Endoscopic Submucosal Dissection Procedure Time Research Articles

Endoscopic submucosal dissection and endoscopic mucosal resection for esophageal and gastric lesions: A comparison of procedures

ObjectiveEsophageal and gastric lesions are effectively managed with minimally invasive upper endoscopic procedures such as endoscopic mucosa resection (EMR) and endoscopic submucosal dissection (ESD), offering patients alternatives to invasive interventions. While ESD is well established in Eastern Asia, its adoption in Denmark for superficial esophageal cancer is recent. This study presents real-world data on the feasibility, safety, and hospitalization duration associated with ESD and EMR for esophageal and gastric lesions. MethodsA retrospective analysis was conducted on patients who underwent ESD or EMR at a specialized center in Denmark from October 2016 to June 2022. Data on treatment, indication, lesion location, hospitalization duration, procedure duration, specimen size, complications, recurrence, and one-year overall survival were collected. Statistical comparisons utilized the Mann–Whitney U test, independent sample median test, and chi-squared test. ResultsThe study included 130 patients (144 procedures): 72 underwent ESD and 58 underwent EMR. Compared with EMR, ESD resulted in greater percentages of en bloc and R0 resections (98.8% vs. 64.1%, p < 0.001; and 83.9% vs. 23.8%, p < 0.001), greater complication rates (28.7% vs. 3.1%, p < 0.001) and longer procedure times (119.5 min vs. 37.0 min, p < 0.001). The ESD procedure time significantly decreased over time (p = 0.01). The local recurrence rates were 14.5% for ESD and 23.8% for EMR (p = 0.767). The one-year overall survival rates were similar between the groups (95.8% vs. 94.8%, p = 0.553). ConclusionBoth ESD and EMR are safe and viable for treating esophageal and gastric lesions. ESD offers advantages but requires more time and skill. These findings support the literature, emphasizing the importance of considering patient-specific factors and surgeon proficiency in selecting the appropriate procedure.

Device-assisted traction methods in colorectal endoscopic submucosal dissection and options for difficult cases.

Endoscopic submucosal dissection (ESD) procedure has a longer procedure time and higher perforation rate than endoscopic mucosal resection owing to technical complications, including a poor field of vision and inadequate tension for the submucosal dissection plane. Various traction devices were developed to secure the visual field and provide adequate tension for the dissection plane. Two randomized controlled trials demonstrated that traction devices reduce colorectal ESD procedure time compared with conventional ESD (C-ESD), but they had limitations, including a single-center fashion. The CONNECT-C trial was the first multicenter randomized controlled trial comparing the C-ESD and traction device-assisted ESD (T-ESD) for colorectal tumors. In the T-ESD, one of the device-assisted traction methods (S-O clip, clip-with-line, and clip pulley) was chosen according to the operator's discretion. The median ESD procedure time (primary endpoint) was not significantly different between C-ESD and T-ESD. For lesions ≥ 30 mm in diameter or in cases treated by nonexpert operators, the median ESD procedure time tended to be shorter in T-ESD than in C-ESD. Although T-ESD did not reduce ESD procedure time, the CONNECT-C trial results suggest that T-ESD is effective for larger lesions and nonexpert operators in colorectal ESD. Compared with esophageal and gastric ESD, colorectal ESD has some difficulties, including poor endoscope maneuverability, which may be associated with prolonged ESD procedure time. T-ESD may not effectively improve these issues, but a balloon-assisted endoscope and underwater ESD may be promising options and these methods can be combined with T-ESD.

Factors associated with increased duration of endoscopic submucosal dissection for rectal tumors: a 22-year retrospective analysis

