Endoscopic Mucosal Resection Research Articles (Page 1)

Tip-in underwater endoscopic mucosal resection for a flat gastric tumor

Thermal ablative methods (such as argon plasma coagulation (APC) and soft tip snare coagulation (STSC) are commonly used to treat polyp margins. We aim to appraise the current literature and compare clinical outcomes between patients with treated (with APC vs. STSC) and non-treated endoscopic mucosal resection (EMR) margins. We searched major databases from inception until November 2023 for randomly controlled trials (RCTs) comparing EMR of large non-pedunculated colorectal polyps with and without treated margins. Pooled data were analyzed for the primary outcome of recurrence at first screening colonoscopy, and adverse events. Analysis was performed using a random effects model and data were reported using 95% CIs. A total of 5 RCT's were found, which included 1020 polyps (577 in treatment and 443 in control groups). Three studies included treatment with STSC and 3 studies used APC as the modality for margin ablation. Of the included patients, 53% were female and the average age was similar between treatment and control groups (65.9 vs. 66.1y). Seventy-one percent of lesions were proximal to the splenic flexure. The mean follow-up to the first colonoscopy and average polyp size were comparable (6.3 vs. 6.2mo; 28.2 vs. 28.0mm, respectively). Pooled analysis showed that margin ablation was associated with significantly lower rates of recurrence [odds ratio (OR) 0.267, 95% CI 0.18-0.4, P<0.001] with low heterogeneity between studies (I2=0%, P=0.47). Pooled analysis showed no significant difference between STSC and APC in terms of recurrence (OR 0.6, 95% CI 0.27-1.7, I2=0%, P=0.3) or adverse events (OR 0.67, 95% CI 0.3-1.6, I2 13%, P=0.46). Our study shows that ablation of EMR margins is very effective at preventing recurrence at first surveillance colonoscopy. We found no difference between STSC or APC in terms of polyp recurrence or adverse outcomes.

The ideal resection strategy for rectal neoplasms extending to the dentate line (RNDLs) remains unclear. Transanal surgical approaches and endoscopic mucosal resection (EMR) have their limitations related to inadequate visualization, device maneuverability, and securing an adequate margin on the anal side. Endoscopic submucosal dissection (ESD) appears to overcome some of the limitations of transanal surgical and snare-based endoscopic techniques. Therefore, we evaluated the safety and efficacy of ESD for resection of distal rectal lesions within 2cm of the dentate line. This is a large-scale multicenter retrospective study of patients who underwent ESD for RNDLs between 2015 and 2023. The primary outcomes were the rates of R0 and en bloc resection. Secondary outcomes were immediate and delayed adverse events. A total of 255 patients across 20 institutions were included (mean age 63.60, women 52.20%). The median lesion size was 40mm (IQR: 30 to 55), and the median resection time was 110 minutes (IQR: 81 to 169). The en bloc resection rate was 93.70% (n=236), and the rate of R0 resection was 85.40% (n=216). The rate of overall adverse events was 8.70% (n=22, 95% CI: 5.22% to 12.17%), with 13 cases of bleeding (5.10%), 4 cases of full-thickness perforation, and 1 case of postprocedural pain requiring intervention. All AEs were managed conservatively without the need for subsequent surgical or endoscopic interventions. ESD is safe and effective for resecting RNDLs with high en bloc and R0 resection rates, offering the potential for complete resection with minimal morbidity. It offers advantages over TEN, TAMIS, and other forms of transanal surgery due to the anatomy being less conducive to the equipment required for these techniques, lower cost, and lower rates of complications. However, careful patient selection, meticulous procedural planning, and close follow-up are essential to ensure optimal outcomes and minimize the risk of complications. Long-term follow-up studies and additional prospective controlled trials are warranted.

