Endoscopic Submucosal Dissection Method Research Articles

A prospective randomized trial comparing the pocket-creation method and conventional method of endoscopic submucosal dissection in early gastric cancers and precancerous lesions

BackgroundEndoscopic submucosal dissection (ESD) is widely used as a standard treatment regimen for early gastric cancers (EGCs). However, such an approach is time-consuming and has a high risk of perforation and bleeding in some corner-site lesions because of the obscured view and difficulty in submucosal lifting. The newly developed pocket-creation method (PCM) provides a clearer view and better traction of the submucosal layer than conventional ESD (c-ESD). Nevertheless, no prospective randomized study has evaluated the efficacy of the PCM in EGCs and precancerous lesions. MethodsThis was a prospective randomized controlled trial. Patients with superficial gastric neoplastic lesions≥20mm were randomly assigned to the PCM-ESD group or c-ESD group. The primary outcome was dissection speed. ResultsThere were 28 patients in the PCM-ESD group and 27 in the c-ESD group. The median dissection speed was significantly higher in the PCM-ESD group than in the c-ESD group (21.5 mm2/min vs. 14.3 mm2/min, P<0.001). Meanwhile, the operation time in the PCM-ESD group was significantly shorter than that in the c-ESD group (30min vs. 40min，P=0.047). In multiple linear regression analysis, the treatment method was independently associated with the resection speed of ESD. ConclusionsPCM-ESD was an effective and safe treatment for EGCs and precancerous lesions.

Water pressure method for endoscopic submucosal dissection of a rectal tumor on the gravitational side close to the dentate line.

Water pressure method for endoscopic submucosal dissection of a rectal tumor on the gravitational side close to the dentate line.

Efficacy and safety of the water pressure method for endoscopic submucosal dissection in superficial pharyngeal cancer

Background: Superficial pharyngeal cancers can be cured with transoral surgery (TOS), which preserves organ function and quality of life. Pharyngeal endoscopic submucosal dissection (ESD) is challenging to perform because of limited manoeuvrability and complex anatomical features. The water pressure method (WPM) is useful for natural traction techniques during ESD, and is potentially useful for pharyngeal ESD. This study aimed to investigate the short-term outcomes of WPM-ESD for pharyngeal lesions. Patients and Methods: Therapeutic outcomes of patients who underwent WPM-ESD for pharyngeal lesions at Keio University between May 2019 and February 2022 were retrospectively analysed. Results: Twenty-one pharyngeal lesions treated with WPM-ESD were analysed. Three lesions were located in the oropharynx and 18 in the hypopharynx. All ESD procedures were performed under general anaesthesia. The endoscopic en bloc resection rate was 100%. The median procedure time was 15 min (range 4–45 min). All patients were successfully extubated on the day of ESD. No serious adverse events related to WPM-ESDs were observed. None of the patients required nasogastric intubation, percutaneous endoscopic gastrostomy, or tracheotomy. The median fasting time and hospital stay were 2 d (range 2–5 d) and 6 d (range 6–10 d), respectively. All the histological results indicated squamous cell carcinoma. The complete histologic resection rate was 76.2%. Conclusions: WPM-ESD achieved a high en bloc resection rate and short procedure time without serious adverse events. Thus, WPM-ESD may be a useful treatment for pharyngeal lesions.

A key to unlocking the door: water pressure method for endoscopic submucosal dissection of a superficial non-ampullary duodenal epithelial tumor with a history of multiple biopsies.

A key to unlocking the door: water pressure method for endoscopic submucosal dissection of a superficial non-ampullary duodenal epithelial tumor with a history of multiple biopsies.

Three-point traction method for endoscopic submucosal dissection using clip-with-thread and clip-with-silicon bands for large early gastric neoplasms.

Three-point traction method for endoscopic submucosal dissection using clip-with-thread and clip-with-silicon bands for large early gastric neoplasms.

A novel method of endoscopic submucosal dissection using a threaded clip for a lesion of the greater curvature of the gastric body.

