESD. The lesser curvature location is recognized as independent ESD difficulty factor for both beginners and intermediates.Cases with lesions located in the lesser curvature should not be selected for gastric ESD training by beginners.

Acceptability of Hybrid Endoscopic Submucosal Dissection Using Multifunctional Snare for Small-sized Gastric Neoplasms: A Prospective Observational Study

The most suitable procedure for resecting small-sized gastric neoplasms remains unclear. Endoscopic mucosal resection leads to non-curative resection owing to slippage of the snare, and technically difficult endoscopic submucosal dissection (ESD) is instrumentally uneconomical. A novel, cost-effective, multifunctional snare called SOUTEN is available as a hybrid ESD (h-ESD) device developed for facilitating ESD. This study aimed to assess the acceptability of h-ESD using the SOUTEN for resecting small-sized gastric neoplasms. This was a prospective observational study conducted at our single institution between March 2019 and March 2021. Fifty-seven consecutive patients who underwent h-ESD using SOUTEN for small-sized gastric neoplasms ≤15 mm involving adenoma and tubular-type mucosal carcinoma without ulceration were enrolled. The primary outcome was curative resection rate for h-ESD. Secondary outcomes were the rates of conversion to ESD, rate of total (h-ESD + ESD) curative resection, procedure time, rates of intra-and post- operative complications, and presence of additional knives excluding hemostatic forceps. The curative resection rate of h-ESD was 89.5% (51/57). The total (h-ESD + ESD) curative resection rate was 94.7% (54/57). The mean procedure time was 21.2 (±16.5) minutes. One case of delayed bleeding occurred. Additional knives were applied in two cases. The cost-efficient h-ESD using SOUTEN can be an acceptable procedure for resecting small- sized gastric neoplasms.

The efficient of application of a fine magnetic traction system simplifies colorectal endoscopic submucosal dissection: A porcine study

BackgroundSometimes it is difficult to maintain good visualization of the submucosal layer during colorectal endoscopic submucosal dissection (ESD). This study aimed to evaluate the feasibility and efficacy of a novel traction method, the fine magnetic traction system (FMTS), in colorectal ESD. MethodsESD was performed 10, 15, or 30 cm from the anus in the colorectums of 10 Bama miniature pigs with or without FMTS. The circumcision and dissection per unit time (cm2/min), en bloc resection, perforation and bleeding rates, size and integrity of the specimen and submucosal injection times were analysed. ResultsA total of 60 ESD procedures were performed with or without FMTS assistance. The en bloc resection rates were 100% at 10 and 15 cm from the anus in both the control group (conventional ESD) and the FMTS group. However, at 30 cm from the anus, these rates were only 10% and 70% (p = 0.006). The resection speeds (control vs. FMTS) at the 10, 15, and 30 cm points were 0.35 ± 0.07 cm2/min vs. 0.39 ± 0.19 cm2/min (p = 0.56), 0.30 ± 0.09 cm2/min vs. 0.38 ± 0.02 cm2/min (p = 0.04), and 0.11 cm2/min vs. 0.26 ± 0.10 cm2/min, respectively. ConclusionsThe FMTS provides effective counter-traction and efficiently reduces the risks and difficulties of difficult colonic ESD in the porcine model.

Endoscopic submucosal dissection for colorectal laterally spreading tumors: Clinical outcomes and predictors of technical difficulty.

We aimed to investigate the clinical outcomes of endoscopic submucosal dissection (ESD) for the treatment of colorectal laterally spreading tumors (LSTs) and the factors related to technical difficulty. Consecutive patients who underwent ESD for colorectal LSTs between June 2013 and January 2019 were retrospectively included. Factors associated with difficult ESD procedures (defined as conversion to piecemeal resection or discontinuation of endoscopic procedure), and dissection with a slow speed (<8 mm2 /min), were determined using the logistic regression analysis. A total of 325 patients with 342 colorectal LSTs (median size 20.0 mm) were enrolled. The proportions of granular (LST-G) and non-granular LST (LST-NG) were 62.9% and 37.1%, respectively. The overall en bloc and complete resection rates were 89.8% and 81.9%, respectively. The endoscopic procedure was discontinued in four lesions (1.2%), and 31 (9.1%) converted to piecemeal resection because of technical difficulty. Using multivariate analysis, positive non-lifting sign (odds ratio [OR] 19.9, P < 0.001), tumor size ≥20 mm (OR 10.0, P < 0.001), and less experienced endoscopists (OR 3.7, P=0.005) were independent factors for technically difficult procedure. Positive non-lifting sign (OR 3.7, P=0.004), lesion size <20 mm (OR 3.7, P < 0.001), LST-NG type (OR 1.8, P=0.034), and less colorectal ESD experience (OR 1.9, P=0.016) were independent factors of slow-speed dissection. ESD was feasible and safe for treating colorectal LSTs. Positive non-lifting sign and tumor ≥20 mm indicated difficult ESD procedures. Technical failure was more likely to occur in lesions resected by less-experienced endoscopists. Dissection speed might be improved with more experienced operators.