Endoscopic resection (ER) is curative for early-stage oesophageal adenocarcinoma (OAC) without high-risk features. Piecemeal endoscopic mucosal resection (pEMR) prevents assessment of lateral margins, complicating risk estimation for neoplastic recurrence. We investigated the risk factors for residual and recurrent OAC post-pEMR. We performed a longitudinal study of two independent patient cohorts: the test cohort who underwent piecemeal or en-bloc ER (n=140) and the validation cohort who underwent pEMR only (n=89). Inclusion criteria were: OAC stage T1a or low-risk T1b, no lympho-vascular invasion, and R0 resection. The primary outcome was residual OAC at first post-ER endoscopy, and secondary outcomes were residual neoplasia (high-grade dysplasia and/or OAC), recurrence of neoplasia at any post-ER endoscopy, and remission of neoplasia, dysplasia and metaplasia at most recent endoscopy. In the test cohort, the incidence of neoplastic recurrence was higher in patients treated with pEMR (n=54, 49%) versus en-bloc ER (n=7, 23%) (p=0.021). The percentage of pEMR specimens with OAC was an independent risk factor for residual OAC at the first post-pEMR endoscopy (OR for a 10% increase=1.24, CI=1.03-1.51, p=0.025). A 50% cut-off of pEMR specimens with OAC was optimal to predict residual OAC (specificity=0.68, sensitivity=0.63). Rates of residual (p=0.039) and recurrent (p=0.0052) OAC were higher when >50% of pEMR specimens were involved by OAC. In the validation cohort, recurrent OAC was also more frequent when cancer burden was >50% (p=0.013). High cancer burden on pEMR specimens correlates with the risk of residual OAC. Post-pEMR site check before endoscopic ablation is recommended if more than 50% of pEMR specimens show OAC.

Reply to the comments on 'Utility of underwater endoscopic mucosal resection combined with a protruding anchor by saline injection for superficial non-ampullary duodenal tumors: a retrospective study in Japan'.

Is the underwater injection endoscopic mucosal resection technique suitable for T1 colorectal cancer?

BACKGROUNDEndoscopic cold snare resection (CSP) can enhance postoperative recovery and minimize bleeding risk in patients with 5-15 mm colorectal polyps. However, more detailed evaluations are required to assess their advantages over conventional methods.AIMTo evaluate the effects of endoscopic CSP on postoperative recovery and bleeding risk in patients with 5-15 mm colorectal polyps.METHODSThis randomized controlled study included 193 patients (mean age: 57.91 ± 5.41 years; 97 men and 96 women) with 5-15 mm colorectal polyps treated at Dongyang People's Hospital between March and June 2023. The patients were randomly assigned to the experimental group (n = 100), who underwent CSP, and the control group (n = 93), who underwent conventional endoscopic mucosal resection (EMR). Operation time, hospital stay, dietary status, and bleeding rate within 3 days were compared.RESULTSThe CSP group had significantly shorter operation times (15.02 ± 2.44 minutes vs 18.78 ± 5.48 minutes, P < 0.001) and hospital stays (3.11 ± 1.08 days vs 4.89 ± 1.35 days, P < 0.001) than the EMR group. The fasting rate on the day of surgery was also lower in the CSP group (P < 0.05). The complete resection rates were similar between groups (98.00% vs 94.62%, P = 0.210), and no perforations occurred in either group. The 3-day postoperative bleeding rate was slightly lower in the CSP group (2.00%) than in the EMR group (6.45%), although this difference was not statistically significant (P = 0.234), indicating limited clinical relevance.CONCLUSIONCSP was safe and efficient for removing 5-15 mm colorectal polyps, offering faster recovery and comparable safety to EMR. The procedural efficiency of CSP supports its broad clinical application.

A tailgut cyst is a rare tumor arising from the persistent embryonic remnants of the postanal gut. The cyst is usually located in the retrorectal space, lying anterior to the sacrum and posterior to the rectum. In rarer cases, it is occasionally found at the perirenal, perianal, subcutaneous, and intradural sites. A 60-year-old woman visited the authors' clinic for a routine health screening examination. Colonoscopy revealed a subepithelial tumor, measuring 5 mm in diameter and located in the lower rectum near the anal sphincter, which may be a neuroendocrine tumor. An endoscopic mucosal resection (EMR) was performed for an accurate histologic diagnosis and treatment, and the rectal lesion was completely removed en bloc and then diagnosed as a tailgut cyst. This paper reports a case of a rectal tailgut cyst treated with EMR in a 60-year-old woman. The 12-month follow-up showed no evidence of recurrence. To the best of the authors' knowledge, this is the second reported case worldwide of a rectal tailgut cyst successfully treated with an EMR, and the first such case reported in Korea.

The widespread use of screening endoscopy has increased the detection rate of ampullary neoplasms. Most of these lesions are adenomas or carcinomas. The recurrence rates after an endoscopic papillectomy have been reported to range from 5% to 40%, even in cases with pathologically confirmed complete resection. An endoscopic mucosal resection (EMR) is commonly performed for residual or recurrent lesions, and endoscopic ablation therapies, such as argon plasma coagulation, may be used either as an alternative to or in conjunction with EMR. Recently, radiofrequency ablation (RFA) has garnered attention as a potential alternative to surgical treatment for intraductal residual or recurrent ampullary neoplasms after an endoscopic papillectomy, showing a 75.7% clinical success rate. In cases of recurrence after initial RFA, additional RFA has enabled oncologic control in nearly all patients without the need for surgery. Nevertheless, further prospective studies and accumulation of evidence are necessary to establish the efficacy and safety of RFA in this setting.