Gastric endoscopic submucosal dissection (ESD) for lesions of the greater curvature of the gastric body is challenging owing to difficulty in approaching the lesion, submersion [1], and vertical confrontation with the lesion. Threaded-clip traction attached to the lesion is widely used in gastric ESD [2] [3]. We report a novel method of ESD using a threaded clip for a lesion of the greater curvature of the gastric body.

New training method for endoscopic submucosal dissection: Teaching with efficient treatment using a tip-deliverable high-frequency knife and an endoscopic pump.

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Efficacy of a new traction method using ring-shaped thread for endoscopic submucosal dissection in the pharynx.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for pharyngeal cancers. However, pharyngeal ESD is sometimes technically challenging because of the narrow and complex space in which to work. Traction is important to complete the procedure efficiently. Here, we report the technical details and efficacy of a new traction method for pharyngeal ESD using ring-shaped thread and grasping forceps. We analyzed pharyngeal ESD performed between January 2016 and March 2021 at our Institute. We designated cases resected using ring-shaped threads "Group R" and those resected without ring-shaped threads as conventional "Group C", and compared the technical outcomes between them. Multivariate analysis and the inverse probability treatment weighting (IPTW) method using propensity scores were adjusted by confounding variables. We analyzed 89 lesions from 68 patients, of which 46 were in Group R and 43 in Group C. Median procedure time and median dissection speed were significantly shorter in Group R than C (37min vs. 55min, and 16.0 mm2/min vs. 7.0 mm2/min, respectively, both P < 0.05). These results were confirmed by both multivariate analysis and after IPTW adjustment. All lesions were resected en bloc, and the complete resection rate was not significantly different between Group R and C (91.3% vs. 79.1%, P = 0.14). There were no treatment-related adverse events in either group. The traction method using ring-shaped thread increases the efficiency of pharyngeal ESD. This simple new traction method should be a useful option for pharyngeal ESD.

Endoscopic mucosal resection with a circumferential incision in the removal of colorectal neoplasms (preliminary results of the prospective randomized study)

AIM: to assess the early results in patients with benign epithelial colorectal neoplasms which underwent endoscopic mucosal resection with a circumferential incision (C-EMR).PATIENTS AND METHODS: a prospective randomized trial included 50 patients who underwent endoscopic removal of benign epithelial colorectal neoplasms sized 20–30 mm (November 2020 — January 2022). The main group included 26 patients which underwent C-EMR. The control group included 24 patients which underwent endoscopic submucosal dissection (ESD).RESULTS: postoperative complications developed in the C-EMR group in 5 (19.2%), and in the ESD group — in 7 (29.2%) cases (p = 0.51). The operative time in the C-EMR group was significantly less than in the ESD group — 30 vs 60 min., respectively (p &lt; 0.001). In all cases in both groups, tumors were removed en bloc. There R0 resection were performed in 22 (84.6%) and in 23 (95.8%) cases in the main and control groups, respectively (p = 0.3). Two (8.3%) procedures in the control group were converted to the C-EMR procedure.CONCLUSION: endoscopic mucosal resection with a circumferential incision is an effective and safe method for removing benign epithelial neoplasms sized 20–30 mm, as well as submucosal dissection. The removal of the tumor by the C-EMR method reduces operative time by half compared with ESD method.

Outcomes of the Conventional versus Pocket-Creation Method for Endoscopic Submucosal Dissection of Gastric Body Tumors Using a Dual Knife: A Retrospective Study.

Various endoscopic submucosal dissection (ESD) methods for gastric tumors have been tried. However, no studies have yet compared results according to the ESD method for gastric body tumors using a dual knife. The objective of this study was to compare outcomes of two ESD methods for gastric body tumors: the pocket-creation method and conventional method. Patients who underwent ESD for a gastric body tumor were retrospectively reviewed. Patients were divided into two groups according to the ESD method: the conventional method (group I) and pocket-creation method (group II). Characteristics of patients and tumors, hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, and laboratory findings were investigated. Of the total of 100 patients, 52 belonged to group I and 48 to group II. All tumors were successfully resected en bloc. Resection margin involvement was found in six (11.5%) of group I and six (12.5%) of group II. Complications were observed in seven (13.5%; major complication five, minor two) of group I and eight (16.7%; major two, minor six) of group II. There were no significant differences in ESD outcomes such as hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, or inflammatory response after ESD between the two groups. Both methods are suitable for treating gastric body tumors with adequate treatment success rates and comparable complication rates.

