Efficacy Of Endoscopic Submucosal Dissection Research Articles

Long-term prognosis after endoscopic submucosal dissection for esophageal cancer in older adult patients

BackgroundThe validity of endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) in older individuals with comorbidities remains unclear. Therefore, this study evaluated the safety and efficacy of ESD and additional treatment for ESCC in older adult patients.MethodsThe clinicopathological characteristics and clinical outcomes of 398 consecutive older adult patients (≥ 65 years) with 505 lesions who underwent ESD for ESCC at the Hiroshima University Hospital between September 2007 and December 2019 were retrospectively evaluated. Additionally, the prognoses of 381 patients who were followed up for > 3 years were assessed.ResultsThe mean patient age and procedure time were 73.1 ± 5.8 years and 77.1 ± 43.5 min, respectively. The histological en bloc resection rate was 98% (496/505). Postoperative stenosis, perforation, pneumonia, and delayed bleeding were conservatively treated in 82 (16%), 19 (4%), 15 (3%), and 5 (1%) patients, respectively. The 5-year overall and disease-specific survival rates were 78.9% and 98.0%, respectively (mean follow-up time: 71.1 ± 37.3 months). Multivariate analysis showed that age and the American Society of Anesthesiologists classification of physical status class ≥III (hazard ratio: 1.27; 95% confidence interval: 1.01–1.59, p = 0.0392) were independently associated with overall survival. A significantly lower overall survival rate was observed in the high-risk follow-up group than in the low-risk follow-up and high-risk additional treatment groups (p < 0.01). However, no significant difference in disease-specific survival was observed among the three groups.ConclusionsESD is safe for ESCC treatment in patients aged ≥ 65 years. However, additional treatments should be considered based on the patient’s general condition.

Endoscopic Submucosal Dissection Criteria for Differentiated-type Early Gastric Cancer Are Applicable to Mixed-type Differentiated Predominant.

There is a lack of sufficient evidence on whether mixed-type differentiated predominant early gastric cancer (MD-EGC) can be treated endoscopically by referring to the criteria for differentiated-type early gastric cancer (EGC). This study aims to evaluate the efficacy of endoscopic submucosal dissection (ESD) in MD-EGC. Patients with differentiated-type EGC treated with ESD first from January 2015 to June 2021 were reviewed, including MD-EGC and pure differentiated-type EGC (PD-EGC). Clinical data, including the clinicopathological characteristics, resection outcomes of ESD, and recurrence and survival time, were collected, and the difference between MD-EGC and PD-EGC was tested. A total of 48 patients (48 lesions) with MD-EGC and 850 patients (890 lesions) with PD-EGC were included. Compared with PD-EGC, MD-EGC had a higher submucosal invasion rate (37.5% vs. 13.7%, P<0.001) and lymphatic invasion rate (10.4% vs. 0.4%, P<0.001). The rates of complete resection (70.8% vs. 92.5%, P<0.001) and curative resection (54.2% vs. 87.4%, P<0.001) in MD-EGC were lower than those of PD-EGC. Multivariate analysis revealed that MD-EGC (OR 4.26, 95% CI, 2.22-8.17, P<0.001) was an independent risk factor for noncurative resection. However, when curative resection was achieved, there was no significant difference in the rates of recurrence (P=0.424) between the 2 groups, whether local or metachronous recurrence. Similarly, the rates of survival(P=0.168) were no significant difference. Despite the greater malignancy and lower endoscopic curative resection rate of MD-EGC, patients who met curative resection had a favorable long-term prognosis.

Characteristics of early gastric tumors with different differentiation and predictors of long-term outcomes after endoscopic submucosal dissection