Colorectal endoscopic submucosal dissection (ESD) is widely used in several countries. However, it is associated with technical difficulties. Rectal ESD is considered an intermediate step in colorectal ESD training. Nevertheless, some rectal lesions require a longer procedure time than usual, and the reason for the prolonged time taken for these specific lesions remains unclear. Therefore, this study aimed to clarify the factors associated with prolonged rectal ESD. In total, 483 rectal lesions resected using ESD from February 1998 to June 2021 were investigated. Prolonged ESD procedure time was defined as the time from the first submucosal injection to lesion removal exceeding 120 minutes, whereas other procedures were defined as average ESD procedure time. Clinicopathologic and endoscopic findings were compared between the 2 groups using univariate and multivariate analyses. One hundred forty-four lesions were resected using a prolonged ESD procedure time of 202.9 ± 92.3 minutes, whereas 339 lesions were resected using an average ESD procedure time of 77.8 ± 29.4 minutes. Multivariate analysis revealed that tumors involving the dentate line (P= .026), resection size≥50mm (P< .001), invasion depth≥T1b (P= .006), and circumferential range≥2/3 (P= .001) were independent risk factors for prolonged-duration ESDs, regardless of whether the procedure was performed by an expert or not. The results of the present study suggest that the location of a lesion involving the dentate line, resection size≥50mm, circumferential range≥2/3, and invasion depth≥T1b are the independent risk factors for prolonged ESD procedure time.

Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos)

BackgroundThe impact of traction direction in traction-assisted gastric endoscopic submucosal dissection (ESD) has not been adequately investigated. A clip with line (CWL) is a classical single-directional traction device. In contrast, a spring and loop with clip (SLC; S–O clip) is a newly developed multidirectional traction device.AimsTo investigate the impact of traction direction in gastric ESD by comparing the procedure-related outcomes of CWL-assisted ESD (CWL-ESD) and SLC-assisted ESD (SLC-ESD).MethodsWe retrospectively examined 140 patients with superficial gastric neoplasms who underwent SLC-ESD or CWL-ESD by a single ESD expert during November 2017–September 2020. The traction direction was classified based on the endoscopic finding in the following five categories: proximal, diagonally proximal, vertical, diagonally distal, and distal. In SLC-ESD, we set vertical traction, using the multidirectional traction function. Propensity score matching was conducted to compensate for the differences in lesion size, injection function of electrosurgical knife, ulcerative lesion, lesion location, and lesion position. The primary outcome was gastric ESD procedure time.ResultsPropensity score matching created 42 pairs. The median gastric ESD procedure time in the SLC-ESD group was significantly shorter than that in the CWL-ESD group (28.3 min vs. 51.0 min, P = 0.022). All traction direction in the SLC-ESD group was vertical, while only 16.7% in the CWL-ESD group. En bloc resection was attained without perforation in all the patients in both groups.ConclusionOur findings suggest that SLC can provide vertical traction, which reduces the gastric ESD procedure time.Graphical Multidirectional traction devices can provide vertical traction in most cases of gastric ESD, unlike single-directional traction devices. Vertical traction may reduce the gastric ESD procedure time.

Usefulness of the combined orthodontic rubber band and clip method for gastric endoscopic submucosal dissection

Background and aimsEffective traction is an important prerequisite for successful endoscopic submucosal dissection (ESD). The combined orthodontic rubber band (ORB) and clip method was effective in colorectal cancer ESD. To date, the method was not reported in gastric ESD. This study aimed to investigate its efficacy and safety for gastric neoplasms ESD.MethodsWe retrospectively analyzed data of 118 patients with gastric neoplasms treated by ESD from November 2020 to April 2022, 43 by ORB-ESD and 75 by the conventional ESD. The primary outcome measure was the ESD procedure time. Clinical data on efficacy and safety were also collected and analyzed. Propensity score matching (PSM) matched the patients in both groups.ResultsPSM successfully matched 31 pairs of patients. The ORB-ESD operation time was shorter (median [interquartile range], 35 [30–48] vs. 49 [40–70] min, P < 0.001) and dissection speed was higher (median [interquartile range], 22.6 [14.4–29.3] vs. 13.5 [9.6–17.9] mm2/min, P < 0.001) than in the conventional ESD. The groups were similar in muscular injury rate, frequency and time of use of thermal hemostatic forceps, postoperative adverse events, en bloc resection, and R0 resection rate (P > 0.05).ConclusionsCompared to the conventional ESD, ORB-ESD significantly reduced the procedure time and increased the dissection speed, proving beneficial to gastric ESD.

Optimal traction direction in traction-assisted gastric endoscopic submucosal dissection.