Modified technique of tumor traction in endoscopic submucosal dissections in the stomach (ex vivo study)

Background : the method of endoscopic submucosal dissection (ESD) allows to remove large neoplasms of the GI tract enblock, which significantly reduces the risk of local tumor recurrence. However, ESD method is technically complicated with high risk of surgical complications. Aim : to modify ESD traction technique and evaluate its efficiency. Materials and methods: experimental comparative study on biological preparations (pig stomachs). 144 ESD with three different methods were performed: the 1 st group—standard ESD method (n-48); the 2 nd —ESD with the method of traction with the clip and thread (n-48); the 3 rd —ESD with a modified method of tumor traction (n-48). Results : the shortest time to submucosal dissection was 4.89 min [2–12] in the 3 rd group, and 13,27 [4–31] min and 9,37 [4–26] min in the 1 st and 2 nd , respectively (p = 0,05). Total operative time in the 3 rd was 21,10 [12–31] min, in the 1 st 23.85 [12–48] min, and in the 2 nd —25.56 [13–49] min, p = 0.002. The max dissection speed was 0.48 [0.20–1.27] (min/cm 2 ) in the 3 rd group, 0.94 [0.47–2.06] (min/cm 2 ) and 1.48 [0.56–4.10] (min/cm 2 ) in the 2 nd and 3 rd , respectively, p=0.003. HM0 was 89.6% [43/48] in group 1, 93.7% [45/48] in the 2 nd , and 100% [48/48] in the 3 rd , p&gt;0.05. Muscle layer damage during submucosal dissection was 25% [12/48] in the 1 st , 6.25% [3/48] in the 2 nd and 12.5% [6/48] in 3 rd , p=0.389. Conclusion : the modified traction method during endoscopic submucosal dissection allows to visualize submucosa layer better, to increase dissection speed thus reducing total time of the operation and time of submucosal dissection.

S1077 Novel Through the Scope Steerable Grasper Reduces Dissection Time and Technical Demand in Endoscopic Submucosal Dissection in Novice Endoscopists Compared to Clip and Line Traction Method: An Ex Vivo Randomized Study

Introduction: Lack of effective devices to aid in tissue traction to facilitate endoscopic submucosal dissection (ESD) leads to prolonged dissection time. Clip and line (CL) method is commonly used to provide traction and improve visualization of the submucosa. A novel through the scope dynamic steerable grasping arm (SGA) has recently been available. We aim to prospectively study the efficacy of this new device with novice endoscopists in an ex vivo setting. Methods: This is a prospective single center randomized trial. In an ex-vivo porcine stomach model, two 25mm circular lesions were marked. Submucosal injection using a lifting agent and circumferential incision was performed. Novice endoscopists with no prior experience of ESD and with one to three years of experience of performing endoscopies were randomized to either SGA (study group) or CL method (control group) first. Each endoscopists performed ESD with both methods. Primary outcome was total dissection time in minutes. Adverse events of muscle injury, perforation, mucosal injury or tissue fragmentation were noted. Participants were asked to choose their preferred traction method for future ESDs. Subsequently, NASA task load index was used to grade subjective mental and physical work load. Results: Ten subjects participated in the study and five were randomized to SGA method first. The mean dissection time was significantly shorter when using SGA compared to clip and line method (5.07 ± 2.19 mins vs 20.07 ± 8.45 mins, P< 0.001) irrespective of order of randomization. Four instances of muscle injury and one perforation were noted with CL and none with SGA. NASA task load index scores across the domains of mental demand (7.9 ± 3.1 vs 15 ± 4 , P< 0.001), physical demand (6.4 ± 2.5 vs 12.9 ± 5.6, P=0.009), temporal demand (5.6 ± 3.3 vs 13.8 ± 4.3, P< 0.001), performance (3.9 ± 3.2 vs 9.2 ± 5.0, P=0.02), effort (8.4 ± 3.5 vs 16.3 ± 2.8, P< 0.001) and frustration (3.9 ± 2.3 vs 14.3 ± 5.1, P< 0.001) were significantly lower with SGA compared to CL. All participants preferred SGA over CL method. Conclusion: With novice endoscopists performing ESD, SGA leads to faster dissection time compared to CL for traction with a reduced mental and physical work load. There was a trend towards reduced adverse events with SGA. SGA is a promising tool to improve efficiency and learning curve of ESD (Table). Table 1. - Dissection times between two methods across the two randomized groups Randomization Number of subjects Dissection time in minutes using SGA (mean +/- SD) Dissection time in minutes using CL (mean +/- SD) P value SGA first 5 5.32 + 2.21 22.6 + 11.42 0.017 CL first 5 4.82 + 2.41 17.5 + 3.70 0.002 Total 10 5.07 + 2.19 20.07 + 8.45 < 0.001 SGA: Steerable grasping arm; CL: Clip and line.