BACKGROUND Gastric cancer is a common malignant tumor of the digestive tract, and endoscopic submucosal dissection (ESD) is the preferred treatment for early-stage gastric cancer. The analysis of the epidemiological characteristics of gastric mucosal tumors with different differentiation degrees and the influencing factors of long-term ESD efficacy may have certain significance for revealing the development of gastric cancer and ESD. AIM To analyze the features of gastric mucosal tumors at different differentiation levels, and to explore the prognostic factors of ESD. METHODS We retrospectively studied 301 lesions in 285 patients at The Second Affiliated Hospital of Xi'an Jiaotong University from 2014 to 2021, according to the latest Japanese guidelines (sixth edition), and divided them into low-grade intraepithelial neoplasia (LGIN), high-grade intraepithelial neoplasia (HGIN), and differentiated and undifferentiated early carcinoma. They are followed up by endoscopy, chest and abdominal computed tomography at 3, 6 and 12 months after ESD. We compared clinicopathologic characteristics, ESD efficacy, and complications with different degrees of differentiation, and analyzed the related factors associated with ESD. RESULTS HGIN and differentiated carcinoma patients were significantly older compared with LGIN patients (P &lt; 0.001) and accounted for more 0-IIc (P &lt; 0.001), atrophic gastritis was common (P &lt; 0.001), and irregular microvascular patterns (IMVPs) and demarcation lines (DLs) were more obvious (P &lt; 0.001). There was more infiltration in the undifferentiated carcinoma tissue (P &lt; 0.001), more abnormal folds and poorer mucosal peristalsis (P &lt; 0.001), and more obvious IMVPs, irregular microsurface patterns and DLs (P &lt; 0.05) than in the LGIN and HGIN tissues. The disease-free survival rates at 2, 5, and 8 years after ESD were 95.0%, 90.1%, and 86.9%, respectively. Undifferentiated lesions (HR 5.066), white moss (HR 7.187), incomplete resection (HR 3.658), and multiple primary cancers (HR 2.462) were significantly associated with poor prognosis. CONCLUSION Differentiations of gastric mucosal tumors have different epidemiological and endoscopic characteristics, which are closely related to the safety and efficacy of ESD.

Efficacy and safety of endoscopic submucosal dissection for colorectal dysplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis.

In this meta-analysis, we studied the safety and efficacy of endoscopic submucosal dissection (ESD) for colorectal dysplasia in patients with inflammatory bowel disease (IBD). Multiple databases were searched, and studies were retrieved based on pre-specified criteria until October 2022. The outcomes assessed were resection rates, procedural complications, local recurrence, metachronous tumors, and the need for surgery after ESD in IBD. Standard meta-analysis methods were followed using the random-effects model, and I2% was used to assess heterogeneity. Twelve studies comprising 291 dysplastic lesions in 274 patients were included with a median follow-up of 25 months. The pooled en-bloc resection, R0 resection, and curative resection rates were 92.5% (95% confidence interval [CI], 87.9%-95.4%; I2=0%), 81.5% (95% CI, 72.5%-88%; I2=43%), and 48.9% (95% CI, 32.1%-65.9%; I2=87%), respectively. The local recurrence rate was 3.9% (95% CI, 2%-7.5%; I2=0%). The pooled rates of bleeding and perforation were 7.7% (95% CI, 4.5%-13%; I2=10%) and 5.3% (95% CI, 3.1%-8.9%; I2=0%), respectively. The rates of metachronous recurrence and additional surgery following ESD were 10% (95% CI, 5.2%-18.2%; I2=55%) and 13% (95% CI, 8.5%-19.3%; I2=54%), respectively. ESD is safe and effective for the resection of dysplastic lesions in IBD with an excellent pooled rate of en-bloc and R0 resection.

Curative Effect Analysis of Endoscopic Submucosal Dissection in Giant Laterally Spreading Rectal Tumors.

The objective of this study was to investigate the clinical efficacy of endoscopic submucosal dissection (ESD) in the treatment of giant lateral developing rectal-type tumors (laterally spreading tumors, LSTs). There are no specialized studies on the efficacy of ESD in the treatment of LSTs measuring >5cm in diameter, surgery was often used in the past, but it has the disadvantages of large trauma, many complications, and high cost. The data of 185 patients with rectal LSTs who had undergone ESD in the digestive endoscopy center of our hospital from January 2012 to June 2020 were retrospectively analyzed. Based on the size of the lesions, the patients were divided into 2 groups: diameter ≤5cm (110 cases) and diameter >5cm (75 cases), and we summarized and analyzed the en bloc resection rate, curative resection rate, procedure time, muscle injury, bleeding, perforation, postoperative stricture, and recurrence. There was no difference in the en bloc resection rate and R0 resection rate between the 2 groups ( P =0.531). Moreover, there was no difference in the incidence of delayed perforation, postoperative stenosis, and recurrence, but the incidence of delayed bleeding was significantly higher in the giant LST group than the small LST group ( P =0.001). Moreover, for giant rectal LSTs, the growth pattern of the lesion, JNET classification, and the extent of postoperative mucosal defect do not significantly affect the efficacy of ESD. It is worth mentioning that the operation time was longer in the group with a diameter >5cm, in which perforation was more frequent and the muscle layer was more likely to be injured during ESD ( P <0.001). The muscle injury during ESD was mainly related to the diameter of the lesion, the crossing the rectal pouch, and the operation time. The use of ESD to treat giant rectal LSTs (>5cm) is relatively difficult and can easily lead to intraoperative muscle injury, perforation, and late postoperative bleeding. However, if active intervention is performed, patients can still achieve good efficacy and prognosis, which can be applied in hospitals with certain conditions.