Various traction devices have been developed to secure a visual field and sufficient tension at the dissection plane during endoscopic submucosal dissection (ESD). However, few large-scale studies have investigated the effectiveness of traction devices in gastric ESD. Clip-with-line (CWL) is one such traction device that is widely used in cases of gastric ESD. The CONNECT-G trial was the first multicenter randomized controlled trial to compare conventional ESD with CWL-assisted ESD (CWL-ESD) for superficial gastric neoplasms. Overall, no significant intergroup difference was observed in terms of the gastric ESD procedure time. However, subgroup analysis according to lesion location revealed a significant reduction in the procedure time of gastric ESD for the lesion located at the greater curvature of the middle and upper third of the stomach in the CWL-ESD group. In this subgroup analysis, lesion location was categorized as follows: anterior wall, posterior wall, lesser curvature, and greater curvature of the upper, middle, and lower thirds of the stomach. However, the gastric ESD procedure time showed no significant difference, except for lesions located at the greater curvature of the upper and middle thirds of the stomach. The traction direction of CWL in the stomach was limited to the cardia and changed depending on the lesion location. Therefore, outcomes of the CONNECT-G trail suggest that the effectiveness of CWL was influenced by lesion location, i.e., traction direction. Further studies are warranted to investigate the optimal traction direction in gastric ESD.

Comparison of endoscopic submucosal resection with ligation and endoscopic submucosal dissection for small rectal neuroendocrine tumors: A multicenter retrospective study.

ObjectivesEndoscopic submucosal resection with band ligation (ESMR‐L) and endoscopic submucosal dissection (ESD) are both standard endoscopic resection methods for rectal neuroendocrine tumors (NETs) <10 mm in size. However, there is no definitive consensus on which is better. Here, we compared the efficacy of ESMR‐L and ESD for small rectal NETs.MethodsThis was a multicenter retrospective cohort study including 205 patients with rectal NETs who underwent ESMR‐L or ESD. Treatment outcomes were compared by univariate analysis, multivariate analysis, and inverse probability treatment weighting (IPTW) using propensity scores. Subgroup analysis evaluated the impact of the endoscopist's experience on the technical outcome.ResultsEighty‐nine patients were treated by ESMR‐L and 116 by ESD. The R0 resection rate was not significantly different between the two (90% vs. 92%, p = 0.73). The procedure time of ESMR‐L was significantly shorter than for ESD (17 min vs. 52 min, p < 0.01) and the hospitalization period was also significantly shorter (3 days vs. 5 days, p < 0.01). These results were confirmed by multivariate analysis and also after IPTW adjustment. The procedure time of ESD was significantly prolonged by a less‐experienced endoscopist (49 min vs. 70 min, p = 0.02), but that of ESMR‐L was not affected (17 min vs. 17 min, p = 0.27).ConclusionsFor small rectal NETs, both ESMR‐L and ESD showed similar high complete resection rates. However, considering the shorter procedure time and shorter hospitalization period, ESMR‐L is the more efficient treatment method, especially for less‐experienced endoscopists.

Efficacy and safety of one-step knife compared to conventional insulated-tip knife for endoscopic submucosal dissection: a preliminary study with prospective data collection and retrospective review.

Endoscopic submucosal dissection (ESD) is not as tiresome as gastrectomy, but it is a time-consuming procedure. One-step knife (OSK) is a novel knife that combines a knife for ESD and an injection needle into one sheath. In this study, we aimed to compare the insulated tip type of OSK and conventional knife (CK) in terms of procedure time and complication rate. Medical records of patients with ESD using CK between February and September 2020 were retrospectively reviewed. Subsequently, data from patients who underwent ESD using OSK by September 2021 were prospectively collected. Total procedure time, procedure time by location and complication rate in the OSK and CK group were compared. In the study period, a total of 203 patients (OSK, 102 patients; CK, 101 patients) were analyzed. On multivariate analysis, using CK, body location, resection size ≥ 40mm, and submucosal fibrosis were associated with longer procedure time. The total procedure time was statistically significantly reduced in the OSK group (median 11 vs. 17min, p < 0.01). The procedure time for each location was more reduced in the body (median 14 vs. 19min p < 0.01) than the antrum (median 10 vs. 14min, p = 0.01) in the OSK group. There was no significant difference in post-ESD bleeding and perforation in the two groups (3.9 vs. 3.9%, p = 0.99 and 1.0 vs. 2.0%, p = 0.56). OSK significantly reduced the total procedure time of ESD. OSK could be an effective and safe knife for gastric ESD, especially for body lesions.