Construction and analysis of an ulcer risk prediction model after endoscopic submucosal dissection for early gastric cancer.

BACKGROUNDEndoscopic submucosal dissection (ESD) has been widely used in the treatment of early gastric cancer (EGC). A personalized and effective prediction method for ESD with EGC is urgently needed.AIMTo construct a risk prediction model for ulcers after ESD for EGC based on LASSO regression.METHODSA total of 196 patients with EGC who received ESD treatment were prospectively selected as the research subjects and followed up for one month. They were divided into an ulcer group and a non-ulcer group according to whether ulcers occurred. The general data, pathology, and endoscopic characteristics of the groups were compared, and the best risk predictor subsets were screened by LASSO regression and tenfold cross-validation. Multivariate logistic regression was applied to analyze the risk factors for ulcers after ESD in patients with EGC. A receiver operating characteristic (ROC) curve was used to estimate the predictive model performance.RESULTSOne month after the operation, no patient was lost to follow-up. The incidence of ulcers was 20.41% (40/196) (ulcer group), and the incidence of no ulcers was 79.59% (156/196) (non-ulcer group). There were statistically significant differences in the course of disease, Helicobacter pylori infection history, smoking history, tumor number, clopidogrel medication history, lesion diameter, infiltration depth, convergent folds, and mucosal discoloration between the groups. Gray's medication history, lesion diameter, convergent folds, and mucosal discoloration, which were the 4 nonzero regression coefficients, were screened by LASSO regression analysis. Further multivariate logistic analysis showed that lesion diameter [Odds ratios (OR) = 30.490, 95%CI: 8.584-108.294], convergent folds (OR = 3.860, 95%CI: 1.060-14.055), mucosal discoloration (OR = 3.191, 95%CI: 1.016-10.021), and history of clopidogrel (OR = 3.554, 95%CI: 1.009-12.515) were independent risk factors for ulcers after ESD in patients with EGC (P < 0.05). The ROC curve showed that the area under the curve of the risk prediction model for ulcers after ESD in patients with EGC was 0.944 (95%CI: 0.902-0.972).CONCLUSIONClopidogrel medication history, lesion diameter, convergent folds, and mucosal discoloration can predict the occurrence of ulcers after ESD in patients with EGC.

Efficacy of the pocket-creation method with a traction device in endoscopic submucosal dissection for residual or recurrent colorectal lesions.