[Efficacy of endoscopic submucosal dissection assisted by metal-clip pocket creation traction for colorectal tumors].

To evaluate the clinical efficacy of endoscopic submucosal dissection (ESD) assisted by metal-clip pocketcreation traction for treatment of colorectal tumors. We retrospectively analyzed the clinical data of 244 patients with colorectal tumors undergoing colorectal ESD treatment between January, 2019 and December, 2022, including 169 patients receiving ESD without metal-clip pocket-creation traction (N-ESD group) and 75 with traction-assisted ESD (M-ESD group). Propensity score matching was used to screen the patients using general clinical data as the covariates for matching. Operative time, surgical resection outcome indicators, incidence of adverse events, and histopathological diagnosis indicators were compared between the two groups of patients after matching. The median operative time was significantly shorter in M-ESD group than in N-ESD group (20.0 [15.0, 30.0] vs 30 [20.0, 45.0] min, P=0.008). No significant difference was found in the en bloc resection rate (100% vs 98.6%), complete resection rate (97.3% vs 96%) and radical resection rate (97.3% vs 96%) between the two groups (P>0.05). The incidence of adverse events was low in both groups and showed no significant difference between them (P>0.05). In patients with colorectal tumors, the use of metal-clip pocket-creation traction can shorten the operative time of ESD although it does not significantly reduce the surgical resection rate or incidence of adverse events.

Endoscopic Submucosal Dissection for Treatment of Early-Stage Cancer or Precancerous Lesion in the Upper Gastrointestinal Tract in Patients with Liver Cirrhosis.

(1) Background: Endoscopic submucosal dissection (ESD) has been widely accepted as the standard method for treating early-stage cancer or precancerous lesions in the upper gastrointestinal tract; however, it may be difficult in patients with liver cirrhosis due to clinical challenges such as coagulation dysfunction, presence of gastroesophageal varices, etc. We aimed to demonstrate the safety and efficacy of ESD in these populations. (2) Methods: The clinical data of patients were retrospectively collected and analyzed. Inclusion criteria of the study were: a. patients with liver cirrhosis; b. patients who underwent ESD; c. patients who were diagnosed with early-stage cancer or precancerous lesions in the upper gastrointestinal tract. (3) Results: Eight patients were enrolled from April 2019 to April 2023, of whom three were male and five were female, with ages ranging from 43 to 70 years old. Seven lesions were located in the stomach and one other lesion was in the esophagus. ESD was performed successfully in all eight patients, and the resected lesion size ranged from 2 to 6 cm. Only one patient encountered postoperative complications, namely, chest pain and fever. No recurrence was noticed during a follow-up of 3 to 45 months. (4) Conclusions: ESD may serve as a safe and effective method for treating upper gastrointestinal early-stage cancer or precancerous lesions in patients with liver cirrhosis.

Effectiveness and Safety of Endoscopic Submucosal Dissection for Colorectal Neoplasm in Patients with High Charlson Comorbidity Index Score: A HASID Multicenter Study.

Endoscopic submucosal dissection (ESD) is an effective method for removing early colorectal lesions. However, research on the safety and efficacy of ESD in patients with various underlying conditions remains limited. This study retrospectively examined ESD outcomes in colorectal neoplasm patients from five tertiary medical centers. The Charlson Comorbidity Index (CCI) and age-adjusted CCI (ACCI) were analyzed, and the differences in complete resection and complication rates were analyzed. The CCI, ACCI, and complication rates tended to gradually increase proportionally, and the complication resection rate increased from CCI 2 to ACCI 4 as the starting point, followed by a decreasing trend. Of these, 140 patients (9.7%) had a CCI score of 3 or higher. The high CCI group was older (70.6% vs. 64.7%, p < 0.01) and had a higher proportion of men (70.7% vs. 58.7%, p < 0.01) than the low CCI group. The high CCI group had a higher incidence of cancer than the low CCI group (77.9% vs. 65.2%, p < 0.01). The en bloc resection rate (90.0% vs. 89.3%, p = 0.79) and complete resection rate (75.7% vs. 81.2%, p = 0.12) were not significantly different between the two groups. Colorectal ESD can be safely and effectively performed in patients with various underlying medical conditions.

