Piecemeal Resection Research Articles

Total en bloc spondylectomy for primary tumors of the thoracic and lumbar spine: A review article

Primary spine tumors present significant clinical challenges due to their potential for local invasiveness and metastasis. Total en bloc spondylectomy (TES) has emerged as a feasible surgical technique for the complete resection of thoracic and lumbar spinal tumors, providing superior local control and long-term survival benefits. This review synthesized the current evidence and clinical experiences and demonstrated that TES achieved lower recurrence rates and higher disease-free survival than those of piecemeal resection. Despite the high perioperative complication rates, TES is essential for treating primary spine tumors. The importance of skilled surgical teams to optimize patient outcomes has been emphasized.

Comparisons of clinical characteristics, treatments, and outcomes among different pathological subtypes of chondrosarcoma in the spine.

Spinal chondrosarcoma exhibits higher invasiveness and a worse prognosis compared to chondrosarcoma in the extremities. The prognosis and therapeutic plan vary greatly among different pathological subtypes of chondrosarcoma. This study aimed to analyze the differences in clinical characteristics, molecular features, therapeutic effects, and prognostic factors among the subtypes of chondrosarcoma in the spine. A retrospective review was conducted on 205 patients with spinal chondrosarcoma. The clinical features and immunohistochemical (IHC) markers were compared among the pathological subtypes of chondrosarcoma grade 1, grade 2, grade 3, mesenchymal chondrosarcoma (MCS), dedifferentiated chondrosarcoma (DCS), and clear cell chondrosarcoma (CCCS). Chondrosarcoma grade 1/2/3 are collectively referred to as conventional chondrosarcoma (CCS) for multivariate survival analysis. Univariate and multivariate analyses were performed to investigate independent prognostic factors for overall survival (OS) and recurrence-free survival (RFS) in patients with spinal chondrosarcoma. Furthermore, independent prognostic factors for OS and RFS were identified in CCS and MCS. MCS patients were younger than the other subtypes. Patients with chondrosarcoma grade 1/2 had better OS than those with chondrosarcoma grade 3, MCS and DCS, while only chondrosarcoma grade 1 patients showed better RFS than chondrosarcoma grade 2/3, MCS and DCS patients. Ki-67 index was higher in chondrosarcoma grade 3, MCS and DCS than chondrosarcoma grade 1/2. The comparison of IHC markers further highlighted the overexpression of P53/MDM2 in MCS and DCS. Gross total resection, including en-bloc and piecemeal resection, significantly improved OS and RFS for CCS patients, while only en-bloc resection significantly improved the prognosis of MCS patients. Chemotherapy appeared to be important for the OS of MCS patients. P53/MDM2 pathway was upregulated in MCS and DCS compared to chondrosarcoma grade 1/2. Radical tumor resection is crucial for the treatment of spinal chondrosarcoma, while MCS patients require further comprehensive treatments perioperatively.

356. TUMOUR BURDEN CORRELATES WITH THE RISK OF RECURRENCE AFTER PIECEMEAL ENDOSCOPIC RESECTION OF EARLY-STAGE ADENOCARCINOMA IN BARRETT’S OESOPHAGUS

Abstract Background Endoscopic resection (ER) is curative for Barrett’s oesophagus-related early-stage oesophageal adenocarcinoma (EAC) without high-risk features, such as lymphovascular invasion (LVI), positive margins (R1), and deep submucosal invasion (T1bsm2-3). Piecemeal endoscopic mucosal resection (pEMR), often used for lesions larger than 15mm, prevents assessment of lateral margins and therefore complicates precise risk estimation for residual EAC at the first post-ER endoscopy. Thus, we investigated alternative clinical factors that could potentially be used to assess the risk for residual and recurrent EAC post-ER. Methods We performed a longitudinal cohort study of patients who underwent ER between 2006-2023. Inclusion criteria were: T1a or well/moderately differentiated T1bsm1 EAC; LVI-, and R0 resection. ER was categorised as pEMR (n=106) or en-bloc ER (n=22 en-bloc EMR, n=9 endoscopic submucosal dissection). The primary outcome was residual EAC at first post-ER endoscopy. Secondary outcomes were residual HGD at first post-ER endoscopy, EAC and HGD recurrence at any post-ER endoscopy, and remission of EAC, HGD and intestinal metaplasia (IM) at latest endoscopy. Multivariate logistic regression, receiver operating characteristics, chi-squared, and Kaplan Meier analyses were performed to investigate possible associated risk factors. Results Rates of EAC/HGD recurrence were higher post-pEMR versus en-bloc ER (p=0.019), with residual EAC at first post-ER endoscopy accounting for 34% of post-pEMR recurrence. The percentage of pEMR specimens with EAC (p=0.022) and T1bsm1 staging (p=0.013) were independent risk factors for residual EAC at first post-pEMR endoscopy (Table 1). A 53.5% cut-off of involved pEMR specimens was identified as the optimal threshold for residual EAC prediction (specificity=0.68, sensitivity=0.67). Indeed, residual (p=0.012) and recurrent (p=0.00077) EAC rates were higher when EAC involvement was >53.5%. However, rates of EAC (p=0.13), HGD (p=0.19) and IM (p=0.76) remission were unaffected by high EAC burden. Conclusions High burden of EAC on pEMR specimens correlates with increased risk of residual and recurrent EAC at post-pEMR endoscopy. Post-pEMR site check is recommended prior to endoscopic ablation, particularly in patients where more than 50% of pEMR specimens show EAC and in cases of flat subtle lesions. This will ensure eradication of any residual disease and high success rates for treatment of early EAC using endotherapy.