Background/AimsEndoscopic submucosal dissection (ESD) for residual or recurrent colorectal lesions after incomplete resection is challenging because of severe fibrosis. This study aimed to compare the efficacy of the pocket-creation method (PCM) with a traction device (TD) with that of conventional ESD for residual or recurrent colorectal lesions. MethodsWe retrospectively studied 72 patients with residual or recurrent colorectal lesions resected using ESD. Overall, 31 and 41 lesions were resected using PCM with TD and conventional ESD methods, respectively. We compared patient background and treatment outcomes between the PCM with TD and conventional ESD groups, respectively. The primary endpoints were en bloc resection and R0 resection rates. The secondary endpoints were the dissection speed and incidence of adverse events. ResultsEn bloc resection was feasible in all cases with PCM with TD, but failed in 22% of cases of conventional ESD. The R0 resection rates for PCM with TD and conventional ESD were 97% and 66%, respectively. Dissection was significantly faster in the PCM with TD group (13.0 vs. 7.9 mm2/min). Perforation and postoperative bleeding were observed in one patient in each group. ConclusionsPCM with TD is an effective method for treating residual or recurrent colorectal lesions after incomplete resection.

New traction method (traction ring) for colorectal endoscopic submucosal dissection.

Colorectal endoscopic submucosal dissection (ESD) is challenging because of the difficulty in adequately visualizing the submucosal layer. Many traction methods have been developed to facilitate submucosal dissection; however, they are not widely applied. Therefore, we designed a new traction device, a traction ring, and conducted this pilot study to evaluate its feasibility and safety for colorectal ESD. Twenty patients with colorectal lesions who underwent traction ring-assisted ESD were retrospectively included. The main outcomes included en bloc resection rate, R0 resection rate, procedure time, resection time, and intraoperative and postoperative complications. The median procedure time was 74.5 min (range 35-269 min). The median resection time was 55 min (range 25-209 min). Application of the traction system accounted for only 2.7% of the entire procedure time. The en bloc resection rate was 95.0% (19/20), whereas the R0 resection rate was 90.0% (18/20). All traction rings were successfully set and retrieved. Significant intraoperative bleeding was not observed. One patient experienced perforation after treatment, but no further intervention was required. No delayed complications were observed within 1 month post-ESD. Traction ring is an effective and safe method for colorectal ESD and can be used at any location in the colorectum.

A traction wire facilitates the pocket-creation method for endoscopic submucosal dissection in the cecum.

A traction wire facilitates the pocket-creation method for endoscopic submucosal dissection in the cecum.

Self-completion method of endoscopic submucosal dissection using the Endosaber for treating colorectal neoplasms (with video)

Endoscopic submucosal dissection (ESD) is effective for the treatment of colorectal neoplasms. We have developed a self-completion ESD (S-ESD) using Endosaber without requiring additional instruments or assistance. This prospective cohort study was conducted to investigate the feasibility of S-ESD for colorectal neoplasms. Patients with colorectal neoplasms measuring 20–40 mm in size were enrolled. A single operator, without assistance, performed ESD using only the Endosaber. The primary outcome was the success rate of S-ESD. Secondary outcomes included procedure time, the rates of en bloc, complete, and curative resection, and complication rates, including the incidence of perforation and delayed bleeding. In total, 15 patients with 15 lesions were enrolled. The median size of the resected lesions was 28 mm (interquartile range 25–29 mm). S-ESD success rate of 100% was achieved. The median procedure time was 44 min (29.5–53.5 min). We observed en bloc, complete, and curative resection rates of 100%, 93.3%, and 86.7%, respectively, and a complication rate of 6.7% (perforation: 0%, delayed bleeding: 6.7%). S-ESD for colorectal neoplasms was successfully performed with favorable treatment outcomes and low complication rates. S-ESD reduces the number of devices and extent of assistance, making S-ESD a simple and cost-effective procedure.

A novel flexible auxiliary single-arm transluminal endoscopic robot facilitates endoscopic submucosal dissection of gastric lesions (with video).

