Endoscopic Submucosal Dissection For Lesions Research Articles

Predictors of residual neoplasia after noncurative (R1) endoscopic submucosal dissection of lesions in the gastrointestinal tract.

Endoscopic submucosal dissection (ESD) is a minimally invasive resection technique that enables the en bloc resection of gastrointestinal lesions. Despite en bloc resection, pathological evaluation of lesions can reveal positive vertical or horizontal margins, which is referred to as R1 resection. Not all R1 lesions referred for surgical resection or endoscopic surveillance show evidence of residual tumor. We aimed to identify the predictors of residual neoplasia in patients with an R1 resection following ESD. All lesions resected via ESD between June 2016 and September 2021 at a tertiary referral center were retrospectively identified. Lesions with an R1 resection and adequate follow-up were eligible for inclusion. Patient, lesion, and procedural characteristics were analyzed to identify predictors of residual neoplasia. Of 614 lesions, 163 (28%) had R1 resection. Of these, 56 lesions in 51 patients had complete follow-up and were included. Thirteen patients (25.5%) underwent surgical resection and the remainder underwent endoscopic surveillance. Seven (12.5%) patients had residual disease. All patients with residual disease had esophageal carcinoma. Positive deep and lateral margins, severe submucosal fibrosis, and moderate/poorly differentiated tumors were identified as significant predictors of residual neoplasia. Most R1 lesions (87.5%) resected by ESD did not have residual disease on follow-up. Those without identified risk factors for residual disease, such as esophageal carcinoma, severe submucosal fibrosis, or both histological margin positivity, may benefit from a strategy of close endoscopic surveillance rather than referral for surgical resection.

Endoscopic submucosal dissection for lesions involving the anastomosis after upper gastrointestinal surgery.

Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging due to severe fibrosis, deformity, staples, and limited space for procedure. We aimed to characterize the clinicopathological characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the upper gastrointestinal tract. We retrospectively investigated 43 patients with lesions involving the anastomoses of the upper GI tract who underwent ESD from April 2007 to February 2021. We collected clinicopathological characteristics, procedure‑related parameters and outcomes, and follow‑up data and analyzed the impact of anastomotic involvement. The median duration from previous upper GI surgery was 60months and the median procedure duration was 30min. The rate of en bloc resection and en bloc with R0 resection was 90.7% and 81.4%, respectively. Two patients (4.7%) experienced major adverse events, including delayed bleeding and febrile episode. During a median follow-up of 80months, 3 patients had local recurrence and 4 patients had metastases. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 89.6% and 95.1%, respectively. Compared with the unilaterally involving group, the straddling anastomosis group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and en bloc with R0 resection, and shorter DFS and OS (all P < 0.05). However, rates of adverse events did not differ significantly between the two groups. The short‑ and long-term outcomes of ESD for upper GI anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for anastomotic lesions.

Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum.

Background/AimsEndoscopic submucosal dissection (ESD) for diverticulum-associated colorectal lesions is generally contraindicated because of the high risk of perforation. Several studies on patients with such lesions treated with ESD have been reported recently. However, the feasibility and safety of ESD for lesions in proximity to a colonic diverticulum (D-ESD) have not been fully clarified. The aim of this study was to evaluate the feasibility and safety of D-ESD. MethodsD-ESD was defined as ESD for lesions within approximately 3 mm of a diverticulum. Twenty-six consecutive patients who underwent D-ESD were included. Two strategic approaches were used depending on whether submucosal dissection of the diverticulum-related part was required (strategy B) or not (strategy A). Treatment outcomes and adverse events associated with each strategy were analyzed. ResultsThe en bloc resection rate was 96.2%. The R0 and curative resection rates were 76.4% and 70.6% in strategy A and 88.9% and 77.8% in strategy B, respectively. Two cases of intraoperative perforation and one case of delayed perforation occurred. The delayed perforation case required emergency surgery, but the other cases were managed conservatively. ConclusionsD-ESD may be a feasible treatment option. However, it should be performed in a high-volume center by expert hands because it requires highly skilled endoscopic techniques.

Is General Anesthesia Needed in Endoscopic Submucosal Dissection for Lesions Located in the Mid to Upper Stomach?

Is General Anesthesia Needed in Endoscopic Submucosal Dissection for Lesions Located in the Mid to Upper Stomach?

Feasibility of endoscopic submucosal dissection for colorectal neoplasia at anastomotic sites: a retrospective study.