296. CLINICAL T1B-SM2-3N0M0 ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background With advancements in endoscopic techniques, safer and more reliable endoscopic resection of submucosal invasive lesions has become feasible. The evaluation of treatment outcomes for superficial esophageal carcinoma has typically been predicated on the depth of pathological diagnosis; however, there have been limited studies based on preoperative diagnosis. Given that treatment decisions in clinical practice are primarily guided by preoperative diagnosis, there is a heightened emphasis on studies grounded in preoperative assessments. This study aims to analyze the accuracy of preoperative diagnosis of T1b-SM2-3 N0M0, evaluate the accuracy of treatment selection and depth diagnosis, and assess long-term outcomes based on these determinations. Methods Thirty-eight patients diagnosed with T1b-SM2-3 N0M0 between April 2010 and December 2020 were included in the study. Depth diagnosis was determined through endoscopic evaluation utilizing white light, NBI, NBI magnification plus EUS, with lymph node metastasis diagnosis performed via CT imaging. Treatment decisions were made following patient consent, and long-term prognosis was assessed for each treatment modality. Results Initial treatment involved ESD in 14 patients, with an additional 5 patients undergoing additional treatment (ESD + AD) based on histological evaluation (surgery: 1, CRT: 4). Surgery or neoadjuvant chemotherapy (NAC) followed by surgery was performed in 15 patients, with CRT administered in 7. Among the 22 patients who did not receive NAC and whose histologic depth was evaluable, the accuracy rate of depth diagnosis was 64%, primarily attributable to overdiagnosis. In the 14 patients who underwent ESD excluding piecemeal resection, the negative rate of vertical margins was 93%. Five-year overall survival rates were as follows: ESD: 64.8%, ESD+AD: 75%, surgery: 86.2%, and CRT: 45.7%, with no statistically significant differences observed. The majority of deaths (83%) were attributed to other diseases or cancers, with only 2 deaths attributed to the primary disease. Conclusion ESD or surgery emerged as the preferred treatment modalities in the majority of cases, with relatively favorable long-term prognoses. Treatment decisions were influenced by comorbidities and other factors, potentially impacting long-term outcomes.

Can optical evaluation distinguish between t1a and t1b esophageal adenocarcinoma: an international expert inter-observer agreement study.

While piecemeal endoscopic mucosal resection (EMR) for T1a oesophageal adenocarcinoma is acceptable, enbloc-R0 excision is advocated for T1b disease as it may offer a potential cure and mitigate recurrence. Thus, distinguishing between T1a and T1b disease is imperative under current treatment paradigms. We sought to ascertain whether expert Barrett's endoscopists were able to make this distinction based on optical evaluation. Sixty sets of endoscopic images of histologically confirmed high grade dysplasia (HGD), T1a and T1b disease (n=20 for each) were compiled from consecutive patients at a single institution. Each set contained four images, and were standardized to include an overview, a close-up in high-definition white light, a near-focus magnification image, and a narrow-band image. Experts were invited to predict histology for each set. 19 experts from 8 countries (Australia, USA, Italy, Netherlands, Germany, Canada, Belgium, and Portugal) participated. The majority had been practicing for >20 years, with a median annual case volume for Barrett's EMR of 50 (IQR 18-75), and Barrett's ESD of 25 (IQR 10-45). Oesophageal adenocarcinoma (T1a/b) could be distinguished from HGD, with a pooled sensitivity of 89.1% (95% CI:84.7-93.4. When predicting T-stage for T1b adenocarcinoma cases, pooled sensitivity was 43.8% (95% CI:29.9-57.7). Fleiss' kappa was 0.421 (95% CI:0.399-0.442, P<0.001), indicating fair-to-moderate agreement. Expert Barrett's endoscopists can reliably differentiate T1a/T1b oesophageal adenocarcinoma from HGD. Although there is fair-to-moderate agreement for T-staging, T1b disease cannot be reliably distinguished from T1a disease. This may have implications on clinical decision making and selection of endoscopic treatment methods.