Background:Endoscopic submucosal dissection (ESD), though effective in the treatment of gastric stromal tumor (GST), is limited by difficult procedures, a long learning curve and a high hospital cost. It is of great clinical value to explore new effective, simple, and safe surgical methods.Methods:The basic data were collected from 25 patients with GSTs < 1.0 cm in diameter who were randomized into endoscopic ligator-assisted mucosal resection (EMR-L) group (n = 12) and ESD group (n = 13). The efficacy in 2 groups was compared in terms of operation duration, cost, complication, length of stay (LOS) and complete resection rate.Results:The complete resection rate of GST was 100% in both groups. In the EMR-L group, the average operation duration was 16.92 ± 4.76 minutes, the average LOS was 6.12 ± 1.55 days, and the average hospital cost was 17,136.87 ± 2959.80 yuan. In the ESD group, the average operation duration was 46.46 ± 12.27 min, the average LOS was 7.53 ± 2.24 days, and the average hospital cost was 22,760.24 ± 5199.45 yuan.Conclusions:EMR-L and ESD can achieve the same safety and complete resection rate, but the former has the advantages of simple operation, short operation duration and low hospital cost. EMR-L may serve as a new option for the treatment of GSTs.

ABSTRACTEndoscopic mucosal resection (EMR) has been widely adopted as an endoscopic treatment for colorectal tumors. However, in non‐lifting lesions, EMR often becomes technically challenging, leading to piecemeal resection or residual tumor. Recently, underwater EMR (UEMR) has been developed as a novel technique that allows mucosal and submucosal layers to float under water, facilitating snare resection without submucosal injection. UEMR has been reported to improve en bloc resection rates and shorten procedure time compared with conventional EMR, and its usefulness has been demonstrated in non‐lifting and residual lesions. We encountered a case in which a 78‐year‐old woman had a small IIa+IIc‐type lesion of the sigmoid colon that could not be completely removed by EMR at a previous hospital due to non‐lifting and snare slippage, resulting in only partial resection. She was subsequently referred to our hospital for further treatment. At our hospital, UEMR was successfully performed, achieving en bloc resection. Histopathological examination revealed well‐differentiated tubular adenocarcinoma with 560 µm submucosal invasion, negative resection margins, and no lymphovascular invasion, thus fulfilling the criteria for curative resection. This case highlights the illustrative and educational significance of applying UEMR, rather than endoscopic submucosal dissection, to achieve a safe and time‐efficient curative resection for a small non‐lifting colorectal carcinoma. UEMR may represent a potential salvage option in selected EMR‐difficult cases, although further accumulation of cases is warranted to clarify its role.

Although rectal neuroendocrine tumors (NETs) ≤1 cm in size are generally considered low-risk tumors that are suitable for endoscopic resection, the long-term outcomes after histologically complete resection remain unknown. We conducted a multicenter retrospective cohort study of patients with rectal NETs who underwent complete endoscopic resection (endoscopic mucosal resection or endoscopic submucosal dissection) between January 2014 and December 2019. A total of 860 patients with ≥6 months of follow-up were included. Recurrence-free survival and its associated risk factors were analyzed using Kaplan-Meier and Cox proportional hazards models. Among 860 patients, the mean age was 47.7 years, and 57.9% of the patients were male. The overall recurrence rate was 1.4% (n=12). Univariate and multivariate analyses identified histological grade 2 (hazard ratio [HR], 19.13; 95% confidence interval [CI], 3.51 to 104.22) and mitotic count 2-20/10 high-power field (HPF) (HR, 20.88; 95% CI, 1.61 to 270.19) as independent predictors of recurrence, while >20/10 HPF (HR, 7.93; 95% CI, 0.90 to 69.87) showed a marginal association. The pathological tumor size, resection method, endoscopic ultrasonography findings, and Charlson Comorbidity Index were not associated with recurrence. The 5-year and 9-year recurrence-free survival rates were 98.4% and 84.7%, respectively. Supplementary analysis excluding patients with missing data confirmed consistent findings. Although recurrence is rare after the complete resection of rectal NETs ≤1 cm in size, patients with grade 2 tumors or a mitotic count ≥2/10 HPF are at increased risk. Risk-adapted follow-up based on histological features should be considered.

