Difficult Endoscopic Submucosal Dissection Research Articles

Predictive factors for technically difficult endoscopic submucosal dissection in large colorectal tumors

Endoscopic submucosal dissection (ESD) for colorectal tumors is dangerous, particularly those that are large. However, the technical difficulty in resecting large tumors in the colonrectum has seldom been investigated. Between October 2012 and January 2015, 36 consecutive large colorectal tumors were resected by ESD at the endoscopic center of PLA Army General Hospital. Five factors were investigated in predicting the technical difficulty in resecting such tumors. En bloc resection, complete (R0) resection, and curative resection rates were 83.33% (30/36), 80.56% (29/36), and 77.78% (28/36), respectively. Tumor location in a flexure was risk a factor for difficult ESD in the colonrectum as measured by perforation (4.55, 0.09-6.25), non-en bloc resection (4.94, 0.10, 9.45), and dissection speed (β±SE: 1.75±0.05). When tumor size increased, the perforation rate also increased (9.93, 0.96-10.32). ESD was more technically demanding in flexures for resecting large colorectal tumors, and for large tumor effective technique to close perforation is essential. Our study will guide endoscopists in using ESD to remove large colorectal tumors.

Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD.

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for superficial gastric neoplasms. Difficult ESD can lead to complications, such as bleeding and perforation. To predict difficult ESD procedures, we analyzed the factors associated with difficult ESD. The medical records of 1052 ESD procedures were retrospectively reviewed. Difficult ESD was defined by any one of three end points: longer procedure time (≥60min), piecemeal resection, incomplete (R1) resection, or gastric wall perforation. To determine the factors associated with difficult ESD, clinical and pathologic features and endoscopic findings were analyzed. The rates of en bloc resection and curative (R0) resection were 93.3 and 92.4%, respectively. The mean procedure time was 27.7±16.7min. After multivariate analysis, larger tumor size (≥20mm) was an independent risk factor for longer procedure time (OR 4.1, P<0.001), for piecemeal resection (OR 2.3, P=0.003) and incomplete (R1) resection (OR 2.1, P=0.005). Location of the lesion (upper third) was an independent risk factor for longer procedure time (OR 5.8, P<0.001), for piecemeal resection (OR 4.1, P<0.001) and incomplete (R1) resection (OR 4.5, P<0.001). Submucosal fibrosis was an independent risk factor for longer procedure time (OR 9.7, P<0.001), for piecemeal resection (OR 2.4, P<0.001) and incomplete (R1) resection (OR 2.6, P<0.001). Finally, submucosal invasive gastric cancer was an independent risk factor for piecemeal resection (OR 2.6, P=0.008), for perforation (OR 19.3, P=0.001) and for incomplete (R1) resection (OR 2.7, P=0.001). Difficult ESD procedures are a function of the lesion size and location, submucosal fibrosis, and submucosal invasive cancer. When a difficult ESD procedure is expected, appropriate preparations should be considered, including consultation with more experienced endoscopists.

Factors predicting clinical outcomes of endoscopic submucosal dissection in the rectum and sigmoid colon during the learning curve.

Background and study aims: Colorectal endoscopic submucosal dissection (ESD) is associated with significant technical difficulty, long procedure time, and increased risk of complications, especially perforation. This study aimed to determine the factors associated with clinical results of ESD during the learning curve. Patients and methods: In total, 44 patients with sessile and flat rectal and sigmoid colon lesions underwent ESD from November 2009 to September 2013. The procedure time, resection method, tumor size, location, gross morphology, presence of fibrosis, histologic findings, rates of en bloc and piecemeal resections and perforation were analyzed. The ESD procedure was classified as technically difficult in the case of procedure time > 120 minutes and/or piecemeal resection. The whole study time was divided into two periods: first period: resections 1 – 22, second period: resections 23 – 44. Results: En bloc and R0 resection have been achieved in 84.1 % of lesions. The mean procedure time was 119.95 ± 11.22 minutes (range 25 – 360 minutes). Perforation was seen in five cases (11.4 %). A larger tumor size was a risk factor for difficult ESD (P = 0.0001). A finding of fibrosis was a risk factor for piecemeal ESD (P = 0.0074), and perforation (P = 0.0012). There was a high direct positive correlation between tumor size and operation time (r = 0.83, P < 0.0001, 0.95 and 0.99 confidence interval for rho 0.71 – 0.904). There was no significant difference between the first and second period in terms of mean procedure time, en bloc resection or complication rate. Conclusion: A larger tumor size was associated with technically difficult ESD. Severe submucosal fibrosis was a risk factor for both piecemeal resection and perforation.

Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum.

Because of technical difficulty, colorectal endoscopic submucosal dissection (CR-ESD) is not widely performed. We aimed to determine risk factors for such technical difficulty as defined by long procedure duration (≥ 150 min), perforation, and piecemeal resection. Patients with consecutive colorectal tumors treated with ESD between April 2006 and December 2010 were enrolled in a prospective cohort study. For prediction of technical difficulty, three types of factor were investigated: tumor location, tumor type, and colonoscopy-related. Cases were subsequently categorized into earlier and later periods (April 2006 - August 2008, 123 lesions; September 2008 - December 2010, 124 lesions). Variables were analyzed using multiple logistic regression, with subgroup analyses for each period. 247 lesions were analyzed. Flexure location was an independent risk factor for technical difficulty as measured by longer procedure duration (odds ratio [OR] 4.1, 95 % confidence interval [95 %CI] 1.1 - 14.9), piecemeal resection (4.7, 1.1 - 17.2), or perforation (8.8, 1.1 - 56.8). Tumor with scarring or locally recurrent was a risk factor for longer procedure duration (4.7, 1.7 - 13.7), and for piecemeal resection (7.8, 2.4 - 25.0). Tumor of size ≥ 50 mm or spreading across ≥ 2 folds was the strongest independent risk factor for longer duration (6.3, 2.8 - 15.4), and was an independent risk factor for longer duration in both time periods (earlier, 3.3, 1.1 - 10.4; later, 27.4, 7.4 - 138.0). Flexure location was an independent risk factor for perforation (13.9, 1.5 - 129.1) and for piecemeal resection (5.1, 0.9 - 25.2) in the earlier but not the later period. Factors predicting technical difficulty of CR-ESDs were clarified. Their importance was influenced by the increasing experience of the endoscopist.

Factors affecting the technical difficulty and clinical outcome of endoscopic submucosal dissection for colorectal tumors

Endoscopic submucosal dissection (ESD) for colorectal tumors is technically difficult due to the anatomy of the large intestine, with its narrow lumen, thin walls, and redundancy. Here, we assessed factors associated with incomplete resection and difficult colorectal ESD. Between November 2009 and April 2013, we performed ESD on 151 consecutive colorectal tumors in 147 patients. We evaluated the clinical outcomes of all cases and conducted multiple logistic regression analysis of the following factors related to incomplete resection and difficult procedure: age, gender, location (right colon, left colon or rectum), tumor size (diameter ≥40 or <40 mm), operation time, morphology [granular-type laterally spreading tumor (LST-G), non-granular-type laterally spreading tumor (LST-NG), or protruded type], fibrosis, and paradoxical movement during the procedure. A procedure that required more than 120 min was defined as a difficult colorectal ESD. Average tumor size was 32.1 ± 10.7 mm, and the average procedure length was 71.8 ± 49.5 min. The rate of en bloc resection was 94.7%, while that of en bloc curative resection was 86.8%. Perforation occurred in 1.3% of the ESD procedures. Multivariate logistic regression analysis revealed that only severe fibrosis [odds ratio (OR) 4.51; 95% confidence interval (CI) 1.36-14.91, p = 0.014] contributed to incomplete resection and that a tumor size exceeding 40 mm (OR 5.73 [95% CI 1.66-19.74], p = 0.006), severe fibrosis (OR 23.31 [95% CI 6.59-82.54], p < 0.001), and paradoxical movement (OR 4.26 [95% CI 1.11-16.44], p = 0.035) were independent factors exacerbating the difficulty of colorectal ESD. Severe fibrosis contributed to both incomplete resection and difficult colorectal ESD. Larger tumor size and paradoxical movement during the procedure were independent factors contributing to the difficulty of colorectal ESD. These factors might enable endoscopists to develop strategies for treating colorectal ESD.