Surgical treatment for local recurrence of spinal hemangiomas.

SH is considered to be the most common benign tumor within the human spine. 1-2% of SH get symptomatic with back pain in most cases. Less often, ingrowth of vessels into the spinal canal is seen. In these cases, more invasive surgical treatment is required. Recurrence of SH following surgical treatment is a very rare condition. We present the results of a retrospective chart review, with description of the clinical course of 12 patients with spinal canal invading SH without recurrence and of 5 patients with a recurrent SH. Recurrence was diagnosed 70 months (mean value) after the first procedure. All patients with a recurrent SH had received an incomplete tumor resection as a first treatment. The distribution of gender, age at the diagnosis, levels involved by the tumor, and initial symptoms were comparable in the group of patients with and without recurrence. The patients with recurrent SH were treated with preoperative embolization and en bloc resection or complete piecemeal resection of the affected vertebra. For stabilization, a combined, circumferential fixation was used consisting in a TSM cage filled by bone graft and posterior pedicle screw rod instrumentation in all patients. We followed these patients until 09/ 2023, mean FU 122 months (range 72-184 months). At this time, we found no evidence of tumor recurrence, good clinical conditions in all patients, no signs of implant failure or pseudarthrosis. Thus, radical excision, sufficient stabilization and fusion is considered to be an adequate treatment concept for recurrent SH.

Microsurgical Resection of Trigeminal Schwannoma Through Transorbital Approach: 2-Dimensional Operative Video.

We present the case of an asymptomatic 34-year-old woman who was found to have an incidental left trigeminal schwannoma.1,2 Owing to the rapid increase in size on imaging, an atypical finding for this type of lesion,3 as well as the risk of cranial nerve involvement and need for tissue diagnosis, the patient underwent a microsurgical left transorbital approach with lateral orbitotomy to resect the lesion.4,5 Piecemeal resection was performed, and the internal contents of the cavernous sinus were preserved. Ultimately, gross total resection was achieved with no residual disease identified on postoperative imaging. No new neurologic deficits were noted after surgery. The technical considerations for the transorbital approach and the literature review on the outcomes for middle fossa lesions accessed by a lateral orbitotomy are reviewed.6-10 The patient consented to the procedure and to the publication of her images. Institutional Review Board approval was deemed unnecessary due to the retrospective, case-report nature of this work.

Efficacy of cold piecemeal EMR of medium to large adenomas compared with sessile serrated lesions

There is growing evidence for the role of cold piecemeal endoscopic mucosal resection (C-EMR) in the treatment of colorectal lesions ≥10mm. However, it is unclear if it is equally efficacious for all histologic subtypes and sizes. This retrospective study compares the efficacy and safety of C-EMR in the resection of medium (10-19mm) and large (≥20mm) serrated and adenomatous lesions. A retrospective analysis was performed of Paris IIa colonic lesions resected utilising a C-EMR technique over a 3.5 year period at our center. C-EMR was performed for 242 lesions in 151 patients. Lesion size ranged between 10mm to 50mm, with median size of 20mm. Ninety-five polyps were adenomatous, with 147 sessile serrated lesions (SSLs). At six month surveillance colonoscopy, the combined recurrence rate was 6.2%. Adenomas ≥20mm demonstrated a higher rate of recurrence (16.1%) compared to large SSLs (4.1%), medium adenomas (3.0%), and medium SSLs (1.4%). There were no adverse events reported following C-EMR. C-EMR seems to be less effective for the resection of large adenomas when compared to medium adenomas or large SSLs. C-EMR is equally safe for all lesion size and histology.

Clinicopathological Findings of Surgically Treated Nasal Cavity Schwannomas: A Case Series.