Construction of a novel predictive nomogram for difficult procedure of endoscopic submucosal dissection for colorectal neoplasms

Objectives To determine the predictors of difficult colorectal endoscopic submucosal dissection (ESD) and to develop a preoperative predictive model for difficult colorectal ESD procedures. Methods Colorectal neoplasms intended to be resected by ESD in our center between August 2013 and February 2019 were retrospectively enrolled. An ESD procedure which took more than 30 min, failed to remove the lesions en bloc or converted to surgery was defined as difficulty. Logistic regression analysis was conducted to find out the predictors of difficult ESD. A nomogram integrating independent predictors was developed and validated with respect to its discrimination, calibration and clinical application, using the receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA), respectively. Results A total of 368 colorectal neoplasms in 355 patients were included. The independent predictors for difficult colorectal ESD were size ≥2 cm (odds ratio [OR] = 6.102, p < .001), positive non-lifting sign (OR = 6.569, p = .005), lesions located in left colon (OR = 2.475, p = .036) or rectum (OR = 2.183, p = .048), laterally spreading tumors (LSTs) (OR = 2.501, p = .008) and less colorectal ESD experience (≤20 cases) (OR = 2.3091, p = .028). The nomogram model incorporating the above predictors performed well in both of the training and validation sets (area under the cure [AUC] = 0.786 and 0.784, respectively). DCA demonstrated the clinical benefit of the nomogram was superior to that of each independent predictor alone. Conclusions The nomogram incorporating tumor size, location, morphology, non-lifting sign and ESD experience of operator can be conveniently used to facilitate the preoperative prediction of difficult colorectal ESD.

Successful duodenal endoscopic submucosal dissection using multiple clip-and-thread traction for a large tumor located in the duodenal bulb

Clip-and-thread traction-assisted endoscopic submucosal dissection (ESD) is useful for treating GI lesions and offers shortened operative times and a reduced risk of perforation.1-4 Duodenal ESD is technically challenging; large tumor size and poor endoscopic maneuverability particularly contribute to technical difficulties and intraoperative perforation.5 Herein, we report a technically difficult duodenal ESD that was performed successfully within a short time using multiple clip-and-thread traction.

Prediction of technically difficult endoscopic submucosal dissection for large superficial colorectal tumors: a novel clinical score model

Endoscopic submucosal dissection (ESD) is a promising technique for removing superficial GI tumors, but ESD is technically difficult. The aim of this study was to establish a clinical score model for grading technically difficult colorectal ESD. Data on patients, lesions, and outcomes of colorectal ESD at 2 centers were analyzed. The objective parameter of successful ESD within 60 minutes was set as an endpoint to evaluate the difficulty. Independent predictors of difficulty in the derivation cohort were identified by multiple logistic regression analysis and used to develop a clinical score. We validated the score model in the validation cohort. The clinical score comprised tumor size of 30 to 50mm (1 point) or≥50mm (2 points), at least two-thirds circumference of the lesion (2 points), location in the cecum (1 point), flexure (2 points) or dentate line (1point), and laterally spreading tumor nongranular lesions (1 point). Areas under the receiver operator characteristic curves for the score model were comparable (derivation [.70] vs internal validation [.69] vs external validation [.69]). The probability of successful ESD within 60 minutes in easy (score= 0), intermediate (score= 1), difficult (score= 2-3), and very difficult (score≥4) categories were 75.0%, 51.3%, 35.6%, and 3.4% in the derivation cohort; 73.3%, 47.9%, 31.8%, and 16.7% in the internal validation cohort; and 79.5%, 66.7%, 43.3%, and 20.0% in the external validation cohort, respectively. This clinical score model accurately predicts the probability of successful ESD within 60 minutes and can be applied to grade the technical difficulty before the procedure.

Predictive factors for difficult endoscopic submucosal dissection for esophageal neoplasia including failure of en bloc resection or perforation.

Endoscopic submucosal dissection (ESD) is accepted as the standard treatment for early-stage esophageal neoplasia. However, esophageal perforation may occur, leading to mediastinitis and pneumothorax, which occasionally require emergency surgery. Moreover, failure of en bloc resection causes local recurrence. However, studies on the predictors of such difficulties during ESD are limited. Hence, we evaluated the predictors associated with the difficulty of ESD for esophageal neoplasia including failure of en bloc resection or perforation. Data of 549 consecutive patients who were treated with ESD between May 2004 and March 2016 at a single institution were retrospectively studied. Exclusion criteria were the presence of metachronous esophageal neoplasia or missing data. The primary outcome was determining the predictors associated with the difficulty of ESD for esophageal neoplasia including failure of en bloc resection or perforation. Altogether, 543 patients with 736 lesions were evaluated. Failure of en bloc resection occurred in 6 patients (1.1%) with 6 lesions, and perforation occurred in 11 patients (2.0%) with 11 lesions (1.5%). Multivariate logistic regression analysis showed that large lesion diameter (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.21-1.84; p < 0.001) and previous chemoradiotherapy (OR 5.24; 95% CI 1.52-18.06; p = 0.009) were independent predictive factors. Larger lesions and previous chemoradiotherapy for esophageal cancer increased the risk for failure of en bloc resection or perforation in patients who underwent esophageal ESD.