Traction method versus conventional endoscopic submucosal dissection for gastric epithelial neoplasms: A randomized controlled trial.

Introduction:Endoscopic submucosal dissection (ESD) is an advanced therapeutic technique for en bloc resection of superficial gastrointestinal neoplasms. Although gastric ESD is minimally invasive and provides favorable outcomes, it is technically difficult and requires a long procedure time for dissection. The traction-assisted approach overcomes some of the difficulties of gastric ESD, but its ability to reduce the procedure time remains unclear. The traction-assisted approach using dental floss and a clip did not reduce procedure time in the total population, but it reduced procedure time for lesions limited to the greater curvature of the upper or middle of the stomach. Although the traction direction of the clip-with-line method may be limited to the oral side via the cardia, EndoTrac ESD may provide flexible traction at any time during the procedure. This prospective randomized control study has been designed to compare the efficacy and safety of EndoTrac and conventional gastric ESD.Methods/design:This multicenter, randomized control trial will enroll 150 patients at 2 hospitals in Japan undergoing EndoTrac or conventional ESD for gastric epithelial neoplasia. Patients with a single gastric epithelial neoplasm who meet the inclusion and exclusion criteria will be randomized to EndoTrac or conventional ESD. Patients will be randomized by a computer-generated random sequence with stratification by operator experience, tumor size, tumor location, and institution. The primary endpoint will be ESD procedure time, defined as the time from the start of the submucosal injection to the completion of resection. Other outcomes will include the rates of adverse events and pathological curabilityDiscussion:The ability of EndoTrac ESD to reduce the long procedure time and/or adverse events observed with conventional ESD can not only reduce physical stress on the patient, but can also reduce length of hospital stay and medical costs. Reduced technical difficulty will contribute to the widespread adoption of this ESD technique worldwide.Trial registration:University Hospital Medial Information Network Clinical Trials Registry (UMIN-CTR), ID: 000044450; Registered on June 6, 2021.https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000050485.Protocol version number:1.1, March 1, 2022. Patient enrolment began on June 6, 2021 and is expected to be completed by July 19, 2025.

The usefulness of combining the pocket-creation method with a traction device using a scissor-type knife for colorectal endoscopic submucosal dissection.

Technical issues and long procedure time still remain a concern in colorectal endoscopic submucosal dissection (ESD). We examined the usefulness of combining the pocket-creation method (PCM) with a traction device (S-O clip; SO) using a scissor-type knife (Clutch Cutter 3.5mm; CC) for decreasing ESD procedure time. We retrospectively analyzed 95 ESD cases of PCM + SO + CC managed from August 2017 to April 2020 and 103 cases of PCM + CC treated from July 2016 to July 2017. We compared these two groups through propensity score matching. The main outcome was the analysis of the ESD procedure times under various conditions in each group. After matching, 52 cases in the PCM + SO + CC and PCM + CC groups were analyzed. The PCM + SO + CC group showed a significantly shorter ESD procedure time than the PCM + CC group (57.8 ± 31.4 vs. 81.7 ± 33.5min, p < 0.01). Additionally, the ESD procedure time was significantly shorter in the PCM + SO + CC group than in the PCM + CC group: tumor size (tumor size < 40mm: 45.6 ± 15.8 vs. 72.7 ± 22.9min, p < 0.01; tumor size ≥ 40mm: 83.1 ± 40.1 vs. 111.8 ± 45.3min, p = 0.04), tumor location (right side: 64.7 ± 33.3 vs. 81.0 ± 29.7min, p = 0.03; left side: 50.5 ± 28.0 vs. 82.3 ± 36.9min, p < 0.01), tumor morphology (polypoid: 39.2 ± 18.6 vs. 74.7 ± 28.6min, p < 0.01; nonpolypoid: 62.3 ± 32.3 vs. 84.5 ± 35.2min, p < 0.01), endoscopist (expert: 67.3 ± 41.2 vs. 91.9 ± 40.2min, p = 0.02; nonexpert: 50.4 ± 18.3 vs. 73.6 ± 24.9min, p < 0.01), and fibrosis (severe fibrosis: 82.0 ± 20.5 vs. 99.8 ± 40.4min, p = 0.169; non-severe fibrosis: 52.1 ± 23.8 vs. 75.6 ± 29.0min, p < 0.01). The combination of the PCM and SO using CC achieved a reduction in the colorectal ESD procedure time.