Objectives: Nasal cavity schwannomas are exceedingly rare, benign neoplasms that pose challenges in clinical differentiation from other nasal tumors. Methods: This study presents 5 cases of nasal cavity schwannoma treated surgically over a 10 year period, along with a review of the literature. Results: The most prevalent symptoms included unilateral nasal obstruction and intermittent nosebleeds. Tumors originated from various nasal sites, including the septum, middle conchae, lateral nasal wall, and alar mucosa. All surgeries were conducted transnasally, with 3 tumors excised en bloc, and the remaining two subjected to piecemeal resection. Ancient schwannoma was identified in 4 cases. No instances of recurrence were observed during the average 61 month follow-up period. Conclusions: The definitive diagnosis of schwannomas necessitates histopathological examination. An endoscopic approach to the nasal cavity, obviating the need for external intervention, proved highly effective and appropriate for both diagnosis and symptom alleviation.

Prophylactic pancreatic duct stenting to reduce the risk of post-ampullectomy pancreatitis: a comprehensive review and meta-analysis of 1858 patients.

The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications. Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics. Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3-14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9-15.7) and without PPDS, 16.6% (CI 13.4-20.4), RR 0.8 (CI 0.51-1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3-81.1) and 25.1% (CI 19-32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively. Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings.

Impact of Annual Case Volume on Colorectal Endoscopic Submucosal Dissection Outcomes in a Large Prospective Cohort Study.

The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort. Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed. Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers. Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

Microsurgical Resection of Calcified C2 Cavernous Malformation: 2-Dimensional Operative Video.

We present the case of a 58-year-old woman presenting with left upper limb paresthesia and bilateral lower limb spasm who was found to have a likely radiation-induced calcified intramedullary cavernous malformation at the level of C2.1-4 Owing to the symptomatic nature of the lesion with progressive increase in size and associated cord edema on serial imaging, through a lateral approach, the patient underwent a microsurgical left C2-3 hemilaminectomy and medial facetectomy to access the ventral exophytic calcified component.5-7 Debulking and piecemeal resection were performed with the aid of an ultrasonic bone aspirator with "claw" attachment while minimizing any manipulation of neural parenchyma.8-13 Ultimately, near total resection was achieved as a rim of capsule was left densely adherent to the spinal cord. Postoperatively, no new neurologic deficits were noted, and imaging as early as 1 week postoperatively showed significant reduction of cord signal abnormality. The technical considerations for the ultrasonic bone claw and the literature on treatment outcomes for calcified intramedullary spinal cavernous malformations are reviewed. The patient consented to the procedure and to the publication of her images. Institutional review board approval was deemed not necessary because of the retrospective, case report nature of this work.

Long-term adenoma recurrence and development of colorectal cancer following endoscopic mucosal resection in large non-pedunculated colonic polyps ≥4 cm

ObjectivesData of long-term follow up for large non pedunculated colorectal polyps (LNPCPs) ≥4 cm removed with piecemeal wide field endoscopic mucosal resection (PWF-EMR) are limited. We primarily evaluated the recurrence rates and secondarily the rates of post colonoscopic polypectomy colorectal cancer (PCPCRC) on a long-term basis. MethodsWe retrospectively reviewed a prospectively-stored electronic database of all patients who underwent PWF-EMR for LNPCPs at the Venizeleion General Hospital, between 2009 and 2020. Eligible patients were those with LNPCPs ≥4 cm, deemed completely removed by endoscopic means and followed-up for a minimum of 36 months with at least two surveillance colonoscopies, the first one (SC1) (4–6) months after the initial PWF-EMR procedure and the second one (SC2) after (12–18) months. In 2023, all cases were checked for PCPCRC development. ResultsResidual/early recurrent tissue was detected in 44 (31 %) cases among the 142 (82 males, 60 females) assessed during SC1. Late recurrent tissue was detected in 9 (6.6 %) cases among the 137 surveyed during SC2. Investigation did not reveal any case of PCPCRC . ConclusionsThis historical cohort shows that the PWF-EMR for LNPCPs ≥4 cm is a safe and definitive removal method while it is not associated with the appearance of PCPCRC.

International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study.

There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices. Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale. Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements onpostresection evaluation; and eight statements on postresection care. An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices.

Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of rectal lesions involving the dentate line

BackgroundThe ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line.MethodsWe identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed.ResultsWe identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions.ConclusionESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

Comparing advanced platforms for local excision of rectal lesions.