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.

Factors associated with conversion to snare resection during gastric endoscopic submucosal dissection.

Although gastric endoscopic submucosal dissection (ESD) achieves a higher en-bloc resection rate compared to that with endoscopic mucosal resection (EMR) for gastric epithelial tumors, the higher complication rate and the longer procedure time are obstacles for its widespread use. Rescue EMR may be a valuable treatment option during difficult ESD procedures. We have aimed to identify the clinical outcomes and associated factors of rescue EMR during ESD. The medical records of patients who underwent ESD between January 2009 and February 2016 were reviewed. The clinical outcomes of rescue EMR during ESD and associated factors with rescue EMR were evaluated. A total of 1778 gastric epithelial lesions were enrolled. ESD without using a snare and rescue EMR were performed in 94.5% and 5.5% of patients, respectively. Lesion locations of mid-third [odd ratio (OR 4.470)], upper-third (OR 1.997), and submucosal fibrosis (OR 1.906) were the significant associated factors with rescue EMR. The en-bloc resection rate and complete resection rate of rescue EMR were lower than that of ESD (98.4% vs. 93.8% and 96.2% vs. 83.5%, respectively). Local recurrence rate was higher after rescue EMR than that after ESD (4.1% vs. 1.2%). Procedure-related complications and procedure time were not significantly different between the two groups. In a difficult ESD procedure, rescue EMR may be an alternative treatment option, especially for lesions located at the mid-to-upper third of the stomach, without increasing either the procedure time or the rate of complications.

Predictors of technical difficulty during endoscopic submucosal dissection of superficial esophageal cancer

Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer (SEC); however, it is sometimes technically difficult. Our aim was to identify the predictors of technical difficulty during ESD for SEC. We reviewed the records of patients who underwent ESD for superficial esophageal squamous cell carcinomas at a tertiary cancer center between April 2008 and March 2016. Patients undergoing ESD after esophagectomy or for residual/recurrent lesions were excluded. Preoperative factors such as tumor subsite, localization, preoperative size, macroscopic type, endoscopic depth of invasion, and treatment for synchronous multiple SECs or previous history of radiation therapy were analyzed. Logistic regression analysis was performed to identify the predictors of technical difficulty, defined as (1) long procedure time (≥ 120min), (2) adverse events (perforation, pneumomediastinum), or (3) incomplete resection (piecemeal resection, positive or indeterminate vertical margin). A total of 679 lesions in 511 patients were analyzed. Difficultly was experienced in 60 cases. The procedure time was > 120min in 43 (6.3%) patients, adverse events occurred in 16 (2.8%), and incomplete resection occurred in 17 (2.5%). Multivariate logistic regression revealed that tumors in the left esophageal wall (OR 2.15; 95% CI 1.17-3.91; p = 0.014) and those encompassing ≥ 1/2 its circumference (OR 5.06; 95% CI 2.40-11.34; p < 0.001) were independently associated with difficulty. Tumors in the left esophageal wall and tumors measuring > 1/2 of the esophageal circumference are predictors of difficult esophageal ESD. These results may contribute to better patient selection according to each endoscopist's skill.

Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases.

Endoscopic submucosal dissection (ESD), which provides a higher en bloc resection rate than conventional endoscopic mucosal resection (EMR), is considered to be a useful treatment option for large colorectal tumors. However, colorectal ESD is not widely used because of its technical difficulty, risk of complications and time required. To overcome these drawbacks, a simpler modified technique, ESD with snaring (hybrid ESD), has been developed. The aim of the present study was to retrospectively compare the safety and efficacy of hybrid ESD and conventional ESD for colorectal tumors. Between September 2008 and June 2016, ESD was carried out on 137 lesions and hybrid ESD on 27 lesions. All hybrid ESD cases were carried out as a rescue treatment in difficult ESD cases. We retrospectively investigated procedure time, and the rates of en bloc resection, perforation, bleeding, and local recurrence. In the hybrid ESD group, procedure time was shorter compared with the ESD group (108±59.5min vs 122±72.2min), but the en bloc resection rate was lower (66.7% vs 94.2%). However, there were no significant differences in procedure time, or in rates of en bloc resection, perforation and bleeding between the two groups. Local recurrence did not develop in any of our cases. Hybrid ESD as a rescue treatment in difficult ESD cases may be less effective for en bloc resection of large colorectal tumors. Indication for hybrid ESD may be limited to scheduled treatment from the outset and emergency cases with patients who present unstable vital signs during ESD.