Comparison of endoscopic submucosal dissection outcomes between early gastric cardiac and non-cardiac cancers: a retrospective single-center study

Objectives This study aims to compare the efficacy of endoscopic submucosal dissection (ESD) between early gastric cardiac cancer (EGCC) and early gastric non-cardiac cancer (EGNCC), and investigate associated risk factors for non-curative resection. Methods Early gastric cancer (EGC) patients who underwent ESD from January 2015 to September 2020 in Beijing Friendship Hospital were consecutively enrolled. The clinical, histopathological and endoscopic data were retrospectively analyzed. The study was registered in Chinese Clinical Trial Registry (ChiCTR1800017117). Results Among 500 patients with 534 EGC lesions, 117 patients with 118 lesions were allocated to the EGCC group, and 383 patients with 416 lesions to the EGNCC group. The rates of en bloc resection, complete resection and curative resection in the EGCC group were 97.5%, 78.8% and 71.2%, respectively, significantly lower than those in the EGNCC group (99.8%, 94.5% and 90.4%, p = .010, <.001 and <.001). Among non-curative resected lesions, EGCC had more cases in both endoscopic curability (eCura) C-1 and C-2 groups than EGNCC (10.2% and 18.6% vs. 2.4% and 7.2%, p < .001). Multivariate analysis showed that tumor size (OR 2.393, 95% CI 1.388–4.126) and submucosal invasion (OR 11.498, 95% CI 3.759–35.175) were risk factors for non-curative resection in the EGCC group. For EGCC larger than 3 cm, none achieved curative resection, 86.7% were classified as eCura C-2 and 46.7% exhibited deep submucosal infiltration. Conclusions The curative resection rate of ESD for EGCC was lower than that for EGNCC. ESD for EGCC larger than 3 cm should be cautiously considered.

Safety and Efficacy of Endoscopic Submucosal Dissection in the Management of Gastric Tube Cancers After Esophagectomy: A Systematic Review.

Esophagectomy is the proposed standard of care for resectable primary esophageal cancers and recurrent lesions in the reconstructed gastric tube (GT); however, it carries significant morbidity and mortality. Endoscopic submucosal dissection (ESD) has established its role in the management of primary esophageal cancers with growing evidence of its safety in resecting recurrent primary lesions in GT. Our study aims to evaluate the safety and efficacy of ESD in the management of recurrent, localized primary esophageal cancers in GT. We searched PubMed, CENTRAL, EMBASE, Scopus, and clinical trial registries from inception to March 2023 for articles evaluating the safety and efficacy of ESD in the management of recurrent cancerous lesions in GT. Our primary outcome was the en bloc resection rate. Secondary outcomes were curative resection rate, complete resection rate, intra-procedural complication rate, post-procedure complication rate, and five-year survival rate. Seven studies with a total of 165 patients undergoing 192 ESDs were included in the review. The pooled en bloc resection rate was 92.5% (95% CI: 87.7-95.6), which was reported in all seven studies. Pooled complete resection rate was 78.9% (95% CI: 64.5-88.5) per three studies, pooled curative resection rate was 73.9% (95% CI: 63.5-82.2) per four studies, and pooled intra-procedural complication rate was 10.2% (95% CI: 1.5-46.3), which was reported in four studies. Only three studies reported a five-year survival rate that was 65.5% (95% CI: 56.0-73.9). ESD is safe and efficacious in the management of GT cancer after esophagectomy.

Safety and feasibility of same-day discharge after endoscopic submucosal dissection: a Western multicenter prospective cohort study.