The feasibility of endoscopic submucosal dissection for colorectal lesions larger than 10cm.

Although endoscopic submucosal dissection (ESD) enables en bloc removal of colorectal neoplasms, its effectiveness for larger lesions (≥ 10cm in diameter) is undetermined. We aimed to investigate the feasibility and safety of ESD for colorectal lesions ≥ 10cm wide. This retrospective study included 3591 consecutive colorectal lesions managed with ESD from June 2012 through December 2020. Clinicopathological characteristics and treatment outcomes were compared between lesions ≥ 10cm wide and lesions 5-10cm wide. There were 50 patients in the ≥ 10cm group and 270 patients in the 5-10cm group. Among patients in the ≥ 10cm group, lesions were most often in the rectum (50.0%), and the laterally spreading tumor-granular nodular mixed type (LST-G-M) was most prevalent (41/50, 82%). Although patients in the ≥ 10cm group a longer mean ESD procedure time (186.0 vs. 94.4min, p < 0.001), the dissection speed was significantly higher in this group (0.50 vs. 0.41 cm2/min, p = 0.003). The en bloc and curative resection rates were comparable between the ≥ 10cm and 5-10cm groups (100% vs. 99.6% and 86.0% vs. 88.5%, respectively). Although the stenosis rate was higher in the ≥ 10cm group (4% vs. 0%), the delayed bleeding and perforation rates were similar between the two groups. ESD for colorectal lesions ≥ 10cm wide is feasible and curative, even though it is associated with higher technical difficulty and longer procedure times compared with ESD for smaller lesions (Number: UMIN 000044313).

Effects of the combined use of a scissor-type knife and traction clip on endoscopic submucosal dissection of colorectal tumors: a propensity score-matched analysis.

Background and study aims This study evaluated the technical aspects of colorectal endoscopic submucosal dissection (ESD) with the Clutch Cutter (CC) (Fujifilm Co., Tokyo, Japan), a scissor-type knife, and the S-O clip (SO) as a traction clip, and compared the safety and efficacy to ESD using a needle-type knife. Patients and methods This was a single-center retrospective study. In Study 1, we evaluated 125 ESD patients: 60 using the SO and CC (SO group) and 65 using the CC (CC group). In Study 2, we evaluated 185 ESD patients: the CC group (N = 65) and 120 using the Flush knife BT-S (Flush group) (Fujifilm Co., Tokyo, Japan). In both studies, the clinicopathological features and therapeutic outcomes were compared using a propensity score-matched analysis. Results In 36 pairs of matched patients in Study 1, the rates of en bloc resection, R0 resection, perforation, and postoperative bleeding (POB) were 97.2 %, 88.9 %, 2.8 %, and 0 %, respectively, for the SO group and 100 %, 91.7 %, 0 %, and 0 % for the CC group (not significant). The mean procedure time for the SO group among less-experienced endoscopists was significantly shorter than in the CC group (42 vs. 65 minutes, P = 0.036). In 49 pairs of matched patients in Study 2, the rates of en bloc resection, R0 resection, perforation, and POB were 100 %, 95.8 %, 0 %, and 0 %, respectively, for the CC group and 98.0 %, 95.8 %, 0 %, and 2.0 % for the Flush group (not significant). The mean procedure time in the CC group among less-experienced endoscopists was significantly shorter than in the Flush group (52 vs. 67 minutes, P = 0.038). Conclusions CC and the combined use of CC and SO reduced colorectal ESD procedure time among less-experienced endoscopists.