Metachronous colorectal lesions sometimes occur at anastomotic sites following colorectal surgery, which increases the risk of developing colorectal cancer. However, these lesions are difficult to treat even with minimally invasive methods such as endoscopic submucosal dissection (ESD). Thus, we aimed to evaluate the outcomes of ESD for colorectal lesions at anastomotic sites following colorectal surgery. We retrospectively investigated 11 patients with post-surgical colorectal lesions at anastomotic sites who later underwent ESD from May 2010 to April 2019 at Keio University Hospital, Tokyo, Japan. We examined the patients' background (tumor location, macroscopic type, tumor size, histological type, and depth of invasion) and treatment outcomes (procedure duration, en bloc resection rate, R0 resection rate, and adverse events). The patients' mean age was 66years. There were two lesions in the transverse colon, six in the rectum, one in the anal canal, and two in the ileal pouch. The median tumor size was 25mm. The macroscopic types were the protruded type (1 lesion) and the flat or depressed type (10 lesions). The pathological diagnoses were adenoma (4 lesions), intramucosal cancer (corresponding to high-grade dysplasia) (6 lesions), and muscularis propria cancer (1 lesion). The median procedure duration was 50min; en bloc resection rate was 88.9% and R0 resection rate was 66.7%. The only adverse event was delayed post-ESD bleeding. A high en bloc resection rate without perforation was achieved with ESD for lesions at anastomotic sites. Although ESD for lesions at anastomotic sites is a technically challenging procedure because of severe submucosal fibrosis, this approach could prevent the need for repeated surgical resection.

Feasibility of endoscopic submucosal dissection of lesions at anastomosis site post-colorectal surgery: a case series

Background and study aims Patients who have undergone colorectal surgery for resection of cancer and benign lesions are at risk for recurrent, residual, or metachronous lesions at the anastomosis site. Surgical resection of such lesions is difficult because of adhesions, and a stoma may be required as there are risks for leakage after resection. The feasibility and safety of endoscopic submucosal dissection (ESD) for these lesions remain unknown. Therefore, this case series aimed to examine the feasibility and safety of ESD by evaluating the clinical outcomes. Patients and methods We retrospectively investigated five patients who underwent ESD by a single expert for superficial neoplastic lesions at the anastomosis site after previous colorectal surgery. Results R0 resections were achieved for all lesions. Mean procedure time was 160.6 minutes. Mean dimensions of the resected specimen and tumor were 52.4 mm and 31.8mm, respectively. None of the patients had complications or recurrence after surveillance colonoscopy 1-year post-resection. Conclusions In an expert’s hands, ESD at the anastomosis site might be feasible minimally invasive treatment for superficial neoplastic lesions.

Endoscopic submucosal dissection for early neoplastic lesions in the surgically altered stomach: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) for early gastric cancer is highly effective and well established. Performing ESD in the surgically altered stomach (SAS) is challenging. The aim of this meta-analysis is to assess the safety and efficacy of ESD for patients with early neoplastic lesions occurring in the SAS with a subgroup analysis of lesions occurring on the suture line compared to non-suture line lesions and outcomes in the remnant stomach compared to the gastric tube. We performed a literature search of the PubMed, Embase, and CINAHL electronic databases from January 2000 to November 2017 for articles reporting the safety and efficacy of ESD in the surgically altered stomach. SAS was defined as the remnant stomach following gastrectomy and gastric tube following esophagectomy. Meta-analysis was performed using Review Manager version 5.3 software. A total of 21 articles, with 903 lesions occurring in the remnant stomach or gastric tube, were included in this study. There was no significant difference between en bloc (RR 0.99, 95% CI 0.91-1.08), curative resection (RR 1.03, 95% CI 0.84-1.26), or bleeding rates (RR 1.40, 95% CI 0.18-10.72) between lesions in the remnant stomach and gastric tube. However, perforation was significantly higher in the gastric tube (RR 5.19, 95% 1.27-21.25). Suture line lesions had a significantly higher risk of perforation (RR 4.55, 95% CI 2.13-9.74). ESD for early neoplastic lesions occurring in the SAS is a safe and efficacious with similar en bloc and curative resection rates compared to the anatomically normal stomach. ESD for lesions on the suture line or in the gastric tube is associated with an increased risk of perforation which can be managed endoscopically.