Recent Western studies support the safety and efficacy of endoscopic submucosal dissection (ESD) for lesions throughout the GI tract. Although admission for observation after ESD is standard in Asia, a more selective approach may optimize resource utilization. We aimed to evaluate the safety and feasibility of same-day discharge (SDD) after ESD and factors associated with admission. This was a post hoc analysis of a multicenter, prospective cohort of patients undergoing ESD (2016-2021). The primary end points were safety of SDD and factors associated with post-ESD admission. Of 831 patients (median age, 67 years; 57% male) undergoing 831 ESDs (240 performed in the esophagus, 126 in the stomach, and 465 in the colorectum; median lesion size, 44mm), 588 (71%) were SDD versus 243 (29%) admissions. Delayed bleeding and perforation occurred in 12 (2%) and 4 (.7%) of SDD patients, respectively; only 1 (.2%) required surgery. Of the 243 admissions, 223 (92%) were discharged after≤24 hours of observation. Interestingly, larger lesion size (>44mm) was not associated with higher admission rate (odds ratio [OR], .5; 95% confidence interval [CI], .3-.8; P= .001). Lesions in the upper GI tract versus colon (OR, 1.7; 95% CI, 1.1-2.6; P= .01), invasive cancer (OR, 1.9; 95% CI, 1.2-3.1; P= .01), and adverse events (OR, 2.7; 95% CI, 1.5-4.8; P= .001) were independent factors for admission. Admissions were more likely performed by endoscopists with ESD volume<50 cases (OR, 2.1; 95% CI, 1.3-3.3; P= .001) with procedure time >75 minutes (OR, 13.5; 95% CI, 8.5-21.3; P< .0001). SDD after ESD can be safe and feasible. Patients with invasive cancer, lesions in the upper GI tract, longer procedure times, or procedures performed by low-volume ESD endoscopists are more likely to be admitted postprocedure. Risk stratification of patients for SDD after ESD should help optimize resource utilization and enhance ESD uptake in the West. (Clinical trial registration number: NCT02989818.).

Comparison of the efficacy of endoscopic submucosal dissection and transanal endoscopic microsurgery in the treatment of rectal neuroendocrine tumors ≤ 2 cm.

Currently, complete tumor resection is considered the most effective treatment for rectal neuroendocrine tumors (NETs). Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are recommended for rectalNETs ≤2 cm, but it is not clear which method is better. Thus, we evaluated the efficacy of ESD and TEM in the treatment of rectal neuroendocrine tumors (NETs) ≤ 2 cm. We conducted a single-centre retrospective cohort study between 2010 and 2021 of rectal NETs ≤ 2cm in 114 patients with long-term follow-up data who were divided into ESD (n=55) and TEM groups (n=59). Our study assessed differences between groups in the complete resection rate of lesions, recurrence rate, surgical complications, procedure time, and length of hospital stay. The co-primary outcomes were the complete resection rate of lesions and the recurrence rate. Compared to that in the ESD group, the complete resection rate was significantly higher in the TEM group (91.5% vs. 70.9%, p=0.005). The median follow-up time was 22 months in our study, and the follow-up outcomes suggested that the rates of recurrence were 1.8% (1/55) and 6.8% (4/59) in the ESD and TEM groups, respectively, with no significant difference between the two groups. The secondary outcomes of the evaluation were surgical complications, procedural time, and length of hospital stay. The rate of complications (gastrointestinal bleeding and perforation) was low in both the ESD (7.3%, 4/55) and TEM (5.1%, 3/59) groups. No difference in hospitalization duration was observed between the two groups in our study. However, the procedure time was significantly shorter in the ESD group than in the TEM group (27.5min vs. 56min, p<0.001). Although the rate of complete resection in the TEM group was higher than that in the ESD group, there was no difference in recurrence rates between the two modalities during long-term follow-up. Depending on the qualities of the available hospital resources in the area, one of the two approaches can be adopted.

Propensity-score matched analysis to evaluate efficacy of endoscopic submucosal dissection for superficial esophageal cancer in gastrectomized patients

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for superficial esophageal cancer (SEC) with high rates of complete resection. However, limited research exists on the efficacy of ESD for SEC in gastrectomized patients. This study aimed to evaluate the efficacy of ESD for SEC in gastrectomized patients. We included 318 patients of SEC treated at our institution between April 2005 and October 2021. To minimize bias between the gastrectomized and non-gastrectomized groups, we conducted a propensity-score matched analysis and compared the ESD outcomes for SEC of the two groups. Of the 318 patients included in the study, 48 and 270 patients were in the gastrectomized and non-gastrectomized groups, respectively. After 1:2 propensity-score matching, we matched 44 patients in the gastrectomized group to 88 patients in the non-gastrectomized group, and found no significant differences in the baseline clinicopathological characteristics. Regarding the ESD outcomes, there were no significant differences in the complete resection rate, procedure time, hospitalized period, and recurrence rates between the two groups. Multivariate analysis also cofirmed that the history of gastrectomy was not a risk factor of the difficult case of esophageal ESD. In conclusion, history of gastrectomy might not negatively affect the ESD outcomes of SECs.