Comparison of sodium alginate-based and sodium hyaluronate-based submucosal injection materials based on rheological analysis

As a viscous high-performance submucosal injection material (SIM) used in endoscopic submucosal dissection (ESD), sodium alginate-based SIM (SA-SIM) was recently introduced as high-performance SIM equivalent to sodium hyaluronate-based SIM (HA-SIM) in Japan. However, a comprehensive, detailed comparison of SA and HA is yet to be performed. In this study, we precisely measured the viscoelastic properties, submucosal elevation height (SEH), and injection pressure (IP). Furthermore, we compared the outcomes of ESD using an ex vivo ESD model. There was no significant difference in SEHs between HA-SIM and SA-SIM at all post-injection times, and the IP of the SA-SIM injection was significantly higher than that of the HA-SIM injection in all conditions (P < 0.0001). The viscosity at high shear rates of SA-SIM was higher than that of HA-SIM; this result was consistent with SEH/IP measurement results. No significant difference was observed in ESD procedure time and total volume of injected SIM between HA-SIM and SA-SIM (18.1 ± 6.7 and 17.8 ± 6.0 min, P = 0.8987; 13.3 ± 5.3 and 11.6 ± 5.9 ml, P = 0.4658, respectively). Although SA-SIM was slightly more difficult to inject than HA-SIM, there was no significant difference in performance between the materials. Thus, this basic study demonstrated that SA-SIM can be used for endoscopic treatment as well as HA-SIM, and supported previous clinical research data.

Long-term outcomes of salvage endoscopic submucosal dissection for local failure after chemoradiotherapy for esophageal squamous cell carcinoma.

Salvage endoscopic submucosal dissection is considered a minimally invasive treatment for local failure after chemoradiotherapy for esophageal squamous cell carcinoma. However, the long-term outcomes have not been fully evaluated. This study investigated the short-term and long-term outcomes of salvage endoscopic submucosal dissection. Patients who underwent endoscopic submucosal dissection for local recurrence or residual tumor after chemoradiotherapy from January 2006 to December 2017 were retrospectively investigated. Follow-up included endoscopic examination and computed tomography at least once every 6months after salvage endoscopic submucosal dissection. Risk factors for disease recurrence after salvage endoscopic submucosal dissection were assessed using the Cox hazards model. A total of 30 patients (33 cases of esophageal squamous cell carcinoma: local recurrence, n=27; residual tumor, n=6) were included. The median endoscopic submucosal dissection procedure time was 40min (interquartile range [IQR], 33-58.5min). En bloc resection was achieved in 31 (94%) of 33 esophageal squamous cell carcinoma cases. One patient with intraoperative perforation did not require surgical intervention and recovered with conservative treatment. A total of 16 patients (53%) had disease recurrence at a median follow-up of 51months (IQR, 33-81months). The 3-year overall, disease-specific, recurrence-free and local recurrence-free survival rates were 75%, 82%, 58% and 90%, respectively. The positive vertical margin, submucosal invasion in the endoscopic submucosal dissection specimen and piecemeal resection were significantly associated with disease recurrence after salvage endoscopic submucosal dissection. Salvage endoscopic submucosal dissection is a feasible treatment for local failure after chemoradiotherapy for esophageal squamous cell carcinoma with acceptable long-term outcomes. However, for cases with positive vertical margins and submucosal invasion in the endoscopic submucosal dissection specimen, salvage endoscopic submucosal dissection outcomes were insufficient and additional treatment might be required.

Differences between two sodium hyaluronate-based submucosal injection materials currently used in Japan based on viscosity analysis

In Japan, two 0.4% sodium hyaluronate (HA)-based submucosal injection materials (SIMs) are currently used in endoscopic submucosal dissection (ESD): MucoUp (HA-Mc) and Ksmart (HA-Ks). HA-Mc and HA-Ks have the same concentration and are, thus, construed by most endoscopists to have no difference. Nevertheless, visual observation conveys the impression that HA-Ks have a higher viscosity than HA-Mc, suggesting that HA-Ks performs better than HA-Mc. This study aimed to examine the differences between HA-Mc and HA-Ks. HA-Ks exhibited higher viscosity due to greater weight-average molecular weight compared with HA-Mc. HA-Ks had significantly greater submucosal elevation height (SEH) than HA-Mc; the SEH of HA-Ks-80% (80% dilution of HA-Ks) was the same as that of HA-Mc. The ESD procedure time was significantly shorter with HA-Ks than with HA-Mc (15.2 ± 4.1 vs. 19.5 ± 5.9; P = 0.049). The total injection volume for HA-Ks was significantly lower than that for HA-Mc (10.8 ± 3.6 vs. 14.4 ± 4.6; P = 0.045). However, no significant difference in these items was observed between HA-Mc and HA-Ks-80%. HA-Mc and HA-Ks were considered to be almost the same. Nonetheless, HA-Ks exhibited higher viscosity and SIM performance than HA-Mc. HA-Ks-80% had almost the same performance as HA-Mc. Thus, understanding SIM performance and characteristics requires a focus on the viscosity of SIMs.