Transanal surgery facilitates organ preservation in select patients with benign and early malignant rectal lesions to avoid the functional consequences of radical surgery. The transanal endoscopic microsurgery (TEM) platform created a standard for local excision with lower margin positivity and recurrence rates than traditional transanal excision. The single-port robot (SP r) presents a promising alternative transanal platform. The goal of this study was to compare perioperative and pathologic outcomes of TEM and SP r for excision of rectal lesions. A review of consecutive patients who underwent local excision of rectal lesions at a tertiary referral center from 1/2001 to 5/2022 was performed. Cases were stratified into TEM or SP rTAMIS in a 1:1 propensity score-matched cohort, adjusting for all baseline characteristics. Clinical, tumor-specific, and perioperative outcomes were compared using χ2, and Mann-Whitney U-tests. The main outcomes were oncologic quality measures, complications, and operative time. Matching resulted 50 patients in each cohort. Groups had similar age, gender, body mass index, comorbidity, diagnosis, lesion characteristics, and neoadjuvant chemoradiation rates. There were no intraoperative complications in either cohort. Three SP rTAMIS cases were converted intraoperatively; there were no conversions in TEM. SP rTAMIS had significantly shorter operative times than TEM (mean 104 vs. 245, p = 0.027). The rates of positive distal margins (2% TEM, 0% SP rTAMIS) and piecemeal resection (4% TEM, 0% SP rTAMIS) were similar. SP rTAMIS had significantly lower postoperative morbidity rates than TEM (9% vs. 20%, p = 0.031). There was no mortality in either cohort. SP robotics provided high-quality outcomes similar to TEM for local excision of rectal lesions. SP robotics had faster operative time with comparable clinical and oncologic outcomes to TEM. These early data are promising for expanding use of SP robotic platforms.

Substratifying the risk of covert malignancy in significant rectal polyps: Outcomes from a specialist multidisciplinary team (MDT).

A treatment strategy for patients with a significant polyp or early colon cancer (SPECC) of the rectum presents a challenge due to the significant rate of covert malignancy and lack of standardized assessment. For this reason, NICE recommends multidisciplinary meetings to improve outcomes. The primary aim of the present study was to report the performance of our specialist early rectal cancer (SERC) multidisciplinary team (MDT) in correctly substratifying the risk of cancer and to discuss the limitations of staging investigations in those patients with "poor outcomes". This was a retrospective review of patients referred to our SERC MDT from 2014 to 2019. Lesions were assigned by the MDT to three pre-resection categories (low, intermediate, high) according to the risk of covert malignancy. Resection method and final histology were compared to the pre-resection categories. Of 350 SPECC lesions, 174 were assessed as low-risk, 108 intermediate-risk and 68 high-risk. The cancer incidence was 4.8%, 8.3% and 53%, respectively (15.5% overall). Eight lesions were categorized as low-risk but following piecemeal resection were found to be malignant. Five lesions, three of which were categorized as high-risk, were ultimately benign following conventional surgery. One pT1sm1 cancer, removed by anterior resection, may have been treated by local excision. A total of 83% of malignant polyps were triaged to an en bloc resection technique and surgical resection avoided for nearly all benign lesions. However, 12 patients from this cohort were deemed to have a poor outcome because of miscategorization. Further comparative research is needed to establish the optimum strategy for rectal SPECC lesion assessment. There is currently no consensus for staging significant polyps of the rectum. This paper reports the effectiveness of a specialist early rectal cancer MDT to correctly risk-stratify significant rectal polyps. It underscores the importance of accurate categorization for treatment decision-making, while acknowledging the limitations of current staging modalities.

A survey of current practices in post-polypectomy surveillance in Korea.

We investigated the clinical practice patterns of post-polypectomy colonoscopic surveillance among Korean endoscopists. In a web-based survey conducted between September and November 2021, participants were asked about their preferred surveillance intervals and the patient age at which surveillance was discontinued. Adherence to the recent guidelines of the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF) was also analyzed. In total, 196 endoscopists completed the survey. The most preferred first surveillance intervals were: a 5-year interval after the removal of 1-2 tubular adenomas < 10 mm; a 3-year interval after the removal of 3-10 tubular adenomas < 10 mm, adenomas ≥ 10 mm, tubulovillous or villous adenomas, ≤ 20 hyperplastic polyps < 10 mm, 1-4 sessile serrated lesions (SSLs) < 10 mm, hyperplastic polyps or SSLs ≥ 10 mm, and traditional serrated adenomas; and a 1-year interval after the removal of adenomas with highgrade dysplasia, >10 adenomas, 5-10 SSLs, and SSLs with dysplasia. In piecemeal resections of large polyps ( > 20 mm), surveillance colonoscopy was mostly preferred after 1 year for adenomas and 6 months for SSLs. The mean USMSTF guideline adherence rate was 30.7%. The largest proportion of respondents (40.8%-55.1%) discontinued the surveillance at the patient age of 80-84 years. A significant discrepancy was observed between the preferred post-polypectomy surveillance intervals and recent international guidelines. Individualized measures are required to increase adherence to the guidelines.