Accurate in vivo assessment of rectal lesion invasion remains challenging despite advances in high-definition endoscopy and AI-assisted diagnostics. Some lesions resected endoscopically for presumed superficial pathology are ultimately found to contain submucosal invasive adenocarcinoma (pT1), prompting reconsideration of treatment. While total mesorectal excision (TME) remains the standard for radical oncologic removal, its morbidity has increased interest in organ-preserving approaches such as transanal endoscopic microsurgery (TEM). We conducted a retrospective, single-centre study including all consecutive patients who underwent TEM after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of rectal lesions unexpectedly diagnosed as pT1 adenocarcinoma. Patients treated between 1995 and 2024 with at least 12months of follow-up were included. Primary endpoints were overall survival (OS) and disease-free survival (DFS); secondary endpoints included residual disease in the TEM specimen and patterns of recurrence. Sixty-six patients were included. TEM identified residual dysplasia in 25 patients (37.9%) but no cases of residual invasive carcinoma. Surgical margins were clear in all cases. Only one patient (1.5%) required salvage TME due to adverse histological features. At a median follow-up of 15months, OS was 100% and DFS 97%, with two patients (3%) experiencing local recurrence successfully managed with salvage surgery. No distant metastases were observed. No stoma formation or major complications occurred. In patients with incidental pT1 rectal adenocarcinoma following EMR or ESD, completion TEM provides excellent short-term oncological outcomes with minimal morbidity. This two-step, organ-preserving approach appears oncologically adequate in well-selected low-risk patients and offers a viable alternative to radical surgery, especially when maintaining function is a priority.

Corynebacterium striatum, which inhabits the human skin and mucous membranes, is generally considered to have low pathogenic potential. It rarely causes infectious endocarditis in immunocompetent hosts without underlying cardiac disease. We report a case of infectious endocarditis caused by multidrug-resistant Corynebacterium striatum in a 75-year-old man with no history of cardiac disease or other predisposing conditions following endoscopic mucosal resection of the rectum. When C. striatum is isolated from blood cultures, careful evaluation of potential underlying risk factors is essential to distinguish true infection from contamination.

BACKGROUNDWith the rising use of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR), patients are increasingly questioning various aspects of these endoscopic procedures. At the same time, conversational artificial intelligence (AI) tools like chat generative pretrained transformer (ChatGPT) are rapidly emerging as sources of medical information.AIMTo evaluate ChatGPT’s reliability and usefulness regarding ESD and EMR for patients and healthcare professionals.METHODSIn this study, 30 specific questions related to ESD and EMR were identified. Then, these questions were repeatedly entered into ChatGPT, with two independent answers generated for each question. A Likert scale was used to rate the accuracy, completeness, and comprehensibility of the responses. Meanwhile, a binary category (high/Low) was used to evaluate each aspect of the two responses generated by ChatGPT and the response retrieved from Google.RESULTSBy analyzing the average scores of the three raters, our findings indicated that the responses generated by ChatGPT received high ratings for accuracy (mean score of 5.14 out of 6), completeness (mean score of 2.34 out of 3), and comprehensibility (mean score of 2.96 out of 3). Kendall’s coefficients of concordance indicated good agreement among raters (all P < 0.05). For the responses generated by Google, more than half were classified by experts as having low accuracy and low completeness.CONCLUSIONChatGPT provided accurate and reliable answers in response to questions about ESD and EMR. Future studies should address ChatGPT’s current limitations by incorporating more detailed and up-to-date medical information. This could establish AI chatbots as significant resource for both patients and health care professionals.

BACKGROUNDImplementing nursing interventions in patients undergoing endoscopic treatment for intestinal polyps and early stage cancer can serve as a reference for reducing the incidence of complications, accelerating the recovery process, and improving the quality of life.AIMTo impact of systematic nursing intervention on recovery, complications prevention, and quality of life after endoscopic surgery for intestinal polyps.METHODSThis retrospective study included 157 patients who underwent endoscopic mucosal resection or endoscopic submucosal dissection at our hospital. The patients were divided into intervention and conventional groups, with no significant differences in age, sex, or surgical methods. The intervention group received multidimensional nursing interventions, including preoperative evaluation, intraoperative cooperation, postoperative rehabilitation, psychological support and nutritional management. The conventional group received standardized care. Clinical efficacy, inflammation and infection indicators, complication rates, rehabilitation indicators, and visual analog scale (VAS) scores were compared.RESULTSOn the 7th day after surgery, C-reactive protein (CRP) and white blood cell levels were lower in the intervention group than in the conventional group. Complications occurred in 9.33% of the patients in the intervention group and 23.17% in the conventional group, with significant differences in fever and abdominal distension. The intervention group had shorter first exhaust and hospitalization durations than the control group. By day 3 post-surgery, the intervention group showed lower VAS scores and reduced anxiety and depression. High-risk factors included diabetes [relative risk (RR) = 2.43, 95%CI: 1.21-4.86], laparotomy (RR = 2.86, 95%CI: 1.22-6.71), CRP > 15 mg/L (RR = 3.12, 95%CI: 1.54-6.33), and procalcitonin > 0.5 ng/mL 1 day after surgery (RR = 2.91. 95%CI: 1.31-6.44), while systematic nursing interventions (OR = 0.40, 95%CI: 0.18-0.89) reduced the complication risk by 60%.CONCLUSIONMultidimensional nursing interventions have clinical value in endoscopic treatment of intestinal polyps and early stage cancer, reducing complications and hospital stay. This study provides a basis for establishing patient-centered guidelines.