Efficacy of Sodium Carboxymethylcellulose Compared to Sodium Hyaluronate as Submucosal Injectant for Gastric Endoscopic Submucosal Dissection: A Randomized Controlled Trial

Introduction: Sodium hyaluronate (SH) is a useful submucosal injectant for gastric endoscopic submucosal dissection (ESD). On the other hand, sodium carboxymethylcellulose (SCMC), which has high viscosity, has also been applied clinically. We evaluated the efficacy of SCMC compared to that of SH in gastric ESD. Methods: A prospective randomized controlled trial was conducted to assess the efficacy of 1.0% SCMC as the injectant (SCMC group) compared to 0.4% SH (SH group) for ESD of gastric neoplasms. The primary end point was the procedure time of ESD. Secondary end points were treatment outcomes such as en bloc and R0 resection rates, number of hemostases, amount of injectant, ease of treatment (visual analog scale, 1–10 points), adverse events, and rate of ulcer healing 8 weeks after ESD. Results: A total of 60 patients were enrolled between October 2014 and October 2018, and 30 patients were allocated in each group. The procedure time (mean ± SD, minutes) was not significantly different between the SCMC (74.7 ± 54.5) and SH groups (67.1 ± 41.4) (p = 0.547). Furthermore, there were no differences between the 2 groups in terms of en bloc and R0 resection rates, number of hemostases, amount of injectant, ease of treatment, and rate of ulcer healing. No serious adverse events were observed in either group. Conclusion: SCMC was comparable to SH in terms of procedure time, treatment outcome, and ease and safety of treatment in gastric ESD. Further studies are needed to demonstrate the differences between the 2 injectants.

Usefulness of the clip-and-snare method using the pre-looping technique for endoscopic submucosal dissection of gastric neoplasia: a randomized controlled trial.

BackgroundThe clip-and-snare method using the pre-looping technique (CSM-PLT) was developed as a traction method for endoscopic submucosal dissection (ESD) of gastric neoplasia. However, its usefulness has not been clearly established; thus, we aimed to assess the efficacy of CSM-PLT in gastric ESD.MethodsIn this multicenter, randomized controlled trial, patients with gastric adenoma or carcinoma with absolute or expanded indications for ESD were randomized into conventional ESD and CSM-PLT groups, using the minimization method based on operator experience, tumor location, tumor size, and excision device. The primary endpoint was ESD procedure time. Secondary endpoints were en bloc and R0 resection rates, and complications.ResultsWe enrolled 402 patients between July 2017 and February 2020. After excluding patients with deviations from the protocol, we finally analyzed the data of 192 and 186 patients in the conventional and CSM-PLT groups, respectively. The procedure time was significantly shorter in the CSM-PLT group than in the conventional group (58.0 vs. 69.7 min; P=0.009). All lesions were resected en bloc. The R0 resection rate tended to be higher in the CSM-PLT group (P=0.09). No significant differences in complications were observed between the 2 groups.ConclusionsCSM-PLT is beneficial for gastric ESD when compared with the conventional technique. CSM-PLT significantly reduced procedure times and improved R0 resection rates.