Efficacy and Safety of Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors Originating from the Muscularis Propria.

The role of endoscopic resection (ER) in gastric gastrointestinal stromal tumors (GISTs) has not been fully elucidated. The purpose of this work was to evaluate the clinical effectiveness and safety of ER in patients with GISTs originating from the muscularis propria (MP). A total of 233 consecutive patients with gastric GISTs originating from the MP layer, who underwent ER between February 2012 and May 2023, were included in this study. Clinical characteristics, tumor features, and outcomes were recorded and compared between patients who underwent enbloc resection and piecemeal resection. Among the 233 patients, the median size of GISTs was 12mm (range 5-60mm). Risk assessment categorized 190 patients as very low risk, 26 as low risk, 10 as moderate risk, and 7 as high risk. The procedures performed included endoscopic submucosal excavation (127 cases), endoscopic full-thickness resection (103 cases), and submucosal tunneling endoscopic resection (3 cases). The complete and R0 resection rate was 93.1%. Complications occurred in 4.7% of cases (perioperative perforations 1.7%, perioperative bleeding 1.3%, both 0.9%), resulting in conversion to surgery in 1.3% of cases. Risk factors associated with piecemeal resection were tumor size [odds ratio (OR) 0.402, 95% confidence interval (CI) 0.207-0.783; P = 0.007] and shape (OR 0.045, 95% CI 0.009-0.235; P < 0.001). ER is proven to be an effective and reasonably safe approach for gastric GISTs originating from the MP. Notably, larger tumor size and irregular shape are identified as risk factors for piecemeal resection during ER procedures.

Long-term outcomes after endoscopic removal of malignant colorectal polyps: Results from a 10-year cohort.

Choosing an optimal post-polypectomy management strategy of malignant colorectal polyps is challenging, and evidence regarding a surveillance-only strategy is limited. To evaluate long-term outcomes after endoscopic removal of malignant colorectal polyps. A single-center retrospective cohort study was conducted to evaluate outcomes after endoscopic removal of malignant colorectal polyps between 2010 and 2020. Residual disease rate and nodal metastases after secondary surgery and local and distant recurrence rate for those with at least 1 year of follow-up were investigated. Event rates for categorical variables and means for continuous variables with 95% confidence intervals were calculated, and Fisher's exact test and Mann-Whitney test were performed. Potential risk factors of adverse outcomes were determined with univariate and multivariate logistic regression models. In total, 135 lesions (mean size: 22.1 mm; location: 42% rectal) from 129 patients (mean age: 67.7 years; 56% male) were enrolled. The proportion of pedunculated and non-pedunculated lesions was similar, with en bloc resection in 82% and 47% of lesions, respectively. Tumor differentiation, distance from resection margins, depth of submucosal invasion, lymphovascular invasion, and budding were reported at 89.6%, 45.2%, 58.5%, 31.9%, and 25.2%, respectively. Residual tumor was found in 10 patients, and nodal metastasis was found in 4 of 41 patients who underwent secondary surgical resection. Univariate analysis identified piecemeal resection as a risk factor for residual malignancy (odds ratio: 1.74; P = 0.042). At least 1 year of follow-up was available for 117 lesions from 111 patients (mean follow-up period: 5.59 years). Overall, 54%, 30%, 30%, 11%, and 16% of patients presented at the 1-year, 3-year, 5-year, 7-year, and 9-10-year surveillance examinations. Adverse outcomes occurred in 9.0% (local recurrence and dissemination in 4 patients and 9 patients, respectively), with no difference between patients undergoing secondary surgery and surveillance only. Reporting of histological features and adherence to surveillance colonoscopy needs improvement. Long-term adverse outcome rates might be higher than previously reported, irrespective of whether secondary surgery was performed.