Using conventional endoscope to perform endoscopic submucosal dissection (ESD) is difficult because of the one-handed operation and blind dissection caused by gravity. Poor visualization of the submucosal plane causes ESD to be associated with a high risk of bleeding and perforation. This study aimed to develop a novel ESD-assistive robot system and to evaluate its efficacy. A novel flexible auxiliary single-arm transluminal endoscopic robot (FASTER) was developed. A total of 36 artificial lesions in ex vivo porcine stomachs were removed using the FASTER-assisted ESD method (n = 18) and the conventional ESD method (n = 18). Lesions were 2cm or 4cm in diameter, located on the anterior and posterior walls of the antrum. Primary outcome measurements were dissection time and dissection speed. The dissection time in FASTER-assisted ESD was significantly shorter than that in conventional ESD (7min vs 13min, p = 0.012), mainly because of the faster dissection speed (148.6 vs 97.0 mm2/min, p = 0.002). The total procedure time in FASTER-assisted ESD was shorter than that in conventional ESD, but the difference was not significant (16min vs 24min, p = 0.252). Complete en bloc resection was achieved in all lesions. No perforations were detected. The FASTER exhibited the ability of regrasp, multidirectional traction, and proper tension control during ESD. FASTER significantly increased the dissection speed by providing proper traction and achieving good submucosal vision. This new device is expected to facilitate ESD in clinical practice.

The pocket-creation method of endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is rapidly becoming the standard treatment for superficial gastrointestinal tumors because ESD can achieve complete local resection facilitating thorough pathological examination of the resected specimen. The pocket-creation method (PCM) has been established to perform safe and reliable ESD obtaining a high-quality pathological specimen. A minimal mucosal incision using PCM minimizes leakage of submucosally injected solution, which results in prolonged mucosal elevation. A limited-space submucosal pocket created using PCM makes the endoscope tip stable. A conical cap, small-caliber-tip transparent (ST) hood is used when performing PCM. The submucosa can be cut along the ideal dissection line just above the muscularis with minimal thermal damage because the tip of the ST hood produces both traction and countertraction to stretch the submucosal tissue in the pocket. PCM is recommended as the standard strategy not only for colorectal ESD but also for upper-gastrointestinal ESD. It is expected that the use of traction techniques will make PCM easier to perform.

Comparison of the Effectiveness and Safety of Different Methods of Colorectal Endoscopic Submucosal Dissection: A Systematic Review and Network Meta-Analysis

Background: Traditional endoscopic submucosal dissection (ESD) has developed different methods, such as pocket method (P-ESD), traction-assisted method (T-ESD), and hybrid method (H-ESD). In this meta-analysis, the benefits and drawbacks of different ESD methods were discussed and ranked. Study Design: Studies comparing different methods of colorectal ESD were searched by using PubMed, EMBASE, and Cochrane Library databases. The study was conducted for five endpoints: en bloc resection rate, R0 resection rate, operation time, dissection speed, and adverse events rate. Pairwise and network meta-analyses were performed through Rev Man 5.4 and Stata 16.0. The quality of all included studies was assessed using the Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale. Results: Twenty-six studies met the inclusion criteria, including 7 RCTs and 19 non-RCTs, with a total of 3,002 patients. The pooled analysis showed that the en bloc resection rate of H-ESD was significantly lower than that of C-ESD, P-ESD, and T-ESD (RR = 0.28, 95% CI [0.12, 0.65]; RR = 0.11, 95% CI [0.03, 0.44]; RR = 8.28, 95% CI [2.50, 27.42]). Compared with C-ESD, the operation time of H-ESD and T-ESD was significantly shorter (MD = −21.83, 95% CI [−34.76, −8.90]; MD = −23.8, 95% CI [−32.55, −15.06]). Meanwhile, the operation time of T-ESD was also significantly shorter than that of P-ESD (MD = −18.74, 95% CI [−31.93, −5.54]). The dissection speed of T-ESD was significantly faster than that of C-ESD (MD = 6.26, 95% CI [2.29, 10.23]). Conclusion: P-ESD and T-ESD are probably the two best methods of colorectal ESD at present. The advantages of P-ESD are high en bloc resection rate and low incidence of adverse events. The advantages of T-ESD are rapid dissection and short operation time.