Efficacy of endoscopic submucosal dissection under nasal intubation for superficial pharyngeal cancer

Efficacy of endoscopic submucosal dissection under nasal intubation for superficial pharyngeal cancer

Rectal Condyloma Acuminatum

A woman between 70 and 80 years of age with a history of cervical cancer presented with changes in bowel habit. The patient took prednisolone for cardiac sarcoidosis. Colonoscopy revealed a 20-mm flat, whitish lesion with diffuse reddish speckles in the lower rectum (Figure 1). Based on the medical history and endoscopic findings, we suspected rectal condyloma acuminatum. However, biopsy results could not provide a definitive diagnosis; thus, we performed endoscopic submucosal dissection for excisional biopsy. The resected specimen revealed squamous epithelial cells with vacuolated cytoplasm (Figure 2). P16 staining, a marker of human papillomavirus infection, was diffusely stained. A final diagnosis of condyloma acuminatum was made. The patient was discharged uneventfully. No recurrence was observed 8 months after treatment.Figure 2Resected specimen showing squamous cells with vacuolated cytoplasm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Condyloma acuminatum, a relatively common disease especially in young adults, has an annual incidence ranging from 160 to 289 per 100,000 individuals.1Patel H. Wagner M. Singhal P. Kothari S. Systematic review of the incidence and prevalence of genital warts.BMC Infect Dis. 2013; 13: 39Crossref PubMed Scopus (230) Google Scholar Condyloma acuminatum is a viral wart caused by human papillomavirus infection and can also be observed in immunocompromised patients, such as those taking immunosuppressive agents. Generally, condyloma acuminatum is detected in the perineum, labia, vagina, penis, perianal area, and anal canal. However, it rarely crosses the dentate line to grow into the rectum. Condyloma acuminatum has malignant potential, often developing into atypical epithelium or carcinoma; thus, surgical resection is the first-line treatment. However, recent reports have shown the efficacy of endoscopic submucosal dissection as a curative, minimally invasive option.2Matsumoto K. Sakamoto N. Murakami T. et al.Long-term relapse-free treatment with endoscopic submucosal dissection combined with magnifying narrow-band imaging for a pregnant patient with flat-type condyloma acuminatum: a case report.Clin J Gastroenterol. 2021; 14: 439-445Crossref Scopus (2) Google Scholar There is no consensus on surveillance of rectal condyloma acuminatum; thus, it is reasonable to apply the surveillance recommendations for anal condyloma acuminatum, with follow-ups every 6 to 12 months.3Long K.C. Menon R. Bastawrous A. Billingham R. Screening, surveillance, and treatment of anal intraepithelial neoplasia.Clin Colon Rect Surg. 2016; 29: 57-64Crossref Scopus (30) Google Scholar The authors report no potential competing interests.

Clinical Efficacy of Endoscopic Submucosal Dissection for the Treatment of Duodenal Lesions in Terms of Operative Technique and Management of Complications.

Background and Aims: Duodenal endoscopic submucosal dissection (ESD) has been considered to be the most challenging because of its high incidence of complications, which has hindered the development of duodenal ESD. The aim of this study is to discuss operation tips for duodenal ESD and to assess the efficacy and safety of duodenal ESD. Patients and Methods: Eighty-two patients who underwent ESD in the digestive endoscope center for superficial duodenal epithelial tumors (SDETs) from January 2017 to June 2021 were studied. Patients were divided into three groups according to the occurrence of complications, and the clinical characteristics and surgical efficacy of each group were compared. Results: SDETs in 82 patients were completely removed by ESD, with a 97.5% R0 resection rate. The average size of resected lesions was 23.8 ± 6.5 mm. There were significant differences in lesion size and operation time between the normal and intraprocedural complication groups (P < .05). Similarly, between the normal and delayed complication groups, significant differences were noted in lesion location, size, operation time, occupied circumference, and postoperative hospitalization duration (P < .05). Conclusion: Duodenal ESD is prone to complications that increase the complexity of the procedure. By improving the necessary technique and skills, duodenal ESD remains safe and effective.