Tu1542 Factors Affecting the Technical Difficulty and Clinical Outcome of Endoscopic Submucosal Dissection for Colorectal Tumors

Endoscopic submucosal dissection (ESD) for colorectal tumors is technically difficult due to the anatomy of the large intestine, with its narrow lumen, thin walls, and redundancy. Here, we evaluated the clinical outcomes of colorectal ESD and assessed factors associated with incomplete resection and difficult colorectal ESD.

Prediction and Treatment of Difficult Cases in Colorectal Endoscopic Submucosal Dissection

Purpose. The aim of this study was to examine the characteristics of difficult cases and the learning curve in colorectal endoscopic submucosal dissection (ESD). Methods. We studied 518 colorectal tumors treated by ESD. Patients were divided into 2 groups such as the difficult ESD group and non-difficult ESD group in view of procedure time and procedure speed, respectively. The clinical features in each group were analyzed, and we also examined cases with severe fibrosis. Furthermore, we divided all cases into 5 periods according to experience of ESDs and investigated the rates of difficult and perforation cases. Results. In view of both procedure time and procedure speed, there were significant differences about mean tumor size, rates of severe fibrosis and perforation, and en bloc resection rate between the two groups. Severe fibrosis was detected in protruding tumors >40 mm in diameter. With respect to the learning curve, the rate of difficult and perforation cases decreased significantly in the late periods compared to the first period. Conclusions. Large tumor size, high rates of severe fibrosis and perforation, and low rate of en bloc resection are related with difficult ESD cases. The increasing of experiences can decrease the rate of difficult cases and perforation.

USEFULNESS AND SAFETY OF SB KNIFE JR IN ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL TUMORS

Use of a Dual knife has become commonplace for endoscopic submucosal dissection (ESD) of colorectal tumors at Hiroshima University Hosipital. A Hook knife has been also used in combination with the Dual knife, depending on the location of the lesion. We have had recent opportunities to use a scissors-type SB knife Jr. We retrospectively compared outcomes of colorectal ESD performed with the Dual knife in combination with the SB knife Jr versus the Hook knife. In conclusion, although the Hook knife was shown to be a very useful auxiliary device for colorectal ESD, the SB knife Jr. yielded better results than the Hook knife in terms of complete en block resection and avoidance of perforation. Use of the Dual knife with the SB Knife Jr shows good potential for improving complete en bloc resection rate and safety of technically difficult colorectal ESD.

Mo1395 Predictive Risk Factors for Difficult Endoscopic Submucosal Dissection in the Colorectum - Treatment Considerations

Colorectal endoscopic submucosal dissection (ESD) is not widely performed because of its technical difficulty, longer procedure time, and increased risk of perforations. Several investigators had reported indications for colorectal ESD, however, their analyses were primarily based on clinicopathological features of colorectal lesions. The aim of this study was to determine risk factors for technical difficulty of colorectal ESDs and clarify technical indications for this procedure.

INFLUENTIAL FACTORS IN PROCEDURE TIME OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC CANCER WITH FIBROTIC CHANGE

Factors correlating with the technical difficulty of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) are still unclear. EGC coexisting with fibrosis inside lesions has been a common therapeutic indication for ESD. The aim of this study was to clarify the most important factor related to difficult ESD for EGC. Fifty-six patients (49 male and seven female, median age 66 years) who received ESD at a single institute for EGC with fibrosis in the resected lesion were selected. Various clinicopathological factors, including the histological findings of fibrotic changes within the cancer area in the resected specimen, were evaluated statistically for correlation with ESD procedure time. Univariate linear regression analysis with logarithmic ESD procedure time revealed the upper-third portion of lesion in the stomach (P = 0.02), histological classification of dense fibrosis (ulcer/ulcer scar-III/IV) within EGC (P < 0.001), and presence of peptic ulcer other than EGC (P = 0.04). Areas of the resected specimen (P < 0.001) and fibrosis (P < 0.001) were significant factors related to prolonged operation times. Multivariate analysis demonstrated that the upper-third portion of lesion (P = 0.007), ulcer/ulcer scar-III/IV findings (P = 0.006), and area of resected specimen (P = 0.006) were significant independent factors influencing ESD procedure time. Histological findings of fibrotic changes coexisting with EGC are closely related to technical difficulty in ESD as well as the location of tumors. Preoperative precise evaluation of fibrotic changes within EGC may be helpful to predict a technical difficulty in ESD.