P-068 - Clinical outcomes of endoscopic submucosal dissection for lesions on the proximal location of the stomach

P-068 - Clinical outcomes of endoscopic submucosal dissection for lesions on the proximal location of the stomach

Su1718 FEASIBILITY OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL NEOPLASIA IN ANASTOMOSIS SITE

Metachronous colorectal lesions are sometimes occur in anastomosis site following surgical resection. Due to poor endoscopic maneuverability caused by adhesions in addition to severe postoperative fibrosis, lesions located at anastomotic sites are hard to treat, even with minimally invasive methods such as colorectal endoscopic submucosal dissection (ESD). The feasibility of ESD for colorectal lesion in an anastomotic site following colorectal surgery has not been assessed. In this retrospective study, we evaluated the treatment outcomes of ESD for colorectal lesion in an anastomotic site following colorectal surgery. Of 675 lesions (649 cases) treated with ESD at the Keio University Hospital between May 2010 and June 2017, 9 lesions (8 cases) of anastomotic sites following colorectal surgery were treated with ESD. Colorectal lesion in an anastomotic site was defined as a lesion expanding to an anastomotic site or a lesion requiring resection including an anastomotic site. Patient background (lesion site, macroscopic type, tumor size, histological type, and depth of invasion) and outcomes of treatment (procedure duration, en bloc resection rate, R0 resection rate, and the presence or absence of complications) were examined in this study. The mean age of patients in this study was 63.2 years. The lesions consisted of 4 in the transverse colon, 3 in the rectum, 1 in the anal canal, and 1 in the ileal pouch. The median tumor size (diameter) was 25 mm (range, 12 to 90 mm). The macroscopic types were Is (1 lesion), IIa (7 lesions), and IIc (1 lesion). The pathological diagnoses were adenoma (3 lesions), M cancer (4 lesions), SM cancer (1 lesion), and MP cancer (1 lesion). The median procedure duration was 50 minutes (range, 15 to 150 minutes), the en bloc resection rate was 88.9%, and the R0 resection rate was 66.7%. The only complication was postoperative bleeding. No perforation was observed. A high en bloc resection rate was achieved with ESD for lesions in the anastomotic site without perforation. Although a low R0 resection rate remains a challenge, this probably reflects the difficulty of making a preoperative diagnosis of lesions in the anastomotic site. This approach could avoid repetitive surgical resection. ESD by highly skilled endoscopists appears to be a feasible treatment for colorectal lesion in an anastomotic site.

The role of endoscopic submucosal dissection for Tis/T1 rectal cancer

Background: Colorectal endoscopic submucosal dis-section (ESD) is widely used as a minimally invasive treatment for neoplasms in the colon and rectum. Rectal ESD is generally thought to be less complex than ESD in other segments of the colon, however difficult time-consuming lesions can be en-countered. Here we investigated the short-term outcomes of ESD for lesions in the upper rectum, lower rectum and anal canal. Methods: From February 1998 to January 2017, 404 consecutive patients with 414 lesions of upper rectum (Ra), lower rectum (Rb) and anal canal (P), that underwent ESD at our hospital were analyzed. Age, gender, macroscopic feature, lesion size, location of the lesion, procedure time, histological diagnosis, depth of invasion and adverse effect such as intra-procedural perforation, delayed perforation and delayed bleeding, were evaluated as short-term outcomes. Univariate analysis between the lesions with depth of Tis/T1a and T1b was performed. Results: The number of the lesions located at Ra, Rb and P was 104, 292, and 12, respectively. Mean procedure time was 109.2 minutes (SD ±77.5) and en bloc resection ratio was 95.2%. The overall ratio of curative resection was 80.9%. The ratio of intra-procedural perforation, delayed perforation and delayed bleeding was 1.0%, 0% and 3.9%, respectively. When comparing T1b lesions to Tis/T1a lesions, there is no difference in lesion size, procedure time, intra-procedural or delayed perforation ratio and delayed bleeding ratio between the two groups. Positive margins were encountered more frequently in the T1b group compared to the Tis/T1a group (21.0% vs. 5.5%). Conclusions: ESD is feasible for Tis and T1a rectal cancers from the aspect of short-term outcomes and quality of life (QOL) for patients. Incomplete resection was still a problem for T1b cancers and collaboration between endoscopists who perform ESD and surgery has potential in the future.

French comment on article: Feasibility and safety of endoscopic submucosal dissection for lesions involving the ileocecal valve.

French comment on article: Feasibility and safety of endoscopic submucosal dissection for lesions involving the ileocecal valve.

Feasibility and safety of endoscopic submucosal dissection for lower rectal tumors with hemorrhoids.

To evaluate the feasibility and safety of endoscopic submucosal dissection (ESD) for lower rectal lesions with hemorrhoids. The outcome of ESD for 23 lesions with hemorrhoids (hemorrhoid group) was compared with that of 48 lesions without hemorrhoids extending to the dentate line (non-hemorrhoid group) during the same study period. Median operation times (ranges) in the hemorrhoid and non-hemorrhoid groups were 121 (51-390) and 130 (28-540) min. The en bloc resection rate and the curative resection rate in the hemorrhoid group were 96% and 83%, and they were 100% and 90% in the non-hemorrhoid group, respectively. In terms of adverse events, perforation and postoperative bleeding did not occur in both groups. In terms of the clinical course of hemorrhoids after ESD, the rate of complete recovery of hemorrhoids after ESD in lesions with resection of more than 90% was significantly higher than that in lesions with resection of less than 90%. ESD on lower rectal lesions with hemorrhoids could be performed safely, similarly to that on rectal lesions extending to the dentate line without hemorrhoids. In addition, all hemorrhoids after ESD improved to various degrees, depending on the resection range.