Endoscopic resection is now the standard of care for the management of colorectal polyps. With increased training and expertise in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), it is important to recognize their complementary roles, as well as their individual strengths and limitations. Here, we draw upon the experience of a real patient scenario to provide a case-based review on EMR and ESD. We will review evidence-based technical refinements to EMR which have improved procedural safety and decreased recurrence rates, as well as how expanded access to ESD and enhanced training has resulted in improvements in outcomes and adverse events. Finally, we will discuss how lesion, patient, and endoscopist factors influence the overall endoscopic resection strategy. EMR and ESD are complementary tools in the modern endoscopic resection toolkit, and the correct resection strategy draws upon a deep understanding of the tools available and is individualized based upon patient, endoscopist, and lesion characteristics.

Introduction: Extramedullary plasmacytoma is a rare manifestation of monoclonal plasma cell disorders, typically involving the upper aerodigestive tract. Gastrointestinal involvement is uncommon, and synchronous lesions in separate GI sites are particularly rare. Case Report: A 58-year-old male was referred to the Gastroenterology department following the incidental identification of two subepithelial lesions, measuring 10 mm and 15 mm in the transverse and descending colon, respectively, during routine screening colonoscopy. A subsequent hospital-based colonoscopy confirmed these lesions and revealed additional nodular subepithelial lesions in the terminal ileum. Endoscopic biopsies were inconclusive. One colonic and one ileal lesion were removed via endoscopic mucosal resection. Histopathological and immunohistochemical analysis confirmed IgG-kappa extramedullary plasmacytomas. Further hematological evaluation revealed no cytopenias, renal dysfunction, or hypercalcemia. Skeletal survey was unremarkable, and bone marrow biopsy showed phenotypically normal plasma cells. Given the multifocal gastrointestinal involvement, systemic therapy with bortezomib, dexamethasone, and lenalidomide was initiated, and the patient was referred for autologous stem cell transplantation. Conclusion: This case involves a rare entity with an exceptionally uncommon presentation – multifocal gastrointestinal plasmacytomas – posing unique diagnostic and therapeutic challenges that require a multidisciplinary approach. Early recognition is crucial, given the risk of progression to multiple myeloma and the need for timely, effective intervention.

The incidence of delayed bleeding after endoscopic mucosal resection (EMR) of colorectal tumors has been reported to be approximately 1.1-1.7%. Some studies have shown that clipping after EMR does not significantly reduce delayed bleeding. Delayed bleeding after colorectal EMR with clips often occurred due to gaps in the clips or the detachment of mucosal areas that were heavily affected by coagulation. To prevent this complication, the perfect closure (PC) technique, with conditions such as secure clipping closely together without any gaps, including not only the ulcer but also the coagulated mucosa as the suture range, and avoiding "clip-on-clip" placement as far as possible, is considered important against delayed bleeding after colorectal EMRs. In this study, in order to verify the usefulness of the PC technique, we conducted a prospective study of patients who underwent PC after colorectal EMR was performed in two clinics and three hospitals. 1744 lesions (1133 patients) were evaluated. No post-procedural bleeding occurred in any patient. The average number of clips used for one lesion was 4.71 ± 2.04, and the average tumor diameter was 8.0 ± 3.78 (5-26) mm. The rate of post-procedural bleeding was 0%. In addition, the analysis of the results using a Monte Carlo simulation showed medical and economic advantages compared to previous studies in which clip closure was performed after colonic EMR. PC has the potential to be an excellent method for preventing postoperative bleeding after colorectal EMRs.

Machine learning-based prediction of short-term recurrence of colorectal adenomatous polyps following EMR: model development and validation study.