S1002 Integration of Endoscopic Submucosal Dissection in a Hospital-Based Practice: A Financial Review

Introduction: Endoscopic submucosal dissection (ESD) is a novel, minimally invasive method for the removal of malignant and premalignant gastrointestinal lesions. Literature has been published establishing the safety and efficacy of ESD and its potential as a replacement for invasive surgery in some patients. Due to a lack of procedure-specific Current Procedural Terminology (CPT) codes many hospitals are challenged with adopting this intricate procedure in a cost-effective manner. The aim of this study was to evaluate the financial metrics from our first three years of ESD practice and gain insight into how to provide this service more cost-effectively. Methods: Financial data was reviewed from ESDs performed at our tertiary care center from 4/2018 to 3/2021 including insurance status, direct costs, charges per case, payments per case, and contribution margin. Pearson’s correlation test was utilized to assess whether charges, payments, and margins correlated within the cohort. Results: A total of 57 procedures were included, of which 7 were performed inpatient (12.2%) and 50 were outpatient (87.8%). Eleven [19.3%] had commercial insurance, 4 [7.0%] had Medicaid, 34 [59.6%] had Medicare, 4 [7.0%] had federal assistance, and 4 [7.0%] utilized a local repayment assistance program. Total charges [median, range] were $1,718,349 [$17,364, $249,687]. Total direct costs were $409,572 [$4,682, $57,446]. Total payments were $217,488 [$1,199, $50,138]. The total contribution margin was -$183,024 [-$3,334, $21,269]. Increasing charges and costs were associated with increased institutional payments while none were associated with contribution margins. Conclusion: The data depicts an overall net loss for nearly all performed ESDs. Notably, only four of the 57 ESDs yielded a positive contribution margin with three of the most recent seven ESDs netting an average of $6,538 per case. This potentially indicates increased financial viability as more experience was gained with both performing and billing ESDs. Standard deviations exceeded the mean in all fields, indicating a significant degree of variability between procedures. Until standardized CPT codes are established, ESD must be undertaken with a cost-conscious and outcomes-focused mindset to reduce institutional losses.Figure 1.: Top: Depicts relation between costs per case in relation to payments showing a strong correlation. Bottom Left: Relation between charges per case and contribution margin (CM). Bottom Right: Relation between payments per case and CM. It is notable that both bottom figures do not have statistically significant correlations. However, if outliers are not considered, there appears to be a clear negative trend in CM with increasing charges and costs per case.

Long-term prognosis after endoscopic submucosal dissection for colorectal tumors in patients aged over 80\xa0years

BackgroundIn Japan, endoscopic submucosal dissection (ESD) is standardized for large colorectal tumors. However, its validity in the elderly population is unclear. We aimed to evaluate the safety and efficacy of ESD for colorectal tumors in elderly patients aged over 80 years.MethodsESD was performed on 178 tumors in 165 consecutive patients aged over 80 years between December 2008 and December 2018. We retrospectively evaluated the clinicopathological characteristics and clinical outcomes of ESD. We also assessed the prognosis of 160 patients followed up for more than 12 months.ResultsThe mean patient age was 83.7 ± 3.1 years. The number of patients with comorbidities was 100 (62.5%). Among all patients, 106 (64.2%) were categorized as class 1 or 2 according to the American Society of Anesthesiologists classification of physical status (ASA-PS), and 59 (35.8%) were classified as class 3. The mean procedure time was 97.7 ± 79.3 min. The rate of histological en bloc resection was 93.8% (167/178). Delayed bleeding in 11 cases (6.2%) and perforation in 7 cases (3.9%) were treated conservatively. The 5-year survival rate was 89.9%. No deaths from primary disease (mean follow-up time: 35.3 ± 27.5 months) were observed. Overall survival rates were significantly lower in the non-curative resection group that did not undergo additional surgery than in the curative resection group (P = 0.0152) and non-curative group that underwent additional surgery (P = 0.0259). Overall survival rates were higher for ASA-PS class 1 or 2 patients than class 3 patients (P = 0.0105). Metachronous tumors (> 5 mm) developed in 9.4% of patients.ConclusionsESD for colorectal tumors in patients aged over 80 years is safe. Colorectal cancer-associated deaths were prevented although comorbidities pose a high risk of poor prognosis.

The Endoscopic Submucosal Dissection Surgery in the Whole-Course Antegrade Endoscopic Approach: A More Effective Treatment Strategy for the Siewert II/III Type Mucosal Lesions of Esophagogastric Junction.