Endoscopic submucosal dissection for duodenal tumors: a single-center experience

The indications for endoscopic submucosal dissection (ESD) for duodenal tumors have not yet been established. We reviewed our experience of ESD performed for duodenal tumors. We analyzed the data of a total of 13 patients with 14 duodenal lesions (excluding papillary lesions) comprising 2 early cancers, 5 adenomas, and 7 neuroendocrine tumors, who were treated by ESD between 2005 and 2011. The mean tumor diameter was 12.7 ± 14.8 mm. En bloc resection was achieved in 85.7% of the cases. The procedure time was 89.1 ± 64.6 minutes. Intraoperative perforation occurred in three cases. The mean length of postoperative hospitalization was 8.4 ± 2.4 days. Because ESD for duodenal lesions was associated with a higher incidence of perforation than ESD for lesions in other locations (stomach, esophagus, and colon) reported previously, its use for duodenal lesions should be considered with caution.

Safety and curative ability of endoscopic submucosal dissection for superficial esophageal cancers at least 50 mm in diameter

Limited data are available regarding the use of endoscopic submucosal dissection (ESD) for superficial esophageal cancers ≥ 50 mm in diameter. The aim of the present study was to investigate the safety and success of ESD for superficial esophageal cancers ≥ 50 mm. A total of 39 patients with superficial esophageal squamous cell carcinoma ≥ 50 mm were treated with ESD at Osaka Medical Center for Cancer and Cardiovascular Diseases between January 2004 and April 2011, and were analyzed in a retrospective study. En bloc resection was achieved in all patients. One mediastinal emphysema without perforation occurred during the procedure. Stricture developed in 11 of 39 patients, requiring a median of five endoscopic balloon dilatation procedures. Thirty-three clinical epithelial or lamina propria mucosal cancers were treated by ESD with curative intent, of which invasion into the muscularis mucosa or deeper was detected in seven and lymphovascular involvement in three. The en bloc resection rate was 100% with a tumor-free margin achieved in 92% of lesions. The curative resection and complication rates during ESD were 70% and 2.5%, respectively. ESD achieved a high en bloc resection rate of 92% with a tumor-free margin. Curative resection rate of ESD in patients with clinical epithelial or lamina propria mucosal cancers was not low at 70%. However, the risk of stricture must be taken into account when considering the use of ESD in lesions ≥ 50 mm.

Ulcerous Change Decreases the Accuracy of Endoscopic Ultrasonography Diagnosis for the Invasive Depth of Early Gastric Cancer

With the development of endoscopic submucosal dissection, an expansion of the criteria for local treatment was suggested for lesions with ulcerous changes or undifferentiated-type adenocarcinoma. To determine the efficacy of endoscopic ultrasonography for such lesions, we retrospectively analyzed factors that influenced accurate diagnosis by endoscopic ultrasonography of the depth of tumor invasion. We investigated 267 gastric adenocarcinomas for which histopathological results were obtained by endoscopic mucosal resection or gastrectomy. The lesions were divided into four groups by histological type and the presence of ulcerous changes. Five clinicopathological factors were assessed for their possible associations with incorrect diagnosis. The positive predictive value (PPV) for cancer limited within the mucosa (endoscopic ultrasonography, EUS-M) and cancer invaded into the submucosal layer (EUS-SM) were 88.0% (125 of 142 lesions) and 60.0% (30 of 50 lesions), respectively. The lesions diagnosed as EUS-M/SM borderline (37 lesions) included 19 lesions (51.4%) of M cancer and 17 lesions (45.9%) of SM cancer. In logistic analysis, ulcerous changes (p < 0.0001) and macroscopic classification (p = 0.0284) were factors that caused incorrect diagnosis by endoscopic ultrasonography. In the group having differentiated-type adenocarcinoma with ulcerous changes, the PPV of EUS-SM was 25% (3 of 12), and there was a significant difference (p < 0.05) between the EUS-SM of this group and that of the differentiated-type adenocarcinoma without ulcerous changes. The accuracy of endoscopic ultrasonography tumor staging was not sufficient for the lesions with ulcerous changes in our study. Therefore, we should be careful to perform endoscopic submucosal dissection for lesions with ulcerous changes.