Impact of Procedure Time of Preceding Endoscopic Submucosal Dissection on the Difficulty of Laparoscopic Rectal Surgery

Objetive: In this study, we addressed which factors, including endoscopic submucosal dissection (ESD)–related parameters, affect the difficulty of laparoscopic rectal surgery. Summary of background data: Endoscopic treatment for gastrointestinal cancer can cause inflammation, edema, and fibrosis formation in the surrounding tissue. Recently, we reported that preceding endoscopic treatment increased the volume of intraoperative blood loss and slightly prolonged the operative time of laparoscopic surgery for rectal cancer. Methods: We retrospectively reviewed 24 consecutive patients who underwent ESD followed by laparoscopic surgery for rectal cancer in our hospital. Short-term surgical outcomes were evaluated by intraoperative blood loss and operative time for laparoscopic surgery. The correlations between the surgical outcomes and preoperative parameter were analyzed by multiple linear regression analyses. Results: The patient cohort comprised 12 men and 12 women. The median distance between primary cancer and anal verge was 7 cm. The median procedure time of ESD was 120 minutes (21 available cases). Based on multiple linear regression analyses, the ESD procedure time (P = 0.007) and tumor location from the anal verge (P = 0.046) were independently predictive of intraoperative blood loss. On the other hand, only tumor location was found to be an independent predictor of surgical time (P = 0.014). Conclusions: A long session of ESD for rectal cancer may make subsequent laparoscopic surgery difficult based on intraoperative blood loss.

Effect of administration of a proton pump inhibitor for ulcerative differentiated early gastric cancer prior to endoscopic submucosal dissection

Predicting the depth of invasion for early gastric cancer (EGC) with ulcerative findings may prove difficult. The purpose of this study was to evaluate the extent of ulcer healing and clinical effectiveness of proton pump inhibitor (PPI) administration for ulcerative differentiated EGC prior to endoscopic submucosal dissection (ESD). A total of 214 patients with ulcerative differentiated EGC who were treated by ESD were retrospectively analyzed, among whom 129 had been administered a PPI prior to ESD and 85 patients had not. The degree of ulcer healing following administration of PPI and the clinical outcome were compared between the PPI and non-PPI groups. The ulcer healing rate (80.7 vs. 30.6%, P<0.001) and complete ulcer healing rate (45.0 vs. 16.5%, P<0.001) differed significantly between the PPI and non-PPI groups, respectively. The ESD procedure time was 86.0 (73) vs. 100.0 (68.0) min (P=0.044). However, no significant differences were observed in the en bloc resection rate, complete resection rate, or the incidence of adverse events. Based on the multivariate regression analysis, PPI administration [odds ratio (OR)=4.909, 95% confidence interval (CI) 2.459-9.799, P<0.001] and mucosal cancer (OR=9.336, 95% CI 2.693-32.362, P<0.001) were independent predictive factors for complete ulcer healing. Partial or complete ulcer healing following PPI administration had a better predictive ability than EUS for mucosal invasion (kappa value 0.553 vs. 0.101; Youden index 0.553 vs. 0.132). Partial or complete ulcer healing following PPI administration predicts differentiated EGC that is confined to the mucosa.

Comparing a conventional and a spring-and-loop with clip traction method of endoscopic submucosal dissection for superficial gastric neoplasms: a randomized controlled trial (with videos)

Several traction methods have sought to overcome the technical difficulties of endoscopic submucosal dissection (ESD). However, traction direction has remained limited in most of these methods, with lack of clarity about the optimal method and traction direction for gastric ESD. A spring-and-loop with clip (SLC) has been developed as a multidirectional traction device. Here, we investigated whether SLC traction-assisted ESD (SLC-ESD) improved procedure-related outcomes compared with conventional ESD (C-ESD) among patients with superficial gastric neoplasms. This single-center randomized controlled trial included patients with superficial gastric neoplasms undergoing SLC-ESD or C-ESD between October 2018 and December 2019. Using the multidirectional traction function, we set traction vertical to the gastric wall for SLC-ESD. The primary outcome was the median procedure time for gastric ESD. The SLC-ESD and C-ESD groups comprised 40 patients each, and all the enrolled patients underwent the assigned treatment. The median ESD procedure time was significantly shorter in the SLC-ESD group (29.1 minutes) than in the C-ESD group (52.6 minutes; P= .005). SLC had a mean attachment time of 1.82 minutes. En bloc resection was achieved without perforation in all the patients in both groups. Our findings suggest that SLC-ESD reduces gastric ESD procedure time without increasing the risk of perforation and that the vertical direction to the gastric wall is the appropriate traction direction for gastric ESD. (Clinical trial registration number: UMIN 000034533.).