Objective: The purpose of this study was to investigate the safety and efficacy of endoscopic submucosal dissection (ESD) for treating cardiac mucosal lesions. Methods: A total of 86 patients with cardiac mucosal lesions were treated with ESD in retrograde endoscopic approach or antegrade endoscopic approach. The relationship between the two methods was analyzed according to the size, location, depth of pathological infiltration, classification, and examination results. The main evaluation indexes of intraoperative complications were operation time, bleeding, perforation, and complete resection (R0 resection). Results: Total R0 excision was performed in 85 patients and curative excision in 77 patients. When the diameter of lesion was 2-4 cm or >4 cm, the median treatment time in the antegrade endoscopic approach group was shorter than that in the retrograde group (P < .001, respectively). When the lesion was confined to the mucosa, the median treatment time in the antegrade endoscopic approach group was shorter than that in the retrograde group (P < .001). When the lesion was located in the posterior wall of the cardia, the average treatment time in the antegrade endoscopic approach group was shorter than that in the retrograde group (P < .05). When the lesion was located in the lesser curvature of the cardia, the average treatment time in the antegrade endoscopic approach group was shorter than that in the retrograde group (P < .001). Conclusion: The ESD surgery in the antegrade endoscopic approach is effective and safe for the treatment of cardiac mucosal lesions.

Novel approaches to minimize intraoperative bleeding during endoscopic submucosal dissection of a large rectal lateral spreading tumor extended to the dentate line with internal hemorrhoids.

Video 1Endoscopic submucosal dissection (ESD) of large rectal lateral spreading tumors (LSTs) that extend to the dentate line with internal hemorrhoids is a challenging procedure because of the increased risk of bleeding from penetrating and hemorrhoidal vessels and the reduced visual field caused by the dilated venous packages and the narrow anal lumen.This video describes novel technical approaches to minimize the risk of intraoperative bleeding.The described approaches are indicated in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. The described selective-vessel approach is also indicated in any vascularized superficial lesion amenable to endoscopic treatment.ESD was performed in the retroflex view using an Evis Exera II video processor, an H180 gastroscope, an ERBE ICC 200, and CO2 insufflation. As tools, IT-nano, needle knife, hook knife, hemostatic forceps, and a distal cap were used. The lifting solution was a mixture of normal saline, hyaluronic acid, epinephrine, and indigo carmine.A hemicircumferential superficial granular lateral spreading tumor was observed in the lower rectum. Indigo carmine dye spray facilitated the identification of the lesion's margin and demonstrated no ulcer, converging folds, or large nodules. After the submucosal (SM) injection, a shallow mucosal incision was made in the retroflex view using a conventional needle knife, followed by the circumferential incision at the proximal side using an IT-nano. The SM layer was dissected at a superficial level to avoid large SM vessels, thus preventing intraoperative bleeding and maintaining a clean surgical field. Small vessels were selectively coagulated mainly by using the small disc located at the back of the insulated tip as the SM later was superficially dissected. To facilitate precise coagulation, a stepwise dissection technique was used for larger vessels. After identification, the vessel was first exposed by dissecting the surrounding SM layer at the left and right sides using the long blade of IT-nano, with blunt dissection of the surrounding tissue at the vessels' posterior aspect using a Hook knife. Double-vessel sealing using a hemostatic forceps was performed both at the rectal and tumor sides. Lastly, the vessel was transected between sealed segments using the IT-nano, without major bleeding. The circumferential incision was completed at the left side and distally extended to the anal canal where large hemorrhoidal bundles were seen. A needle knife was used to complete the SM dissection and, here, the final cut. En bloc resection was successfully achieved without intraoperative bleeding.The en bloc resected specimen was 85mm in size, and squamous epithelium of the anal canal was observed at the distal margin. Colonoscopy 5 months post-ESD revealed adequate healing, no stenosis and no hemorrhoids.Coagulation and hemostasia should be promptly carried out whenever inadvertent injury to large vessels and subsequent bleeding occurs during lateral exposure, posterior blunt dissection, double coagulation, and transection of vessels.Curative ESD can be achieved in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. Strategies to minimize intraoperative bleeding during ESD should be considered and include the following:•An SM dissection from the proximal tumor margin in the retroflex view to circumvent contact with hemorrhoids.•A differential level of dissection to prevent inadvertent vessel injury-shallow first to avoid large SM vessels and deeper above the muscular layer closer to the dentate line to shut off blood supply by penetrating hemorrhoidal vessels.•Last but not least, a selective approach to vessels to reduce the risk of bleeding, with direct coagulation for small vessels and with lateral exposure, posterior blunt dissection, double-vessel sealing, and transection between sealed segments for larger vessels.